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Six JOHN Y. W. MacAIJ.ST.EK
L\Nl>i?l< TI1K OIUJSCTImS <*F
K 1)1 TORIA L COM M ITTEE
VOLUME THE TWELFTH
8E8S10W !:>J8-19
CART J 1 1 ••
sections;.:— ;
OBSTETRICS A NO OYN/ECOLOGV ODONTOLOGY • OPHTHALMOLOGY
OTOLOGY PATHOLOGY PSYCHIATRY SURGERY
TH E H APEDTl CB AND PH ARM AGO LOG Y
m'nfflb books
•I ■ LONDON
LONGMANS, GREEN & CO , PATERNOSTER ROW
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London :
John Bale, Sons and Danielsson, Ltd.,
Oxford House,
83-91, Great Titchfield Street, Oxford Street, W. 1.
PROCEEDINGS
RfUTEIv Bt
Sir JOHN y. w:
TBS yillfiOTitMS or
THE EDITORIAJj COMMITTEE
VOLUME THE
SESSION 19.18-19-
SECTION OF OBSTETRICS k GYNECOLOGY
GOB D O N
• 1 . , % r ( i •' - ■
LONGMANS, GREEN & CO., PATERNOSTER ROW
1919
Section of ©bstetrics anb <5\>najcolo(H>,
OFFICERS FOR THE SESSION 1918-19.
President —
J. D. Malcolm, F.R.C.S. Ed.
Past Presidents —
Sir Francis H. Champneys, Bt.,
M.D.
Sir J. Halliday Croom, M.D.
Alban Doran, F.R.C.S.
Sir William J. Smyly, M.D.
W. D. Spanton, F.R.C.S.
Herbert R. Spencer, M.D.
G. F. Blacker, M.D.
Vice- Presiden ts —
H. Russell Andrews, M.D.
T. B. Grimsdale, M.B.
J. B. Hkllier, M.D.
J. M. Munro Kerr, M.D.
T. G. Stbv
CUTHBERT LoCKYER, M.D.
Hugh J. M. Playfair, M.D.
Amand Routh, M.D.
G. Bellingham Smith, F.R.C.S.
(s, F.R.C.S.
Hon. Secretaries —
Comyns Berkeley, M.D. J. S. Fairbairn, M.B.
Other Members of Council —
Victor Bonney, M.S.
Aleck W. Bourne, F.R.C.S.
Maud M. Chadburn, M.D.
Douglas Drew, F.R.C.S.
T. Watts Eden, M.D.
W. E. Fothergill, M.D.
A. E: Giles, M.D.
W. S. A. Griffith, M.D.
H. T. Hicks, F.R.C.S.
R. W. Johnstone, M.D.
(Jordon Ley, F.R.C.S.
Louise McIlroy, M.D.
G. Drummond Robinson, M.D.
G. F. Darwall Smith, M.D.
W. C. Swayne, M.D.
E. Hastings Tweedy, F.R.C.P.I.
Ethel Vaughan-Sawyer, M.D.
Clifford White, F.R.C.S.
Representative on Library Committee —
Herbert Williamson, M.B.
Representative on Editorial Committee —
T. W. Eden, M.D.
SECTION OF OBSTETRICS AND
GYNAECOLOGY.
CONTENTS.
November 7, 1918.
John D. Malcolm, F.R.C.S.Ed. pagk
President’s Address: Developments in Abdominal Surgery since 1884 ... 1
John Adams, F.R.C.S.
Treatment^ of Ante-natal and Post-natal Syphilis (Abstract) ... ... 9
December 5, 1918.
G. Drummond Robinson, M.D.
(1) Skiagram of Foreign Body in the Gravid Uterus ... ... ... 17
(2) A Uterus in which Changes had taken place as the Result of
Procidentia ... ... ... ... ... ... 18
(3) A Short Communication on a Case of Labour in a Paraplegic
Woman ... ... ... ... ... ... ... 22
Clifford White, F.R.C.S.
Two Cases of Puerperal Anuria in which the Renal Capsule was incised
and Portions of the Kidney Substance removed for Examination 27
February 6, 1919.
DISCUSSION ON RECONSTRUCTION IN THE TEACHING OF
OBSTETRICS AND GYNAECOLOGY TO MEDICAL STUDENTS.
W. S. A.’ Griffith, M.D.
A General Survey of the Subjects to be taught and of the Methods of
teaching them ... ... ... ... ... ... 33
390180
IV
Contents
John S. Fairbairn, M.B.
The Teaching of Obstetrics and Gynaecology from the Standpoint of
Preventive Medicine
Lovell Drage, M.D.
The Teaching of Obstetrics and Gynaecology from the Point of View of a
General Practitioner
The President, Mr. J. D. Malcolm, F.R.C.S.Ed, (p. 53), Dr. Amand Routh (p. 53;.
Dr. G. F. Blacker (p. 56), Dr. T. W. Eden (p. 58), Dr. Eardley Holland
(p. 59), Sir Walter Fletcher, K.B.E., M.D., F.R.S. (p. 60), Dr. F. J.
McCann (p. 62), D*. E. L. Collis (p. 63), Mr. Victor Bonney (p. 64), Dr.
Herbert Williamson (p. 65), Dr. Lapthorn Smith (p. 67), Lady Barrett.
C.B.E. (p. 68), Dr. R. W. Johnstone (p. 68), Dr. T. G. Wilson (p. 70), Dr.
H. R. Andrews (p. 72), Dr. W. S. A. Griffith (reply) (p. 73).
May i, 1919.
Victor Bonney, M.S.Lond., F.R.C.S.Eng.
The Continued High Maternal Mortality of Child-bearing: The Reason
and the Remedy
Report to Council on Teaching of Obstetrics and Gynaecology to Medical Students
and Graduates in London
April 3, 1919.
Clifford White, F.R.C.S.
(1) A Fostus undergoing Spontaneous Evolution removed by Laparotomy
during Labour
(2) A Case of Full-time Pregnancy in a Rudimentary Uterine Horn
Gordon Ley, F.R.C.S.
Two Cases of Full-time Extra-uterine Pregnancy, with a Tabulated
Abstract of 100 Cases from the Literature
Herbert Williamson, M.B.
Specimen of a Lower Limb of a Mature Feet us contained in an Osseous
Cyst, and remaining in the Abdomen of the Mother for Fifty-two
Years
H. R. Andrews, M.D.
Cases of Extra-uterine Pregnancy ...
Bellingham Smith, F.R.C.S.
Case of Extra-uterine Pregnancy
PAGE
40
49
75
108
135
138
140
171
173
... 176
Contents
v
W. Gilliatt, M.S. page
Two Cases of Full-term Extra-uterine Gestation ... ... ... 177
J. D. Malcolm, F.R.C.S.Ed. (President).
Case of Extra-uterine Pregnancy ... ... ... ... ... 179
Cecil Marriott, M.Ch. (Shown by the President).
Specimen from Case of Extra-uterine Pregnancy ... ... ... 180
June 5, 1919.
\V. S. A. Griffith, M.D.
A Fibrolipoina weighing 18 lb. which Invaded or Originated in the Right
Broad Ligament ... ... ... ... ... ... 188
T. G. Stevens, F.R.C.S.
Specimen of Subperitoneal Lipoma weighing 16J lb. ... ... 189
Gordon Ley, F.R.C.S.
Case of Congenital Teratoblastoma of the Vulva (Rhabdomyoma) ... 190
Ccthbert Lockyer, M.D.
Lipoma of the Broad Ligament ... ... ... ... ... 195
H. R. Andrews, M.D.
Severe Retro-peritoneal Bleeding after Dilatation of the Cervix ... 199
Eardley Holland. M.D.
The Syphilitic Placenta ... ... ... ... ... ... 204
July 3, 1919.
AV. Gilliatt, M.S.
Obstructed Labour due to Ventrifixation ... ... ... ... 216
The Society does not hold itself in any way responsible for the statements made or
the views put forward in the various papers.
OB.
London :
John Bale, Sons and Danielsson, Ltd.,
Oxford House,
83-91, Great Titchfield Street, Oxford Street, W. 1.
Section of ©betetnce ant) <5\>nfccoloop.
President—Mr. J. D. Malcolm, F.R.C.S.Ed.
PRESIDENT’S ADDRESS.
Developments in Abdominal Surgery since 1884. 1
By John D. Malcolm, F.R.C.S.Ed.
A striking illustration of the changes in abdominal surgery
is found in the nursing conditions. When I first knew this work
each patient at the Samaritan Free Hospital had a room set apart
for her own use in which the operation was performed, and in which
she remained during the first five or six days of convalescence.
She was attended to by one nurse who, with as little assistance
as possible, was in sole charge until the patient was considered
out of danger. In a simple case this meant two or three days of
constant attention followed by two or three days in which the work
was fairly easy. The nurses seemed to learn to sleep when the patient
slept, and to awake with the patient, and sometimes they would look
after a serious case for ten days or more. I believe most of them were
taught their work in the Samaritan Free Hospital, and therefore they
had no pretention to being what is now called fully trained, but they
knew all that was known at that time about the care of cases of
abdominal surgery. They were keenly jealous of their right to “ see
a case through ” the period immediately following an operation, and
when, the time came to adopt night and day shifts some of these
women positively resented the change.
This system continued for about seven years after I joined the
hospital in 1884. At that date Spencer Wells had retired from the
1 At a meeting of the Section, held November 7, 1918.
1)—6
2 Malcolm : Developments in Abdominal Surgery since 1884
acting staff, and the abdominal surgery was carried on chiefly by
Knowsley Thornton and Granville Bantock.
The surgeons to the hospital were not supposed to undertake any
operations by way of the vagina; all procedures by that route were
handed over to the so-called physicians, to whom opening the abdomen
was forbidden, the method of approaching the peritoneal cavity through
the vagina not being then more than a very rare procedure. This
division of the work was made in the belief that vaginal manipulation
caused such a contamination of the hands and person of the operator
that he could not safely open the peritoneal cavity for many days
afterwards. That view was acted upon, although the surgeon did
regularly examine his patients through the vagina, this being of course
often necessary for diagnostic purposes.
The isolation of the operator upon the abdomen as much as
possible from all sources of contamination was one of the early results
of Lister’s teaching, which was then very generally accepted by the
profession. Knowsley Thornton carried out fully Lister’s methods in
their latest development. Stated shortly, these involved the utmost
cleanliness of everything coming in contact with wounded structures
supplemented by a bacteriological cleanliness obtained by the use of a
per cent, solution of carbolic acid as a lotion for cleaning exposed
structures, and in which instruments and sponges, were kept until
required. A spray of carbolic acid solution was arranged to cover the
whole area of the operation; and to prevent the access of living
organisms to the wound from the air. Incidentally this spray had a
very chilling effect upon everything it touched, which could only be
harmful to the patient. There was no boiling of instruments, and
rubber gloves were not then employed. Marine sponges were used as
swabs. Little attention was paid to the irritating nature of the
carbolic acid, and in cases of rupture of an ovarian tumour with
glutinous contents,* practically the whole intestine would sometimes
be scrubbed from end to end before the toilet of the peritoneum, as
the cleaning process was called, was considered complete. Very
often after such energetic treatment an altogether uninterrupted
convalescence followed.
Although this antiseptic method was very generally practised, a
small minority of surgeons, headed by Lawson Tait and represented
in the Samaritan Free Hospital by Granville Bantock, opposed Lister’s
teaching strenuously, with a bitterness which was very remarkable, and
which seems to crop up from time to time in connexion with this subject.
Section of Obstetrics and Gynaecology
3
The opponents of Lister maintained that a solution of carbolic acid
when applied to raw tissues and to the peritoneum was harmful to
these structures, and that no chemical solutions were necessary. We
all know now that this is true if the raw tissues and peritoneum
are not contaminated. But when the holders of these new views
scoffed, as they did, at Lister's teaching, they clearly did not under¬
stand what they were discussing, and this ignorance led to frequent
disasters.
The central idea of Lister’s teaching was in no way concerned
with or dependent upon the use of carbolic acid. He has left a
definition of his views which might have been cunningly devised with
a foreknowledge of the wrangling which was to take place, and with
the definite object of confounding criticism. He wrote that “the
antiseptic system of treatment consists of such management of a
surgical case as shall effectually prevent the occurrence of putrefaction
in the part concerned.” 1 The essential fact taught by Lister was that
the presence and growth of putrefactive organisms is the chief
cause of the prevention of healing of injured animal tissues, and
his definition encompasses all our modern methods, whether by
sterilizing by heat, by attempts to wash away or kill putrefactive
organisms already lodged in the tissues, or by means directed to
increasing the power of living structures to resist and destroy patho¬
genic organisms. In fact every known and every unknown method of
attaining asepticity in a wound must come under the conditions of
Lister's definition of his antiseptic system which is quoted above, and
however brilliant and original any future new method of attaining
asepsis may be its author will deserve the more credit if he freely
acknowledges that he is adding a detail in full harmony with
Lister’s teaching, the essential feature of which must remain
unchanged.
The supporters and the opponents of Lister were also sharply* at 1
variance on the question of giving or withholding opium during the
convalescence of a case of abdominal surgery. The adherents of
Lister were dominated by the fear of an onset of peritonitis, and by
the belief that opium was a specific for this condition. To bind up
the bowels for the best part of a week was the orthodox treatment.
For this purpose 20 minims of tincture of opium were administered
per rectum every six hours, and additional doses were given if there was
1 Introductory Lecture, University of Edinburgh, 1869.
4 Malcolm: Developments in Abdominal Surgery since 1884
|any complaint of pain. As little as possible in the way of food and
even of fluid was given by the mouth. Three ounces of beef tea were
administered by the bowel every three hours. Occasionally the rectum
was washed out by small quantities of water. Large injections were
avoided because the last thing desired was an early movement of the
bowels. No attempt was made to supply fluids to the body in large
quantities after an operation. An important point of the treatment
was the passage of a tube into the rectum every three hours before
each injection of beef tea, to allow of the escape of any remains of the
last injection, and of any gases which had come down to the rectum. If
gases escaped freely the patient usually made a good recovery. If they
did not escape at all the patient died. The attempt to bind up the
bowels was a survival from the time when there was no surgery of the
peritoneum beyond an occasional operation for the relief of a strangu¬
lated hernia, and when patients who could not recover whilst the
bowels were firmly locked up had to die. The new school declared that
the bowels should be evacuated early, and that opium should not be
given at all. Numerous attempts were made to prove the superiority
of the rival methods by the publication of statistics of mortality, but
neither side succeeded in showing a definite advantage, and the ill
feeling which existed was, if anything, intensified by this method of
argument.
It was my duty to perform the post-mortem examinations at the
Samaritan Free Hospital for about six years, which involved my
exclusion from all participation in surgical work for a week after each
autopsy. It quickly became evident that although the mortality of the
old and of the new methods did not show a superiority for either, yet
each had its own peculiar mode of death. With the free use of carbolic
acid and a' continuous administration of full doses of opium after an
operation the deaths were chiefly associated with symptoms of intestinal
obstruction, and after death signs of a slight diffuse peritonitis were
found. A performance of many second operations in the hope of finding
an intestinal obstruction showed that this diffuse peritonitis developed
after the symptoms of obstruction were well advanced, and therefore
this peritonitis could not be the cause of the intestinal symptoms or of
the deaths which usually occurred on the fifth day. These deaths were
caused by a deficient propelling power in the intestine, associated with
an increased resistance to the passage of faeces through the colon, the
combined effect amounting to a complete and fatal intestinal obstruction.
When chemical solutions were discontinued as lotions, cleanliness
Section of Obstetrics and Gynaecology 5
alone being relied upon, and when purgatives were used freely and early,
the most common mode of death occurred about the third day after the
operation, and a diffuse suppurative peritonitis was found at the autopsy.
This cause of death occurred as readily after the simplest operations as
after any others, and believers in the teaching of Lister had no hesita¬
tion in attributing the suppurative peritonitis to an introduction of
septic infection in the course of the operation. The methods adopted,
which did not include boiling of instruments, were clearly imperfect,
and an occasional onset of septic peritonitis was not to be wondered at
when the surgeon openly derided Lister’s teaching. These deaths
naturally met with angry criticism from believers in the germ theory
of septic infection.
If it had not been for these cases of septic peritonitis a definite
superiority in statistics of mortality would have been easily attained by
the new school which would have reached almost at a bound to* our
modern technique. It‘was known that water and instruments could be
sterilized by boiling and at a later date the use of rubber gloves durirg
operations followed rapidly upon the disuse of chemical antiseptics as
lotions by the followers of Lister. Coarse rubber gloves were already
available for post-mortem purposes. The new school adopted empirical
methods which when brought into harmony with Lister’s teaching
proved to be distinct advances on former treatment, but this school
fought hard against the well established germ theory and thus missed
a great opportunity. No advance was made until it gradually became
recognized that sterilization of instruments and lotions could be effected
by heat and that to bind up the intestines for a long period after an
abdominal operation was harmful.
In 1884, the removal of uterine fibromata was effected by bringing
the uterus out of the body through a median abdominal incision and
constricting its base behind the tumours by means of a serre-noeud
until the circulation was arrested. The uterus and growths were then
cut away through bloodless tissue, leaving about an inch to separate by
sloughing, the abdominal wall being secured round the uterus at the
level of the constricting wire. The separation of the slough and healing
of the wound were seldom completed under six weeks. The mortality
from this operation was small if there was no drag on the constricted
neck of the uterus, but the danger increased with the amount of
traction and the removal of deeply placed fibroids by this method was
very dangerous. In all cases the scar was weak and liable to develop a
hernia, and when modem methods were introduced their superiority
was quickly apparent.
6 Malcolm: Developments in Abdominal Surgery since 1884
One of the most important changes of method in the period under
consideration was the introduction of the influence of gravity for
removing the intestines from the pelvis. We now expect the patient’s
hips to be raised as a matter of course for all pelvic operations, and
those who have always been accustomed to this do not think Of what
operating without it meant. Very little consideration however is
necessary to recognize that, for example, the removal of the uterus
for cancer of the cervix by the abdominal route as practised at the
present day would be well nigh impossible with the patient on a
horizontal table.
A widespread principle has been gradually evolved and has exercised
an immense influence on our work. In 1884 the abdomen was rarely
opened when an acute inflammation was in progress. If febrile
conditions developed and increased or continued the patient was usually
left to undergo a natural solution of the mischief whatever it might be.
Even an operation for the removal of a newly strangulated ovarian
tumour was usually postponed. Now a large proportion of our work is
directed to the arrest or prevention of an onset of inflammation. This
applies particularly to intestinal -work. Cases of obstruction of the
bowel and rupture of the bowel now give extraordinarily good results if
surgical interference takes place sufficiently early. The chief object of
the surgeon in these and many other cases is to anticipate danger.
The gradual evolution of preventive surgical interference has had a
very definite influence upon war surgery. At the end of the South
African campaign the general opinion amongst surgeons was that
abdominal wounds were best left to nature, and this was the teaching
when war broke out in 1914. But a rapid swing of the pendulum has
taken place and now if a patient with a penetrating abdominal wound
can be conveyed to a suitable place, in fairly good condition, and
without too much delay, his chances of recovery are considered to be
improved if the abdomen is promptly opened. Of course the death-rate
is very heavy, but the patients who die would not have lived without an
operation, whereas the patients who recover would almost certainly
have died without surgical interference. Patients who, after a gunshot
injury of the abdomen have wounds of the intestine immediately closed
or treated by resection and who arrive in this country a few weeks later
with their incisions firmly healed, are triumphs of modern methods of
which every surgeon must feel proud. Another advance, initiated
I believe chiefly by French surgeons, is also founded upon the view that
surgery should be preventive whenever this is possible. I refer to the
Section of Obstetrics and Gynaecology
7
excision of gunshot wounds at the earliest possible moment. This plan
cannot be adopted in every case, but when it is possible the result may
be a healing by first intention substituted for a long, exhausting and
perhaps dangerous or even fatal suppuration.
I have strayed somewhat from gynaecology and I should like to say
one word about the relations of gynaecological surgery to that of the
rest of the abdomen. At the Samaritan Free Hospital, ever since
I have known it, some of the surgeons have undertaken work outside
the pelvic area. In many cases this was begun because of mistakes in
diagnosis or because the surgeon happened upon some complication
in the course of an operation upon the female generative organs.
The mistaking of a hydronephrosis for an ovarian tumour seemed to be
particularly common although it is not easy to fall into this error if the
possibility of floing so is remembered. A large hydronephrosis may
exactly simulate an ovarian tumour in all respects except that the loin
on the affected side is always absolutely dull on percussion. A need for
resection of the bowel may also arise in a most unexpected manner and
the discovery of appendix trouble when a salpingitis is diagnosed cannot
always be avoided.
I do not know how the division of the work is arranged in the
general hospitals but the appearance in our Proceedings from time to
time of cases that are not strictly gynaecological seems to show that
the>boundaries of the work of the surgeon and of the gynaecologist are
somewhat elastic. This is of good augury, for there is no doubt that
when a surgeon, whether general or gynaecological, opens the abdomen
for any cause he will best serve his patient’s interests if he has
sufficient knowledge and experience to deal with every condition,
however unexpected, that'may be found. Any rule or practice tending
to limit his activities after the abdomen has been opened is unscientific
and dangerous.
Statistics are not always reliable indications of goo.d surgery, but
those of the Samaritan Free Hospital in 1884 and in 1916 (the last
available) are so different that they clearly indicate a great advance.
The death-rate from ovariotomy in 1884 was 10 per cent.; from
hysterectomy 14 per cent.; from nephrectomy (six cases) 50 per cent.;
and from splenectomy (two cases) 50 per cent. The whole mortality
from abdominal operations was about 14 per cent. In 1916 the
mortality from operations involving the peritoneal cavity was under
4J per cent., and this improvement took place in spite of the fact that
a very much larger and more dangerous area of operative work was
covered in 1916.
8 Malcolm : Developments in Abdominal Surgery since 1884
The points which I have noted show clearly that the abdominal
surgery of thirty-four years ago has undergone vast changes for the
better. The advances have, on the whole, been gradual and it is of
course easier to reduce a mortality of 14 per cent, than one of 4J per
cent., but I have no doubt that thirty-four years hence my successor in
this chair will, if so minded, be able to show that many of the methods
of to-day have been improved almost beyond recognition. We cannot
of course count upon such advances as those made by Lister and by
Morton, yet such are possible, and this is an age of big events. One
advance outside the limits of our professional work, but of a purely
scientific nature, may be mentioned. It is just ten years (last
September) since Wilbur Wright gave his first exhibition of flying in
this country, and how many of us as late as tbe spring of 1914 believed
that flying was of no practical use ? Yet the superiority of the Allies
in aviation has been one of the chief factors in winning the war.
So, at any moment, some great surgical advance may arise. The
cancer problem still seeks a solution and septic infection is often
beyond our control.
I trust that we will bear a large share in effecting the advances
which will certainly take place and may I be allowed to express the
opinion that the time has now come when we, as a Section, should
endeavour to throw off the inertia which has overtaken our work as
a consequence of the war. The number of our meetings of course
depends upon the directions of the Council and still more upon the
activity of the members. If you, ladies and gentlemen, do not send in
sufficient material for consideration there can be few or no meetings,
but a cessation of hostilities is practically • assured at an early date,
certainly before our present session ends, and therefore, although there
may for a long time be much to distract our attention, I hope that we
may be able quickly to resume our monthly exhibitions, discussions and
criticisms, and again to contribute our full share to “ the promotion of
knowledge in all that relates to obstetrics and gynaecology,” which is
the official description of the objects of our Section.
Section of Obstetrics and Gynaecology
9
Treatment of Ante-natal and Post-natal Syphilis. 1
By John Adams, F.R.C.S.
(ABSTRACT.)
[This paper is printed'in e.vtenso in the British Medical Journal , November 1G, p. 541.]
It is estimated that in England and Wales alone 27,000 deaths
occur annually from syphilis contracted during the ante-natal period,
or immediately after it. Evidence was given before the Royal Com¬
mission on Venereal Diseases that nearly 50 per cent, of all syphilitic
foetuses are stillborn, and that 75 per cent, of those born alive die
within the first year of life, generally within the first week.
The following is a brief outline of the treatment which is adopted at
the Thavies Inn Venereal Centre :—
(1) Ante-natal treatment of the unborn child, by means of anti¬
syphilitic treatment of the mother.
(2) Post-natal treatment of the child immediately after birth.
The ante-natal treatment of the mother is of the utmost importance
to the unborn child. The pregnant woman may be treated with one of
the salvarsan substitutes and mercury with perfect safety up to the day
of confinement, and the earlier the treatment is begun the better.
A Wassermann test should be made in every suspected case, and the
treatment of the mother begun as soon as syphilis is diagnosed.
This treatment consists of weekly intravenous injections of one of the
salvarsan substitutes, galyl and novarsenobillon being those used,
commencing with 20 cgm. galyl and increasing up to 30 cgm.
Intramuscular injections of mercury, 1 gr., are given at the same time
in the opposite buttock; the B.P. 40 per cent, emulsion has been
the preparation used, it being less painful than the usual 5 per cent,
emulsion.
Immediately on the birth of a child a specimen of the blood is
taken from the vessels of the divided umbilical cord for a Wassermann
test; a portion of the placenta is also obtained for examination for
spirochtetes. Further specimens of blood from the child are best
obtained by pricking the heel with a medium size Hagedorn’s needle in
three or four places near one another, allowing about i to i c.c. of blood
At a meeting of the Section, held November 7, 1918.
10 Adams : Treatment of Ante-natal and Post-natal Syphilis
to drip in a 1 c.c. glass tube. This should be repeated, if necessary, at
intervals of a month or six weeks for a further test.
Anti-syphilitic treatment of the baby is begun during the first week
and may be commenced as early as the second day. It is almost
impossible to give an intravenous injection to a new-born baby, but
galyl in glucose is found to be an excellent preparation for intra¬
muscular injections, and this is the preparation which has been
invariably used. The dose is determined by comparing the weight
of a baby with that of the mother. A newly-born baby is about
one-seventeenth the weight of the mother; the average dose of galyl
for an adult is 30 cgm. One-seventeenth of that quantity is about
2 cgm.; this should be gradually increased up to 5 cgm., or more
as the child grows. The mercury is given at the same time in the
opposite buttock in doses from J to J gr., and more recently in addition
£ gr. of hyd. c. cret. is given daily by the mouth, when the child is two
or three weeks old.
The site chosen for the intramuscular injections of salvarsan and
mercury is the middle third of a line drawn from the anterior superior
iliac spine to the commencement of the gluteal fold. It is advisable
that there should be an interval of from a week to a fortnight before
repeating the injection of galyl, but the mercury should be given
weekly, unless it is decided to administer it by the mouth entirely ;
in that case £ gr. should be ordered once daily for the first fortnight,
and afterwards the dose may be repeated night and morning.
Inunction is an excellent way of giving mercury to babies, but the
results depend upon the preparation used, the time given to the
rubbing, and the variations in the absorbing power of the skin.
Moreover, to obtain the full effects of the inunction it is necessary
that it should be given by someone experienced in the art.
It is found most convenient to give the intramuscular injections
both of salvarsan and mercury, with a special syringe graduated in
fifteen divisions, each of which is one-fortieth of a cubic centimetre.
Thus each division of the syringe corresponds to 1 cgm. of mercury
when 40 per cent, grey oil is used. The size of the needles found
best adapted for the purpose of the injections is 0*8 mm.
The average number of doses of galyl required to bring about a
negative Wassermann reaction was found to be 6*5, and the amount
per case 26 cgm.
When possible the child should be fed by the breast, but after a
few weeks it is generally found necessary to supplement the mother's
Section of Obstetrics and Gynaecology
11
feeding with artificial food, for the milk of a syphilitic mother is usually
deficient both in quantity and quality. The weight of the baby should
be carefully taken weekly, and it will be found almost invariably that
thdre will be an increase.
Up to a recent date it was said that the Wassermann reactions of
congenital syphilitic children never became negative under treatment.
(Dr. Amand J. Routh, Lancet, January 12, 1918.) My investigations
show this statement to be incorrect.
The results of the treatment as carried out at the Thavies Inn
Venereal Centre for pregnant women has been very encouraging.
Of twenty-four consecutive cases treated from September, 1917, to
September, 1918, six babies have been born free from any evidence
of syphilis, showing a negative Wassermann reaction which has
remained negative; seven were born with a positive Wassermann
reaction which became negative after treatment; in all these cases
the babies’ reaction became negative before the mothers’. Six babies
born with a positive reaction remain under treatment and are doing
well, show no signs of syphilis, and are gaining weight regularly. 1
In three cases the babies died in utero, the mothers having had no
treatment before confinement; one child died from syphilis and one
from some intercurrent disease. In no case did a baby once having
become negative afterwards develop a positive Wassermann reaction;
in one case the test has extended at three months’ intervals over a
period of a year.
The treatment described has been put to the test of experience
sufficiently long to show that much can be done for ante-natal and
post-natal syphilis, and the conclusions arrived at are:—
(1) Syphilitic pregnant women can be treated with salvarsan, even
up to the day of their confinement, with safety and every advantage.
(2) A mother whose blood gives a positive Wassermann reaction
may, after treatment, be delivered of a child whose blood gives a
negative reaction. The child may continue to thrive and give a
negative blood-test.
(3) Syphilitic children can be treated by salvarsan immediately
after birth.
(4) Salvarsan, combined with treatment by mercury, has a more
certain and quicker action in producing a negative Wassermann in a
child than in the mother.
January 1 : The reaction has now become negative in all these cases.
12 Adams : Treatment of Ante-natal and Post-natal Syphilis
(5) In nearly all syphilitic children born alive, treatment can
soon convert a positive into a negative Wassermann reaction, and
such children appear to become healthy and show a regular weekly
gain in weight.
DISCUSSION.
Chairman—Dr. AMAND Routh.
Dr. Amand Routh : Mr. John Adams has been successful in his practical
efforts to treat and cure ante-natal syphilis. The mothers, who were all cases
of primary and secondary syphilis, had not been long enough under treatment
for a cure to be effected, and all but one of the twenty-four cases continued to
have a positive Wassermann reaction. Of the children, eight of the twenty-
four died, a mortality of 33 per cent., but five were stillborn (four macerated),
and almost certainly had died before tbeir mothers began treatment. Of the
remaining sixteen children who survived four showed a negative reaction at
birth, which remained so, whilst in three with reactions strongly positive, two
positive, and two feebly positive at birth the reactions became negative. Mr.
Adams’s observations have not extended beyond ten months in any of the cases,
so that his results are not final either as regards the Wassermann reactions or
the clinical history, of his patients, but he has shown that, contrary to accepted
theories, 12 per cent, of the children born with strongly positive reactions
became negative under treatment. He has also proved that new-born children
whose mothers had been treated during the pregnancy were able to stand
injections without risk. Of the sixteen children who survived fifteen received
injections of galyl in glucose, and thirteen had also mercury in some form.
These two facts, proved by Mr. Adams’s statistics, are valuable. Syphilis
during pregnancy destroys a greater percentage of fertilized ova than any other
condition or cause, except perhaps at the very end of pregnancy, when
44 accidents and complications of childbirth ” cause 25 per cent, of infantile
deaths “ during or soon after birth .” In Poor Law Hospitals over 16 percent,
of stillbirths are due to syphilis, and this percentage is doubled in illegitimate
pregnancies. The astonishing thing is that the relatively large infecting
Spiroch&ta pallida , with its enormous powers of multiplication, does not at
once destroy the fertilized ovum. The explanation is that there is some con¬
dition present from the moment of conception until parturition, which to a
large extent controls the situation, by directly or indirectly producing chemical
ferments and their derivatives, which can render biologically inactive, and in
some cases destroy, the infecting mature organism. The chorionic ferments
fulfil this chemical function, and at the same time saturate the blood of the
mother with antibodies which are able usually to prevent spirochaetes from
further developing in her own body during pregnancy. As soon as childbirth
is over, both mother and child get gradually freed from chorionic chemical
influences, and syphilis may develop either rapidly or slowly in both in un¬
treated cases. The chorionic ferments in the mother are probably accumulative
Section of Obstetrics and Gynaecology
13
in successive pregnancies, and this explains how it is that syphilitic mothers
at first suffer miscarriages with dead children, then have stillbirths, then
diseased children dying in early infancy, and eventually may have children
showing no signs of disease, some of whom may become general paralytics at
puberty or in early adolescence. It also explains an opinion formed by J. E. R.
McDonagh that “ in some cases repeated pregnancies have undoubtedly
resulted in a spontaneous cure of the disease.” There seems very little
doubt that the chorionic ferments -control the growth of spirochaetes by granu-
losing them—i.e., breaking them up into granules by transverse division of the
spirals. Professor Noguchi, working in the Rockefeller Institute, U.S.A.,
has described (in the April, 1917, number of the American Journal of Syphilis ),
how he began to take cultures from such granules in 1910-11, and succeeded
in growing the mature spirochaete. He has continued to make a series of
cultures from granules derived from his different generations of spirochaetes
till the date of his article (1917), and he has been able by means of these
various generations of spirochaetes, spread over seven years, to infect rabbits
and monkeys with true syphilis. It is easy therefore to understand that the
chorionic ferments can in many cases control the syphilitic infection by
granulosing the spirals of the mature spirochaete, and if the granules are not
destroyed would continue to render them biologically inactive, or would be able
to destroy any developmental buds, and so keep the mature spirochaete from
becoming generalized in the tissues during pregnancy. Nature therefore is
doing much to protect the foetus in utero from its conception to its birth, and
the obstetric physicyan must come in, as Mr. John Adams has done, to supple¬
ment the action of the chorionic ferments by giving the mothers salvarsan and
mercury during the pregnancy, and continuing the treatment to both mother
and child after parturition.
Dr. GRIFFITH : I am responsible for having asked Mr. Adams to read his
paper before the Section, because I felt sure that the sooner the subject was
brought forward for discussion, the sooner would the value of the treatment be
determined, and the criticism which Mr. Adams has invited be forth¬
coming. The treatment appears to me to be of great promise, but it is
obviously too early to draw final conclusions.
Mr. W. G. SPENCER: Mr. Adams and the.City of London Authorities have
taken two important steps—the City of London in providing in-patient treat¬
ment for venereal cases, and Mr. Adams in combining an early intensive
salvarsan and mercury treatment and applying this to new-born infants. The
salvarsan has the drawback that, whilst rapidly removing the manifestations of
syphilis, it does not cure. Out-patients are in consequence liable to neglect
the real curative treatment by mercury. It is dangerous to carry out such an
intensive combination of the salvarsan and mercury treatment among out¬
patients. For such a procedure patients must be prepared, thoroughly
examined and watched afterwards. If the authorities of London as a whole
14 Adams: Treatment of Ante-natal and Post-natal Syphilis
really aim at diminishing the severity of venereal disease among those already
infected, they must follow the lead of the City, and provide in-patient
accommodation. When the main effect of the disease has been arrested by
an intensive salvarsan and mercury course whilst the case is an in-patient,
treatment as an out-patient may then be continued indefinitely.
Dr. HANDFIELD-JONES : The difficulty in discussing the paper is that so
few have enough cases of acute syphilis to be able usefully to criticize the
results and conclusions. But if one has cases where the disease has been
manifested before the sixth month, and the mother's condition has been satis¬
factory afterwards, and the child is healthy, there is reason to suppose that the
child will remain so. I have watched such a case until the age of 12 years,
and the child has remained perfectly free from syphilis.
Mr. W. GIRLING Ball: It is difficult for me to criticize Mr. Adams’s
paper, first, because I have not had an opportunity of examining this record
of cases with which he has provided us in any critical manner in the short
time at our disposal, and also because I fear that he will not be so inclined to
take cases from me which present themselves at St. Bartholomew’s Hospital
in the same way as he has done in the past. At the same time there are one
or two points which force themselves upon one’s attention, Mr. Adams has
told us that he does not admit his cases to his institution before the patient
has advanced into the sixth month of pregnancy, at a time when syphilis is
well developed in the mother and no doubt also in the child. Some of these
patients have had treatment before the birth of the child, and few of them
before admission to hospital. It seems a curious fact that in those cases
which have been treated by salvarsan substitute and mercury—even with
several doses—in no case was a negative Wassermann reaction obtained
before the birth of the child. Surely this should be an important position to
arrive at, if possible, before the birth takes place, for no doubt if such a
condition is arrived at in the mother the drugs must also have some effect on
the child and thus render it a more desirable subject for post-natal treatment.
With some considerable experience in the treatment of syphilis it is no
uncommon expei'ience for me to obtain a negative Wassermann reaction with
a single course of six doses of salvarsan substitute with six mercurial injections,
in fact, it is the almost invariable rule with cases of primary syphilis.
A second course almost always abolishes the reaction, even with those having
advanced secondary conditions. A few cases do not get this result, of course.
In none of these mothers has a negative reaction been obtained, from which I
argue that the treatment of the disease is not commenced soon enough and
that the mothers ought to be admitted for treatment at an earlier stage.
As Mr. Adams points out, this is not possible with so small a number of beds
available. We shall never do any good in the treatment of congenital syphilis
until a large number of beds are provided for this form of treatment. The
Corporation of the City of London is to be congratulated in having started,
Section of Obstetrics and Gynaecology
15
but it remains for the profession to urge that this plan should be adopted on a
much larger scale, if they are to tackle what is the bed-rock of the trouble.
With regard to the remark that he has had harmful results from the use of
novarsenobijlon, I can only tell Mr. Adams that during the past year I have
had no trouble at all with it. I have seen some few cases treated by others
and believe that in those the harm has been produced, by the use of too
large doses. I should like to hear more of the results later.
Dr. W. H. Kelson : I consider that Mr. Adams’s treatment has been
very successful so far as it goes, but it is extremely important that this batch
of cases be followed up in respect to both mothers and infants. I hope their
social position is not such as to preclude this. It is a very difficult thing to
say when syphilis is actually cured.
Dr. A. E. Stansfeld : I carried out the Wassermann tests in Mr. Adams’s
cases, and it does not appear quite fair to these results to take the percentage
of deaths as a criterion. Cases of syphilis vary very much in their response to
treatment, and that fact is well demonstrated in this particular paper. Three
of the children with strong positive reactions at birth subsequently, in the
course of two or three months, developed negative reactions which remained
negative. I am struck by the extremely short time ^hich has elapsed in these
three cases for the change from the positive to the negative reaction to take
place. In older children with strongly positive Wassermann reactions, the
reactions never become negative in anything like that time. Once a strongly
positive Wassermann reaction has been made negative there is every hope that
continuation of treatment w T ill render it persistently negative. So that even if
Mr. Adams has only these three cases to show he has made out a strong case
for the treatment after birth.
Mr. ADAMS (in reply) : The taking of the test while the patient is under
treatment makes no difference in these cases. The positive remains positive,
and the negative remains negative. The question has been asked as to what
happens to these women in their next confinement. I am well aware that
observations extending only over a year are not sufficient for me to elaborate
anything like a perfect system of treatment, but a good many of my friends
have urged me to bring the cases at their present stage before the Section.
Mr. Girling Ball has raised a very pertinent question by speaking of the early
treatment in the case of the mothers. One cannot treat any case too soon.
In the early stages of primary syphilis we can, if the case is brought under
treatment early enough, so deal with it as scarcely to see any secondaries at all.
I am accustomed to wait for my reports before I begin any treatment; now if
a woman has a positive reaction the baby is treated at once. I look upon
the seven cured cases very hopefully (cases which, had a strongly positive or
positive reaction at birth and have come to have a negative reaction later), and
I should be very disappointed in the future if a child born alive dies from
syphilis. Through the generosity of the City Authorities, I have been enabled
16 Adams : Treatment of Ante-natal and Post-natal Syphilis
to have th^se cases looked up after their removal from the hospital; a visitor
is appointed to keep in touch with them. What impresses me most is this,
that the scientific and theoretical treatment of syphilis by salvarsan and
mercury is followed by the clinical results, that the child does not die, that the
test may become negative, and that the child may grow fat and look well.
If we cannot get science and practice to go together wo do not get very far,
but in this case they do go absolutely together. Dr. Kelson has asked what
kind of persons the mothers are. They are of all sorts and conditions, married
and single. The great thing is to have them under one’s control. I demur to
Dr. Rouths deductions with regard to the mortality rate in my list of
cases. The mortality of syphilitic children—of those born alive—is 75 per cent.
Of these twenty-four cases, nineteen were born alive r four children died in
utero before the mothers received any treatment and one child, a six and a half
months* baby, died a few hours after birth ; of these nineteen, 75 per cent,
should have died within the first year, mostly in the first few weeks, but as a
matter of fact out of the whole of the nineteen cases born alive only two have
died, and one of these did not die of syphilis. All the babies born alive
regularly put on weight except one baby that died thirty-five days after birth,
and from this it would seem that if these children should develop syphilis later
on they would at least have a chance under treatment.
Section of Obstetrics and "ftgniecolog#;
President:—Mr, ,1. D. Mat-Cui.m, P.R.C.HPd
Skmgrziirf of Edreign Body m the Gravid Utfems.; 1
Exhibited by G. I>kt;:mmivnd Uomnson, M.l>
Ax unmarried woman waff admitted W Westminster Hospital with
the history that ia the belief that she was pregnant/ she had tried to
pass a erochet needle, the hook end of which was covered by a metal
v At'4 meeting of the Section, held Dcnmibst S } 1$18
18 Robinson : Changes in Uterus as Result of Procidentia
cap, into her uterus per vaginam. On withdrawing the crochet needle
she was alarmed to find that the cap had not come away with it. She
had haemorrhage from the vagina, and, becoming frightened, came to the
hospital. On examination the uterus was found to be bulky ; the os
uteri was slightly patulous; no part of the metal needle cap could be felt.
Dr. Worrall then took several X-ray photographs, in one of which the
metal cap of the crochet needle is very clearly seen (p. 17). As no similar
case has been recorded in this Section of the Society, so far as I am aware,
it seemed to me that the skiagrams would be of interest to the Fellows.
Shortly after the skiagrams were taken, the patient passed an ovum of
about two months, together with the metal cap, spontaneously, during
an action of the bowels. The metal cap measures 2 X ^ in. in length.
Dr. Amand EoUTH : I once removed a hollow glass stem pessary from
which the glass knob had been broken off, by splitting up the cervix and uterus
anteriorly after turning up the bladder.
A Uterus in which Changes had taken place as the
Result of Procidentia.
By G. Drummond Robinson, M.D.
N. G., aged 46, had complete procidentia of the uterus in 1900
(eighteen years ago), after the birth of her second child. In 1901
(seventeen years ago) hysteropexy was performed on her at the Soho
Hospital for Women. In 1902 (sixteen years ago) the patient was
confined at Queen Charlotte’s Hospital of her third child. Shortly
after this confinement the prolapse reappeared.
In 1903 (fifteen years ago) I first saw the patient. The vagina was
completely prolapsed ; the sound passed 8 in. The supravaginal portion
of-the cervix could be felt through the vaginal walls, much elongated
and very thin. The fundus uteri appeared to be attached to the
anterior abdominal wall. I performed an extensive perineal operation,
which enabled the patient to retain a pessary. Within a year of this
operation the uterine canal had become so shortened that the sound
only passed 3| in. There has been no further pregnancy.
Recently the patient had haemorrhage from the vagina, and on
December 1, 1917, I removed the uterus by Wertheim’s method for
Section of Obstetrics and Gynaecology
19
carcinoma of the cervix. The fundus uteri was found firmly attached to
the anterior abdominal wall. Immediately after operation the sound
passed through the external os 4£ in. into the uterus. The body of
the uterus appeared to be enlarged. The patient has made an
uneventful recovery.
I show the specimen. The carcinoma of the cervix is seen, but the
interest of the case centres in the history of the supravaginal cervix.
It has long been known that when the cervix protrudes from the vulva
in cases of so-called prolapse of the uterus there is usually an increase in
the length of the supravaginal cervix. Whether this elongation of the
supravaginal cervix is due to stretching of that structure alone or to
new growth of its tissues, or to both conditions, has been discussed from
time to time. In the present cage when the patient was first seen by
me in 1903, the sound passed the enormous distance of 8 in. into the
body of the uterus, and the end of it could be felt at the fundus at the
lower end of the abdominal scar. Within a year from the time the
uterus had been kept in place by a pessary this length had decreased by
4 J in. Presumably the supravaginal cervix had been elongated at least
to that extent by the prolapse and had shortened again to that same
extent after the uterus had been supported in its normal position for a
few months.
So far as I am aware no specimen of a uterus and cervix in which
the changes I have described in the supravaginal cervix have been care¬
fully watched clinically has ever been shown before our Section, or its
predecessor the late Obstetrical Society. The specimen shows the
area of attachment of the body of the uterus to the abdominal wall.
Remarks.
(1) Whatever be the nature of the elongation of the supravaginal
cervix in cases of procidentia, this case proves that it may disappear to
the extent of 4£ in. after the uterus has been replaced even when the
procidentia (and presumably the elongation of the supravaginal cervix)
have lasted for as long as three years.
The fact that this elongation comes quickly in cases of procidentia,
—as I think we have all experienced—and may disappear rapidly, as
in this case, when the procidentia is relieved, compels me to the
view that such elongations may be, and probably always are, at
first entirely due to mechanical stretching of the cervical tissues.
Whether this elongation becomes permanent upon the development
20 Robinson: Changes in Uterus as Result of Procidentia
of a new growth of tissue after a longer or shorter time I do not
know. In my case such new growth was certainly not in evidence to
any appreciable extent after a lapse of three years.
(2) Ventrifixation (for prolapse) without support of the vagina by
some means from below is insufficient for the relief of a really bad case
of prolapse.
It must be the experience of all of us to have seen many cases
similar to this one (I myself have seen a large number) in which
complete procidentia occurred within a few months of ventrifixation.
•
Report on Specimen by Dr. Braxton Hicks, Pathologist to
Westminster Hospital.
The case first came under my notice in December, 1917, when a
portion of the cervix was sent up for histological examination to the
laboratory. It proved to be a carcinoma, the cells of the* growth
varying considerably in size and shape, and tending to be arranged in
masses and columns. It had the appearance of a squamous carcinoma
of the vaginal cervix, these variations in appearance from that of typical
squamous carcinoma elsewhere being well known.
The entire uterus and adnexa came under my notice later when
removed by my colleague Dr. Drummond Robinson. When freshly
removed from the body the sound passed in., but after hardening in
formalin with its consequent shrinkage, the sound passed 4 in. only.
After making a section through the uterus, the actual cavity is found to
measure If in., and the cervical canal (i.e., internal to external os)
2J in. As can be well seen on examination of the hardened
specimen, the cervix and cervical canal are invaded extensively with
growth, which makes demarcation of uterine cavity from cervical
canal difficult to determine with accuracy, though the rough limits
are.readily seen.
The after-history of this case should be interesting, as the general
appearance of the growth under the microscope and its extent as seen
in the anatomical specimen lead me to suspect an eventual re¬
currence, in spite of the extensive and temporarily successful Wertheim
operation.
DISCUSSION.
Dr. W. S. A. Griffith : I cannot understand why some authorities deny
the existence of tensile elongation of the supravaginal cervix, the commonest
and almost invariable condition present where the cervix is found protruding
Section of Obstetrics and Gynaecology
21
from the vulva, and so easily demonstrable by measuring the length of the
uterus before and immediately after replacement It is equally true that
hyperplasia of this portion does occur in some cases, and in others neither
stretching nor hyperplasia. An essential condition for the stretching of this
very tough cervix is the resistance to the descent of the body of the uterus, the
least supported portion of the uterus; for this I can offer no explanation, other
than what was described as the “ retentive power of the abdomen ” by Matthews
Duncan, but this seems quite inadequate in so many cases where the abdominal
walls are flaccid. I have long given up hysteropexy for this condition : the
support by repair of the pelvic fascia in the anterior and posterior vaginal
walls is essential.
Dr. FAIRBAIKN : The chief interest in this specimen centres in its showing
no permanent elongation of the cervix after prolapse of many years* standing.
This should suggest that the common practice of amputating enough cervix to
bring the uterine canal to somewhere near its normal length, usually performed
as part of the operative treatment of prolapse, may often be unnecessary. If
marked elongation is present at the time of operation the cervix cannot be got
into a satisfactory position without removal of some of the hypertrophied
canal; hence, even if the elongation is temporary, amputation will be required
in those cases in which it has not disappeared by the time the operation
is done.
Dr. Amand Routh : I believe that the supravaginal elongation of the
cervix is due to traction of the prolapsed vaginal walls whilst the uterus is in
normal position. This elongation in early cases is stretching only, but it leads
to thickening in some of the chronic cases. I have found amputation of about
3 in. of the cervix with removal of some vaginal tissue, and the temporary use
of a ring pessary, usually sufficient to cure, though partial recurrences are apt
to take place.
Dr. Lapthorn Smith : Like most operators I have seen many cases of
enormous hypertrophy of the cervix. At first I used to remove all the surplus
length in excess of in., but later I found that this was not necessary, and
that if 3 in. or even 3i in. of uterus were left, a process of involution occurred,
and in a few months the small surplus was found to have been absorbed. I
attribute this to the improvement in the circulation following the operation, as
I believe that the hypertrophy is due in the first place to defective circulation.
In women who have had bad confinements, which have formed the bulk of my
cases of hypertrophy of the cervix, which in some instances has been enormous,
the process f believe has begun with a tear of the cervix and perineum, fol¬
lowed by subinvolution, retroversion, prolapse, rectocele and cystocele ; and in
these cases my invariable practice has been amputation of 3 in. or 4 in. of the
cervix, anterior and posterior colporrhaphy, making sure to bring the separated
levator ani muscles together, and then a ventrifixation. The results of these
combined operations at one sitting have been eminently satisfactory. If the
22 Robinson: Case of Labour in a Paraplegic Woman
woman is still of a child-bearing age I prefer a round ligament operation, as
with a restored perineal floor and a lightened uterus, such operations are
especially successful.
Dr. Herbert Williamson : There can be little doubt that elongation of
the supravaginal cervix may be due either to stretching or to tissue formation.
I have been in the habit of demonstrating to students the stretching of the
supravaginal cervix in cases of prolapse of the second degree, by measuring the
uterine cavity when the uterus was down, then replacing it and measuring the
cavity again ; li in. to in. difference in the two measurements is usually
found. There are on the other hand cases in which the elongation is per¬
manent and not due to stretching; there is a specimen in St. Bartholomew’s
Hospital Museum of a uterus with a supravaginal cervix measuring 3^ in. in
length. It is probable that in the early stages the elongation is entirely due
to stretching, but that in the later stages in some instances the elongation
becomes permanent. Dr. Lapthorn Smith appears to be confusing two different
conditions. The cases he describes in nulliparae are evidently cases of elongation
of the vaginal portion of the cervix—a congenital condition, and not the result
of prolapse.
A Short Communication on a Case of Labour in
a Paraplegic Woman.
By G. Drummond Robinson, M.D.
In 1897 Dr. Amand Routh read a paper before the Obstetrical
Society in which he recorded a case of labour in a woman suffering
from paraplegia. . He also gave notes on all the cases of a similar
nature, seven in number, which had been recorded in medical literature
and discussed the whole subject in a very exhaustive and able manner.
In 1909 a case of this sort came under my own care. I had
intended *to record it at the time but I thought it would be more
satisfactory to wait until I could get an opportunity of verifying the
cause of the paraplegia by a post-mortem examination. Unfortunately
whilst waiting, through inadvertence, the matter slipped my memory,
and only recently has it been again brought to my mind. The case is
as follows:—
L. D., aged 31, seven children, one miscarriage, was admitted to
Westminster Hospital, on August 21, 1909, under the care of Dr. R. G.
Hebb, with the following history : On the night of August 13 the '
Section of Obstetrics and Gynaecology
23
patient woke up with acute aching pain in the back, chest and legs.
She could not lie down but sat and dozed in a chair. To be on her feet
was the least painful position; bending forward of the head caused
great pain. This pain continued until August 19 when numbness
occurred in the legs, back and abdomen and the patient found that she
could not move her legs. At the time of admission, August 21, it was
stated that she had not passed water for three days and a distended
bladder was emptied by catheter. The bowels had not acted for some
days. There were two bed-sores, one just behind the anus, the other
over the sacrum. There was complete paralysis of the lower limbs
with loss of sensation up to the level of the umbilicus in front, and»of
the twelfth dorsal spine behind. Immediately above this level there
was a zone 1£ in. broad of diminished sensibility. There were no
reflexes in the legs or abdomen. There was no reaction to faradism
or galvanism in the legs. There was pain and tenderness in the back,
especially in the region of the tenth dorsal spine. There was a foul
vaginal discharge. Incontinence both of urine and faeces occurred soon
after admission. The urine was offensive and alkaline and contained
the Bacillus coli, a Gram-negative coccus and a Gram-positive strepto-
bacillus.
Dr. Hebb diagnosed complete transverse myelitis in the dorsal
region.
On inquiry it was found that the patient’s last menstrual period had
ceased on July 2. On October 15 the following note was made : “ Per
abdomen an elastic mass, presumably the gravid uterus, can be felt.
It extends about 2 in. above the symphysis pubis. Bimanually, the
abdominal mass is found to be the body of the uterus presenting the
characters of a pregnancy of about the third month.”
The case was then transferred to my ward.
During the following weeks the patient’s general condition was
unsatisfactory. There were many rises of temperature—up to 103° F.,
and there were two attacks of congestion of the lungs, one in September
and the other in December. The urine was offensive in spite of
repeated irrigation of the bladder. There was inflammation of the
gums. The bedsores remained unhealed.
On December 17 the patient declared that she had quickened and
from that time onwards she thought that she could feel the foetal
movements. At no time could the foetal heart be heard or the foetal
movements felt per abdomen. When the fundus uteri had reached the
level of the umbilicus it seemed to stop growing and as no sign of foetal
24 Robinson: Case of Labour in a Paraplegic Woman
life could be detected I thought that the foetus had died. However the
woman stoutly maintained that she could feel the foetal movements.
Careful measurements were taken and after a time it was ascertained
that without doubt the uterus was still increasing in size, though at a
very slow rate. (At the end of the pregnancy the distance of the fundus
uteri above the symphysis pubis was 12 in., and the whole uterus was
considerably smaller than usual.) .
• On March 20 contractions of the uterus were first noticed during
palpation. At 4.30 a.m. on April 10, 281 days from the last menstrual
period, the nurse was going to dress the bed-sores when she noticed
a , blood-stained discharge from the vagina. Well marked uterine
contractions could be felt per abdomen coming every two minutes.
At 8.10 a.m. (that is three hours and forty minutes after the first
sign of labour was noticed) a living female child, weighing 5 lb. 13£ oz.
L.O.A. was spontaneously delivered. During some of the uterine
contractions the patient experienced a “very slight niggling pain,”
but such a sensation was very occasional and otherwise the labour
was entirely painless. The placenta was expelled spontaneously at
8.35 a.m. No vaginal examinations were made. The involution of
the uterus was normal. Abundant milk wa£ secreted but it was
unsatisfactory in quality and as the child rapidly lost weight it was
weaned and put on a diet of cow’s milk on which it did excellently.
After delivery the bed-sores gradually healed.
Strong pressure was brought to bear on the patient to get her to
remain in the ward for incurables which we have in the hospital.
Unfortunately she refused and discharged herself. I kept in touch
with her for some months and then found that she had suddenly
become much worse and had been taken to an infirmary, where she died
shortly after admission. Unfortunately no post-mortem examination
was made, and I did not know of the patient’s death until some
weeks after it had occurred. The child was alive a year after its
birth.
In the above case, as in that recorded by Dr. Routh, there were
bed-sores, cystitis and congestion of the lungs together with irregular
rises of temperature. Unlike Dr. Routh’s case no long hair developed
over the anaesthetic area of the body, and the uterine contractions,
relaxations, and retraction were quite normal.
One striking feature of the case was the exceedingly slow rate of
growth of the uterus after the fifth month and its small size at the
full term. The normal gravid uterus is said to grow at the rate
Section of Obstetrics and Gynaecology
25
of 3*5 cm. (1 in. ~ 2*54 cm.) every four weeks after the fifth month.
The growth in this case was nothing like so rapid as this. In fact it
was so slow that I thought at one time the foetus was dead, especially
as neither foetal heart sounds nor movements could be detected. At the
end of pregnancy the uterus had the general appearance and size of one
only at the end of thp seventh mouth. The fundus extended to half¬
way between the umbilicus and the ensiform cartilage, and measured
12 in. from the symphysis! At the end of the seventh month of a
normal pregnancy the fundus usually measures 12 in. from the
symphysis, and at the full term a uterus that measures 15 in. is not
unusually large. This clinical feature has not been noted in any of
the other recorded cases. *
I have already mentioned that Dr. Routh gives records of seven
other cases besides his own, the latest recorded having occurred in 1874.
Since his paper was read twenty years ago no other case has been
recorded. I do not propose again to raise the many points so ably
discussed by Dr. Routh in his most interesting paper and I would refer
Fellows of the Society to the Obstetrical Society's Transactions for
1897 (vol. xxxix, pp. 191-227). It would however be of interest for me
to qupte his conclusions (p. 220)
14 The above cases and experiments seem to show that in women affected
with paraplegia, from either injury or disease in the dorsal‘region of the spinal
cord, labour may commence at the normal period of gestation, and may
progress in an approximately normal manner, but without sensation of pain.
Involution and lactation are also normal.
It is proved also from both cases and experiments thflt conception may
take place during paraplegia.
Further experiments, as well as clinical facts, are required before the
physiology of parturitipn can be known, and much will be done when it is
discovered with certainty what is the force by which the process of labour
is initiated at the end of gestation.
Meanwhile the following views seem to be fairly established :—
(1) The act of parturition is partly automatic and partly reflex, these
actions corresponding in the main to the first and second stages of labour
respectively.
(2) Direct communication with the brain is not essential to co-ordinate
uterine action, though the brain seems to have a controlling influence upon
the pains, helping to make them regular, with well defined intermissions.
(3) Direct communication between the uterus and the lumbar enlargement
of the cord, through the medium of the sympathetic ganglia between the
first and third lumbar, is probably essential to the regular and co-ordinate
contraction and retraction of the uterus, as occurs in normal parturition.
26 Robinson : Case of Labour in a Paraplegic Woman
(4) It seems also probable that the uterus is able automatically to expel its
contents as far as the relaxed part of the genital canal, even when deprived
absolutely of spinal influence, spinal reflexes being then necessarily absent.
But in the absence of reflex action the entire parturition would be irregularly,
and probably incompletely, performed.
(5) Lactation is not solely due to nervous influence, but partly to chemical
changes in the blood, affecting secondarily the mammary glands and other
tissues of the body. This chemical change in the blood is not of ovarian
origin, but is probably due to the metabolism of the pregnant uterus.”
In the discussion which followed the reading of Dr. Routh’s paper
the interest chiefly centred round the nature of the physiological
stimulus that excites the uterus to expel its contents at the full term.
Dr. Mott suggested that this “ physiological stimulus ” to labour might
be a biochemical condition of the blood of the foetus at full term. The
trend of all recent work seems to be in this direction. The importance
of “ internal secretions ” in certain physiological processes is being
more and more recognized. In the recent editions of all the principal
works on physiology the view is expressed that the physiological
stimulus to labour is the result of the action of some chemical substance
or substances produced probably in some part of the reproductive
system (ovary, placenta, foetus, &c.) and conveyed .direct to the uterine
muscle by the blood stream.
DISCUSSION.
Dr. Amand Routh : With reference to my case of parturition during
paraplegia, which .1 described in the Transactions of the Obstetrical Society
off London in 1897, fracture and displacement had occurred between the fourth
and fifth dorsal vertebrae when the patient was seven months pregnant.
Labour occurred at nearly full term without sense of pain, and with rapidly
recurring strong “pains” throughout. These cases point to a biochemical
cause both of the onset of labour and of lactation, which may each be due to
different changes in the chemical constitution of the chorionic ferments or the
resulting syncytiolysins. The onset of labour is probably due to the influence
of* the altered chemical contents of the blood stream upon both the lumbar
enlargement of the spinal cord and the uterine muscle.
Dr. DRUMMOND Robinson (in reply) : So far as I am aware no experimental
work has been done on the “ physiological stimulus ” which is the cause of
labour, but Professor Starling and Miss Lane-Claypon have made some
interesting observations on the function of lactation. These observers found
that the injection of an extract made from foetal rabbits into a virgin rabbit
produced changes in the mammary glands similar to those which result from
Section of Obstetrics and Gynaecology
27
pregnancy. They conclude that in rabbits the function of lactation is the
result of the Stimulation of some chemical substance or substances contained in
the foetus. Foil has confirmed these observations. I am interested in learning
that in France a number of confinements have taken place normally and
painlessly under spinal anaesthesia. I have myself performed a Caesarean
section under spinal anaesthesia, and in that case the contraction and
retraction of the uterus were quite normal.
Two Cases of Puerperal Anuria in which the Renal Capsule
was incised and Portions of the Kidney Substance
removed for Examination.
By Clifford White, F.R.C.S.
The sections of the kidney which I am showing to-night were both
removed by operation from patients suffering from partial anuria
during the puerperium. As their appearance is unusual and may have
a bearing on the causation of the suppression of urine, I shall be
interested to know if members of the Section have met with similar
conditions of the kidney: The clinical histories of the cases are briefly
as follows:—
L. B. The patient was a primigravida admitted to Queen Charlotte’s
Hospital on April 7,1918, comatose from eclampsia at the twenty-fourth
week of pregnancy. She was distinctly cyanosed and faintly jaundiced.
The blood-pressure was 160 mm., there was slight oedema of the ankles
and free fluid was present in the peritoneal cavity. Catheterization
yielded but an ounce of dark bloody urine. Fits recurred at short
intervals. She was delivered of a dead child by abdominal Caesarean
section and when the kidney was directly palpated at the end of the
operation, it was found to be very hard. As recorded in detail in the
British Medical Journal of July 6, 1918, it has been my custom to open
the fibrous capsule of the kidney when performing Caesarean section
on eclamptic patients who are passing very little water if, on direct
palpation, the tension of the kidney is greater than usual. This has
been done on the supposition that the increased tension inside the
fibrous capsule of the kidney is a factor in causation of a diminished
flow of urine by producing pressure on the collecting tubules. However,
owing to the early period of the pregnancy in this patient, the Caesarean
28 White: Two Cases of Puerperal Anuria
incision was too low to permit of the kidney being reached without
extending the incision, and this, was considered unadvisable owing to
the critical condition of the patient. After the operation no further fits
occurred and consciousness was regained in two hours. From April 8
to April 17, although large quantities of fluid were administered, there
was almost complete suppression of urine. There were, however, none
of the usual symptoms of uraemia; the patient was conscious although
inclined to be drowsy, but vomiting, convulsions, headache, twitchings
and delirium were absent. The tongue was clean, the breath not
offensive and the optic disks normal. On April 17 her general condition
was much worse and the oedema rapidly increasing, so I incised the
right loin and exposed the kidney, which was dark purple in colour and
hard. On incising the fibrous capsule of the kidney, the renal substance
bulged slightly through the cut: a minute piece of the kidney was
removed for microscopic examination. In the sixteen hours before the
operation she had passed only 2 oz. of urine, in the next eight hours
she passed 6 oz. per urethram besides a quantity that escaped through
the drain in the loin. The next day (April 18) 38 oz. wefe passed, on
the 19th, 37 oz., and on the 20th, 50 oz. Casts were absent till the day
after the operation, when blood and leucocytic casts were passed in
quantity. The patient rapidly convalesced and was discharged in good
condition.
The other case is that of S. 0., who was admitted to University
College Hospital under Dr. G. F. Blacker, on March 12, 1912, being
then at the sixth month of her second pregnancy. She had had severe
albuminuria for several week's and although labour was induced on
April 1, the albuminuria did not improve and oedema became intense
and universal. In spite of treatment never more than 9i oz. of urine
were passed in each twenty-four hours and on April 17 four fits
occurred and the patient seemed to be dying. On the 18th nephrotomy
was performed. In this case the kidney did not bulge much through
the capsule but she started passing 20 oz. of urine a day and rapidly
recovered.
The sections from both cases are very similar. In both there is
well-marked dilatation of the tubules; the extent of this dilatation can
be seen in the tracings made from the actual sections sho^vn to-night
compared with a tracing made from a section of a normal kidney
(see fig., p. 29). The cells lining the tubules are more or less
degenerate and some tubules are filled with granular material. The
glomerular cells show little change but the clear space round them is
Section of Obstetrics and Qfiiwcologij *2$
greater than in a ii-oi'iim) kidney. Tbefft is small-cell infiltration, of fcbe
interstitial tissne arixi the eetmecfcive tisgnii is, iti places, increased in
amount and is itedeiaiatons. No thrombosis of ‘vessels is present-
The question of importance is. what is the causation of the dtnont-
tioq uv the tjUantify oi arore exereted in these cases Anuri;-: In the
puerperi.nm is a well known although intco.imuou event and, following
the publication uf Bradford s and Liawrenue's post-mortem findings in.
«
WMm
* f '' / - 0
Normal
To show ofucct,nn> of nonriul Mdrvoy r\omi>an*d wifcb Bcctfons from
fpaiimiWL. B, a6<l £. 0. ‘^b0ii}Jvai ! ijiiion is maJ« lip from ^r^citigs. from
s Miiecotyopit *£csiib\i9y *?tx ^curate cdinpanaon of tbc sizcf? of the
l&98>’ it has been usual to ascribe it to thrombosis of the intertubular
vessels-vvf,ii necrosis of the renal cortex. Holies ton 3 collected eleven fatal,
cases recorded with post-mortem findings, Tti these cases the clinical
Joutm. Pathv ; 0:- ras-goi,
LmUxU Oe'MWr i»13, v m 3 .
30
White: Two Cases of Puerperal Anuria
symptoms are similar to those present in the case of L. B., i.e., similar
to the symptoms which occur when both ureters are blocked by calculi,
and to which the name “ latent anuria ” is given. As far as I am aware
the “ thrombotic kidney ” theory rests on post-mortem findings, as the
condition of the kidney during life has not been investigated, nor have
minute portions removed by operation been submitted to microscopic
examination.
The possibility that inflammatory swelling producing increased
tension within the fibrous capsule of the kidney may be a factor in
causing a diminution in the flow of urine is supported by clinical
observation. Direct palpation of the kidneys during Caesarean section
for eclampsia has shown them to be harder than normal in some half
dozen of my patients in whom the urinary output was distinctly
diminished. Whereas it was interesting to find the kidney compara¬
tively soft on palpation in two recent cases in which large quantities of
urine were being passed. In both these cases the patients were pro¬
foundly toxaemic, but plenty of urine (in one case 12 oz.) was obtained
by * catheterization immediately before operation, and free diuresis
continued after delivery by simple Caesarean section. The immediate
passage of leucocytic casts after incieion of the capsule, although
they had been absent previously (in the case of L. B.), is also
suggestive.
The sections shown to-night seem to support the view that the
deficient excretion of urine is due to obstruction to the flow from the
renal tubules; thus the tubules become overdistended and dilate.
When the pressure of urine in the tubules becomes sufficiently
high, secretion ceases or re-absorption commences. Experimentally,
when the ureters are ligatured in animals, the pressure of urine in
the manometer rises to 60 mm. Hg. and then stops, thus showing
that a comparatively low pressure is enough to prevent further
excretion.
I suggest that the thrombosis and cortical necrosis found post¬
mortem in these cases are terminal phenomena, and not the actual cause
of the suppression during life. The immediate improvement following
the relief of tension inside the fibrous capsule of the kidney suggests
that the increased tension is the immediate cause of the diminished
urinary output, and, if so, the condition instead of being necessarily
fatal, is amenable to surgical treatment.
The small number of the cases that I have so far investigated
makes it impossible to draw any definite conclusions, but I bring
Section of Obstetrics and Gynaecology
31
forward these observations in the hope that members of the Section
will be able to confirm or contradict them a result of further
experience.
DISCUSSION.
Dr. Fairbairn : As far as I can remember the cases described by Law¬
rence and Bradford and by Rolleston are not really on all fours with these
eclamptic anurias of Mr. Clifford White’s two cases. My impression is that
the characteristic clinical features of these cases consisted in the anuria being
unaccompanied by fits or by uraemic symptoms ; indeed, until'near their fatal
termination there were very few symptoms of any kind. The effect of the
anuria was compared to that produced by ligature of the ureters in animals or
double calculous anuria in the human being. The post-mortem changes were
those of an extreme necrosis of* the renal cortex, while the pyramids remained
unaffected. Lawrence and Bradford ascribed this to an obliterative endarteritis,
but surely the primary cause is now recognized as a toxic one which picks out
the cortical area. How could increased tension within the capsule explain the
very selective character of the necrosis in these cases ? I have seen two cases
of this kind, and the striking feature in both was the marked differentiation of
the necrosed cortex from the unaffected pyramids.
Mr. Clifford White (in reply) : Regarding Dr. Fairbairn’s criticism that
one of the two cases was clinically unlike the typical case with necrosis of the
cortex found post-mortem, in that uraemic manifestations were present, I would
point out that Rolleston states that “ analysis of the eleven collected cases does
not justify the statement sometimes made that uraemia is constantly and entirely
absent.” I suggest that further knowledge may indicate that the vascular
changes found post-mortem are terminal phenomena, and not the primary
cause of the symptoms that come on some ten days before death. If the cause
be toxaemia, increased diuresis, however obtained, will aid in eliminating the
toxin.
Section of ©batetnes anD (5\>naecolo0\>.
President—Mr. J. D. Malcolm, F.R.C.S.Ed.
DISCUSSION ON RECONSTRUCTION IN THE
TEACHING OF OBSTETRICS AND GYNECOLOGY
TO MEDICAL STUDENTS . 1
A General Survey of the Subjects to be taught and of the
Methods of teaching them.
By W. S. A. Griffith, M.D.
The importance of a thorough training in obstetrics for students
of medicine, who with few exceptions will enter general practice, is
generally accepted : my duty this evening is to introduce a discussion
on this subject in order that we who have the great responsibility of
teaching may consider our aims and methods, so to ensure that our
training shall be as perfect as possible and our students made capable
of rendering the great service to the nation that the efficient care of
mother and infant can afford.
We who are teachers can help each other by comparing our
methods; those who have profited more or less by our teaching can
assist us even rhore by pointing out from their own experience of
practice where our teaching methods have been deficient. We shall
welcome candid criticism from any source, directed not to schools or
individuals but to the methods which are more or less common to all.
Gynaecology is so intimately bound up with obstetrics that any
attempt to teach these as separate subjects is futile, though there is
much in each subject to be taught independently. . It appears to me
that our aims should be to give the student a good general knowledge
1 At a meeting of the Section, held February 6, 1919.
F— 4
34 Griffith: Teaching of Obstetrics and Gynaecology
of the special diseases of women in order that the practitioner may be
able to deal adequately with the simpler cases, and to know when he
ought to obtain more skilled assistance. Preventive gynaecology necessi¬
tates very thorough teaching : the prevention of infection, the prevention
of the extension of infection, and the prevention and the early relief
of various complications of pregnancy, labour and the puerperium, such
as lacerations and imperfect involution. While advanced and operative
work is for the post-graduate who has the time and opportunity for
further study, our aim should be to stimulate every student to take a
keen interest and pride in the advancement made and to be made in
our knowledge of these subjects, and so far as in him lies to do
something towards the elucidation of the many problems which await
solution.
I propose to divide my subject under the following heads :—
(1) Subjects necessary to be taught.
(II) Methods of teaching.
(I) Subjects to be Taught.
The Obstetric Anatomy of the Pelvis. —This must be taught by the
obstetrician.
The anatomy of the pelvic organs, not necessarily in minute detail,
but the gross anatomy must be taught with the greatest accuracy.
The Physiology of the Generative Organs. —Menstruation, puberty,
and the climacteric : This subject, so fundamental to gynaecology, is
generally neglected by the teachers of physiology, and must be taught
by the obstetrician whose experience will enable him to give the student
a view of its far-reaching importance in health and disease mental and
physical.
Pregnancy. —(1) The general structural changes in all parts of the
body affected by pregnancy as well as the special Organs and their
functions, by which the symptoms and physical signs are recognizable
in diagnosis.
(2) The general development of the ovum into the mature foetus,
placenta and other parts. (Minute details of development are
unnecessary in this course.)
(3) Morning sickness.
(4) Duration of pregnancy and the prediction of the probable day
of confinement.
(5) The various positions of the foetus and the means for recognizing
them.
Section of Obstetrics and Gynaecology 35
Labour. —(1) The general process and phenomena.
(2) The doctor’s and nurse’s duties in preparation for and during
labour.
(3) Anaesthetics and substitutes.
(4) Drugs—ergot and pituitrin.
The Puerperium. — The process in general and phenomena.
Lactation; breast-feeding; care of the breasts; doctors’ and nurses’
duties: doctors’ and nurses’ fees.
Pathology. —(1) The pathology of pregnancy, intra- and extra-
uterine; with the diagnosis and treatment.
(2) The pathology of labour: The treatment of many obstetrical
complications should be taught, not only by methods applicable when
skilled assistance, trained nurses and the most approved instruments
are available, but in the circumstances in which the attendant has to
rely on himself and simpler resources.
(3) The pathology of the puerperium.
(4) The pathology of the young infant.
(5) Artificial feeding of the infant.
(II) Methods op Teaching.
We have now to consider how these various matters can be taught
in the most advantageous way. In the discussion of this, the most
important part of our subject, I suggest that we consider it without
being tied to old customs and methods, rather to aim at the best that
experience affords us.
The means at our disposal comprise demonstration-lectures, labora¬
tory museum and post-mortem work, clinical work and teaching in
wards and out-patient departments.
It appears to be obvious that all the subjects which involve diagnosis
and treatment should be taught during the time that the student is
engaged in his clinical work in obstetrics and gynaecology, and that
instruction in obstetric anatomy, menstruation, normal pregnancy and
labour should immediately precede this course. Also, that as the
practice of obstetrics and gynaecology is the practice of medicine and
surgery applied to special organs and conditions, the student should
have completed his course in those subjects, including pathology with
bacteriology, before taking the special course.
I think we may take for granted that the long, wearisome courses of
lectures which were customary in the medical schools are not the best
method of teaching any branch of medicine and surgery to students.
36 Griffith : Teaching of Obstetrics and Gynaecology
I am equally sure that good lectures, well illustrated by personal experi¬
ence, are of great value to advanced students who have already been
grounded in the principles of the subject and have begun to obtain
some experience of their own.
I am equally sure of the value of demonstration-lectures, well
illustrated and with plenty of viva voce questioning, which helps to
maintain the close attention of the students, and enables the lecturer to
discover if they have learned anything from his previous lectures. It
is well to select men from the back rows for viva voce, men whose
modesty or fear of the process lead them to take a back seat. One
great advantage of lectures over the admirable text-books of the present
time consists in the opportunities which the lecturer has for empha¬
sizing and repeating points of fundamental importance and for illus¬
trating them from his own experiences.
The subjects which can be well taught in this way are the obstetric
anatomy of the pelvis and its contents, menstruation, the anatomy
of pregnancy, of labour, of the puerperium, and the mechanism of
labour, which should be taught with a foetus, not with the foetal skull
only. I do not know of any doll which is Fufficiently* flexible.
The remaining subjects, comprising the great bulk of the whole,
should be taught by demonstration-lectures accompanying clinical work
in the wards and out-patient rooms.
With regard -to gynaecology, the large out-patient departments of
the hospitals, if properly organized for teaching, afford most valuable
means of instruction, the students attending for three months and
having charge of the cases allotted to them, preparing the notes and
examining the patients individually with the physician. The chief
difficulty I had personally during the thirty years that I assisted or
was in charge of the out-patient department of St. Bartholomew’s, was
from the large number of patients who attended, and it w r as necessary
for' one of my clinical assistants to supervise the case-taking by the
students and to prepare a list of cases so that I could select those I
required for teaching. If the case-taking is done systematically,
according to a scheme of which each student has a copy, and accurately
(a very difficult thing for the beginner, the patient misunderstanding
the question and the student her answer), he will gradually acquire the
power of forming correct opinions about the nature of the ailment from
the history ajone; a very valuable asset to the young practitioner,
especially in gynaecological cases, where the patient might hesitate to
allow him to make a proper examination.
Section of Obstetrics and Gynaecology
37
This personal responsibility for forming correct opinions for
diagnosis, prognosis and treatment cannot be inculcated too soon; it
is an unpleasant experience to have to begin to acquire it in practice.
The amount of time that this kind of instruction takes is considerable,
and much patience is needed, but the value not only to the individual
student but to the whole class is well worth it, and it gives rise to
much good humoured criticism not only on the part of the other
members of the class, but often from the patient herself.
Out-patient obstetric work comprises two distinct departments :—
(1) The attendance by students on patients in their own
homes.
(2) The attendance of pregnant women in the out-patient
department of the hospital.
(1) The value of the former to the student, if he has had the neces¬
sary instruction as well as experience in the proper management of
cases in the labour and lying-in wards, is very great. The responsi¬
bility he meets with compels him to find out his deficiencies on the
one hand, and gives him confidence and self-reliance on the other. The
#
results obtained bear witness to the care taken by students of their
patients and to the great freedom from the calamities of obstetric
practice. This attendance of patients in their own homes is also of
great value in bringing the student into direct touch with the domestic
difficulties and social relations of the poor, and in developing that
sympathetic feeling for their troubles and privations so characteristic
of our profession, and which is so often accompanied by practical advice
and unostentatious assistance.
(2) The value of the training to the student attending this department
is also great if he is held to be personally responsible for the history
and examination of the patients. He learns to diagnose pregnancy
when advanced, not usually a very difficult procedure, but one in which
most unexpected mistakes are not very uncommon even in the practice
of men of experience. He learns to diagnose the position of the foetus
and the presentation by abdominal and vaginal examination. He learns
to measure the pelvis; if he also does this in the post-mortem room
where he can compare his results with the actual internal measure¬
ments, he will be in a better position to realize the uncertainties and
errors of the method and its great value in certain circumstances.
He will occasionally meet with breech and other abnormal presenta¬
tions, and will learn the easy and advantageous operation of external
version. He will occasionally meet with other complications and learn
38 Griffith : Teaching of Obstetrics and Gynecology
how to recognize and deal with them. He will examine the breasts,
and learn what can be done to relieve conditions which may interfere
with lactation. He will examine the urine, and in doubtful cases
obtain a catheter specimen. He will examine the vulvo-vagina for
evidence of infection, and learn to take the necessary steps for thorough
disinfection and treatment. He may meet with cases of chorea or
early mental trouble, but for the treatment of mental cases he must
visit, an asylum and learn the principles of treatment which, if properly
carried out, are followed by such a high proportion of recoveries.
Above all, he will learn the value of the systematic examination of all
women advanced in pregnancy, and the advantage of being sure that
all important details are normal before confinement, and be forewarned
of difficulties and complications..
Gynecology .—The chief difficulty in ward teaching at the present
time is due to the abundance of surgical material which interests and
occupies the time of the gynaecologist to the exclusion of cases of great
importance for teaching. Some experience of the major operations,
though advantageous, is of small value to the student; he learns too
little of the minor gynaecology which will come to him in general
practice, and he is induced to take little interest in cases not needing
operative treatment. What for instance does the student learn about
the treatment of the ordinary common cases of dysmenorrhoea, of the
methods for the relief of cases of inoperable carcinoma, which he will
have to attend to the end ?
When we consider the clinical means for teaching obstetrics, that
most important branch of practice for every general practitioner whose
ignorance or want of care may lead to great suffering and long illness,
and may even involve the life of his patients and their babies, and,
indeed, that of his own wife and child; we find ourselves face to face
with great difficulties. Owing to the better systematizing of our small
resources we are somewhat better off than in 1906, when I had the
opportunity in Toronto of discussing this subject in my address
at the meeting of the British Medical Association. How can any
branch of medicine and surgery be properly taught in an out-patient
department only ? and the department scattered over an area of say
a square mile, with no real and effective supervision, and without the
aid of competent nursing. Hospital authorities have provided a few
beds for special cases, but though these are of immense value what are
they but a pittance?
I am not of the opinion that the value of a hospital for teaching
Section of Obstetrics and Gynaecology
39
purposes is necessarily improved in proportion to the large number of
its beds; this depends on the number being adequate and on the
ability of those in charge of it to make the best use of them. At Queen
Charlotte’s, where I worked regularly for twenty years, we had admir¬
able opportunities for teaching. We had the great advantage of
teaching- at the bedside and in the labour wards mixed classes of
students and post-graduates, together with midwives and monthly
nurses, and it would be difficult to determine who. gained most from
the mixed classes, the students who soon discovered how little they
knew of the nurses’ duties, or the nurses who gradually began to realize
their own ignorance and the difference between their superficial train¬
ing and that of the doctors. This combined training, if general, would
in my opinion, also do much to place the relations of doctor and
midwife on the friendly footing of mutual confidence and help that
should exist for the benefit of the poorer women and their infants.
It is in the organization of maternity wards or hospitals in our
great teaching centres, comparable to those devoted to medicine and
surgery, that we must look for our next great improvement in the
teaching of obstetrics, and without these we are severely handicapped
in our endeavours. A three months’ combined course in obstetrics and
gynaecology, the whole time being given up to the subjects, would
probably prove to be sufficient.
May we invite those present who have suffered at our hands during
their student time to tell us what sort of men we have been turning out
from the schools as regards their knowledge of these subjects ? Are
they generally competent, self-reliant, ready to take reasonable respon¬
sibility, or are they incompetent and timid, or worse still, reckless,
rough and inconsiderate, and their patients left with unrepaired injuries
to suffer for life or to crowd the gynaecological departments of the
hospitals ?
40 Fairbairn : Teaching of Obstetrics and Gynaecology
The Teaching of Obstetrics and Gynaecology from the
Standpoint of Preventive Medicine.
By John S. Fairbairn, M.B.
I have chosen this aspect of the reconstruction of our teaching
methods, because if we look at the trend of medical practice with a view
to meeting its future developments, the most definite movement in
medicine is clearly that towards its preventive side. It has already in¬
volved the introduction of new medical services, has thrown many addi¬
tional statutory obligations on the general practitioner, and has increased
and will continue to increase the proportion of whole or part time ser¬
vice demanded from the profession by the State and public authorities.
The proposed Ministry of Health and the talk of a State medical ser¬
vice are further indications of how this movement dominates the situa¬
tion. The gradual shifting of medical practice from a service almost
entirely to the individual towards a service to the community must,
therefore, be kept prominently in our minds in considering how our
students can best be fitted for the part they will have to play when
they are practitioners of medicine.
Another reason influencing my choice of subject is that I recently
delivered myself of a short paper 1 urging the importance of developing
the preventive bent in our students, and since it was written the case
for reform in this direction has been greatly strengthened by the pub¬
lication of the Memorandum on Medical Education in England by the
chief medical officer to the Board of Education, Sir George Newman.
My purpose this evening is to develop the position I took up in the
paper just referred to with the help of the suggestive criticisms of Sir
George Newman’s memorandum, to which I will show my indebted¬
ness by constant reference. 2
I cannot do better than begin by selecting two passages from this
memorandum in support of my argument and as a text for my remarks.
1 “Clinical Teaching in Midwifery and Diseases of Women.” Read at the Inquiry on the
Training of the Student of Medicine under the auspices of the Edinburgh Pathological Club,
June, 1918. reported in Edin. Med . Joum ., 1918, n.s. xxi, p. 286.
* The figures in brackets at the end of quotations from the Memorandum are those of tho
numbered paragraph from which the passage is taken.
Section of Obstetrics and Gynaecology
41
Sir George Newman's chief criticism on the teaching of obstetrics and
gynaecology is: “ Above all, the student is not being taught midwifery
from the standpoint of preventive medicine. It is not sufficient to
require mere attendance on twenty cases of childbirth, to be got through
somehow. There are direct and serious responsibilities resting on
medical practice during the ante-natal stage, at the confinement and
post-natal. The maternal accidents of confinement, the gynaecological
conditions following unskilful obstetrics and the infant mortality inci¬
dental to childbirth must be prevented. The need is insistent and
widely recognized " [117].
In speaking of the teaching of preventive medicine, he says : “ But
much more important will be the revitalization of the whole subject of
Medicine by the experimental, the scientific and the preventive spirit.
For Preventive Medicine is not a subject which can be taught ad hoc
or in a watertight compartment. Its purpose and its spirit should
pervade the entire curriculum and system of Medicine—the Practice
of Physic, Surgery, Obstetrics, Psychiatry, Pediatrics and the other
specialities, for they all need the inspiration of the true preventive
method, yielding a deeper and a wider consideration of each
patient" [144].
Those words of criticism will be accepted by all as justified—our
teaching has hitherto not been sufficiently “ from the standpoint of
preventive medicine." Before discussing the means by which “ the
revitalization of our teaching with the spirit and purpose of Preventive
Medicine " is to be effected, I would like first to point out why we
teachers of midwifery and gynaecology have special opportunities and
therefore special responsibilities in this regard.
(1) The student comes to us trained in clinical medicine and surgery,
having completed his general professional work, so that we have to deal
not with the raw material but the nearly finished article, and are, there¬
fore, responsible for his training at the most favourable moment for
developing the preventive bent of mind. Early in his career it is
disease in a readily appreciated and generally in a well-developed form
that impresses the student—the failing heart with murmurs, thrills and
dropsy, or the lump that can be seen and felt and perhaps handled after
its removal by operation. When his education has proceeded beyond
this stage (“ the student who has an eye only to gross forms of disease
has not been properly educated " [134] ) the, wider outlook is more
readily developed and he is now in a position to appreciate the preven¬
tion of disease and the detection of its beginnings.
42 Fairbairn: Teaching of Obstetrics and Gynaecology
(2) A fully equipped maternity and gynaecological department can
give a practical demonstration of prevention applied to a section
of the community as cannot be equalled elsewhere in the hospital.
(3) His attendance on his extern cases affords an opportunity,
to which I shall refer more fully later, of arousing his interest in the
way his patients live and have their being, thus helping to meet
another criticism of Sir George Newman’s, that the student is not
sufficiently taught to associate his clinical medicine with the social life
and conditions of his patient [119].
(4) Midwifery is concerned with such questions as the birth-rate,
the survival of the race and the rearing of a healthy stock ; the start of
life is the time at which all measures of preventive medicine must
originate.
For these reasons, then, I urge that it is especially incumbent on
us teachers of obstetrics and gynaecology to carry on the training of our
students in this preventive atmosphere. How is it to be effected ?
To begin with, midwifery and the diseases of women must be
considered as two branches of one subject and studied clinically at
the same time and under the same teachers. The old casual method
of allowing the student to put in his maternity cases at a time
dictated solely by his own inclinations and often independently of his
gynaecological clerking has not entirely disappeared. I urged this
conjoint clinical teaching some years ago, 1 and in the paper read at
Edinburgh I advocated the systematic lectures as well as the clinical
instruction being treated as one subject. Sir George Newman makes a
point of the teaching of the two subjects of obstetrics and gynaecology
being taken together [115]. In this way the study of the normal and
abnormal processes of reproduction will go hand in hand with the
diseases of the organs concerned in reproduction, so that cause and
effect will be considered together—labour and abortion in the production
of pelvic disease and pelvic disease in the production of abortion and
sterility. This simultaneous soaking-in of the two divisions of the one
subject is essential if the preventive aspect is to be emphasized. In the
one the student is taught how to avoid the injuries and infections
of childbed, and‘in the other is shown their consequences, immediate
and remote.
I take it there will be no difference of opinion on the necessity of
treating obstetrics and gynaecology as one subject and I will proceed
1 Brit. Med. Journ ., 1912, ii, p. 100G.
T
Section of Obstetrics and Gynaecology 43
to discuss what the medical school must provide for the adequate
training of its students. It will be best considered under the following
heads:—
(1) The complete maternity centre.
(2) The department for diseases of women.
(3) The staff for working the centre.
(1) The maternity centre will require both out- and in-patient
accommodation for the pregnant woman, the woman in labour, and
the mother and nursling. In many hospitals this will involve an
increased provision of beds for maternity work, say five or six beds for
pregnant women, a maternity ward sufficient to allow each student
five or six cases indoors before attending cases in the outdoor district,
and three or four observation beds and cots for mothers and infants.
As this provision for teaching is absolutely necessary, it is useless for
any of us to accept a non possumus attitude from our medical colleagues
or hospital committees. The accommodation must be provided if the
medical school is to train the practitioners of the future, and if it
cannot be done by any school, then that school must go out of the
business. A self-contained department within the hospital, or under its
control, is clearly to be preferred, and will give the student a much
better view of the work as a whole. It lies with us to press this on
our colleagues and committees, but in the event of failure to obtain
the best, arrangements must be made with lying-in hospitals, Poor
Law infirmaries, maternity centres and infant welfare clinics in the
neighbourhood, and the work of the student carefully organized so that
he obtains a proper perspective of the scheme as a whole.
(2) Little need be said of the department for diseases of women, as
it is part of the establishment of every hospital with a niedical school.
Provision must be made for the reception of cases of puerperal infection
in all stages, and for cases of gonorrhoea in the earlier stages, as
they are often withdrawn from the student’s range of vision by
being relegated to a special venereal disease clinic, thus spoiling the
completeness of the preventive view.
(3) A full staff of workers is the necessary complement to the addi¬
tional accommodation, and the student should be made to feel that for
the time being he is one of them, though but a learner, and to recognize
the place and duty of each member of the team. The staff will consist
of (a) medical—the visiting and resident medical officers, with their
understudies, the students ; (6) nurses and midwives for indoor and
outdoor patients; (c) almoners and health visitors for visiting the
44 Fairbairn : Teaching oj Obstetrics and Gynaecology
patients in their homes, for staffing the social and educative organiza- •
tions for the mothers, and for forming the connecting link with outside
agencies for the assistance of patients.
I now come to what I feel is the most difficult part of my task, and
that is how to describe the atmosphere in which the student should be
drained in the practice of midwifery and diseases of women; and I have
decided to risk the charge of being too commonplace and follow the
student through his term of office, the length of which I will assume
for the moment to be three months as at present.
In the clinic for pregnant women the student is taught not merely
to look for the very beginnings of disease and for warnings that may
spell danger later, but to consider the individual character, mode of life
and home conditions of each patient as factors in her case. This one is
a young and ignorant mother in her first pregnancy, perhaps unmarried
and without prospect of making proper provision for her confinement or
the care of her infant afterwards ; the next is the overwrought mother
of a large family ; another has to go out to work if she is to obtain
proper nourishment for herself during her pregnancy. The student
finds that there are other considerations besides the purely medical
aspect of the case; that it is important to know if the patient is a good
mother who has successfully reared a large family, or is a shiftless
creature who is satisfied with having buried more children than she
has reared, and that these and other matters are of moment in deciding
how the pregnancy is to be managed and what is to be done for the
mother. The almoner or senior health visitor is constantly being called
on for information or to receive instructions, and the student readily
appreciates her place in the scheme, for she plays in this social and
health work the same part the ward sister does in nursing.
In the maternity ward, the student having already learnt the routine
of surgical cleanliness in the operating theatre, finds no difficulty in
applying it to the woman in labour. Throughout the month spent
in this ward the preventive side of the work is easily kept in view.
All preventable conditions which occur are discussed as to why they
were not foreseen and what could have been done—eclampsia, macerated
foetus, or some unexpected difficulty in labour. All failures as well as
successes in ante-natal management should be emphasized, especially
failures to breast-feed, retracted and sore nipples and such points which
are not likely to attract the student’s attention unless specially drawn
to them. His interest is easily stimulated in breast-feeding as an
Section of Obstetrics and Gynaecology
45
important part of the prevention of infant mortality and is one of the
matters on which pupil midwives, nurses and medical students can all
be taught together. I generally have a few pupil midwives who attend
the clinical instruction in the lying-in ward with the students and find
it advantageous to both; when occasion offers, the duties of the midwife
are discussed, and her relation to the medical practitioner, so that both
pupil midwife and medical student may learn their respective spheres
in the health service of the community.
Having learnt the routine management of pregnancy, labour, and
lying-in under hospital conditions, the student then attends the rest of
his cases on the district, where he has to adapt methods acquired under
ideal conditions with every convenience to' his hand to conditions quite
the reverse. This in itself is a great education, but we teachers must
try to make more of it as the unique opportunity the curriculum
affords for the student to study patients in their homes, to see how
they live and what is needed to improve their health and diminish
infantile sickness and mortality. It is a point in which to my mind
Sir George Newman has not recognized the educative possibilities.
He speaks of the way the young practitioner goes out into the
world almost entirely ignorant of the “ setting ” of his professional
studies, of the relationship they bear to human society and the great
social problems which he will soon discover to be pressing around him
[119], but does not suggest the district practice as a help in gaining the
required experience. The student should be associated in the work of
the social side—obtain reports from it as to his patients, and be
encouraged to make a report to it on ceasing attendance. If in¬
structed on the proper points to observe he might give much valuable
information as to the hygiene of the home, the woman’s capacity as a
mother, whether she followed her instructions as to the feeding and care
of the baby, and possibly be able to offer suggestions as to special watch¬
ing of the patient afterwards. In this way he will obtain a wider idea
of how the health of these women may be cared for than any indoor
hospital work will give, and he will also appreciate the co-operation of
other workers.
I now come to that part in which the teacher of obstetrics in the
past has especially been found wanting, and that is in regard to instruc¬
tion about the new-born infant. So little was done that the student
grown into a practitioner of medicine was quite incapable of taking his
rightful place as the adviser of the mother on the health and upbringing
of her babies. He attended the mother at her labour, handed the
46 Fairbairn: Teaching of Obstetrics and Gynaecology
infant “ mewling and puking ” into the nurse’s arms, and from that
moment abdicated his position to the monthly nurse and her successor,
the children’s nurse, save when the infant’s ailments had developed
to so grave a degree as to alarm the mother and make her think it was
beyond the capabilities of even her most capable nurse. Hence the
common view that the doctor is little use for what are thought to be the
minor' disorders of infancy, and yet unless the infant is under constant
observation prevention has little opportunity. Perhaps the most needed
reform in our obstetric teaching is that a greater effort must be made
to interest the student in the study of the baby, and to keep up the
study long after the infant has passed from our care. This leads up to
the very important question which must create considerable discussion
as to where the dividing line between obstetrics and pediatrics is to be
drawn. The baby—the product of reproduction—must be a charge of
the obstetrician for the first few weeks, but once mother and infant pass
into the baby clinic the question is more difficult. At St. Thomas’s the
clinics for infants up to twelve months have been supervised by the
Obstetric Department, but that was because they evolved out of that
department. The extension clinics for children up to school clinic age
are supervised by the Department for the Diseases of Children. Though
this is but an evolutionary phase there is something to be said for
mother and nursling remaining under the Obstetric Department and the
weanling and older children going to the Children’s Department. The
mothers who were patients of the obstetric side during pregnancy,
labour and lying-in are known and understood and more readily
influenced by its officers; difficulties in breast-feeding and the over¬
coming of them are frequent problems in the maternity ward and
naturally a continuance of the same interest and supervision is
advantageous. However, the plan we have in contemplation is prob¬
ably the best compromise, and that is the appointment of a special
officer for the child-welfare clinics who will begin by taking part in
the teaching on the infant in the maternity ward, where he will become
known to the mothers and learn to know them, and thus preserve
continuity from the maternity clinics to the baby clinics.
It is the personal touch between mothers and medical officers and
other hospital workers which is essential to success in gaining the mothers’
confidence and educating them in the bringing up of their families,
and hence unless some liaison officer, such as I have mentioned, is
appointed, the work will suffer by the mothers coming under fresh and
unknown supervision. But some such arrangement is necessary because
Section of Obstetrics and Gynaecology
47
it is clearly impossible for the obstetric officers to undertake the great
additional service which out- and in-patient infant welfare involves, to
say nothing of what it will grow to. The beds for mothers and nurslings
need be but few—three or four will suffice, unless the department is
very large—and into them will be admitted cases of difficult breast¬
feeding and such like : they are as necessary for the student’s education
as for the mother’s.
Whether the obstetric side resigns the nursing mother early or late,
there is no doubt the student should follow the mother and child through
the clinics so as not to lose the practical object lesson in prevention which
a complete survey of the scheme gives him. The curse of the exami¬
nation system is at present our great difficulty : the examination lags
ages behind practice requirements and loudly calls for reform—root
and branch. It has become our master instead of our servant, and
the sooner we teachers put it into its place the better for our teaching.
However, that is another story, and all I would point out now is that
the student’s time is so far occupied with work that has a distinct
examination value that he cannot spare the time for work that has
only a practice value, and therefore little more than casual attendance at
the welfare clinics can be expected, except perhaps by a few of the
more far-seeing or specially interested students. What I would urge
is that every student should have a six months’ training in obstetrics,
gynaecology and pediatrics. The first half of this term would be as
sketched, and would be followed by three months in the various
children’s clinics. I am not going beyond my subject, because the
reform for which I am agitating is to give the student a complete
view of a preventive scheme while training him in midwifery and
diseases of women, and, to widen his horizon, he should follow the
baby, whose intra-uterine development and birth he has watched,
through its early extra-uterine development—certainly so long as it is
directly dependent on its mother for its sustenance. By breaking off
his study of mother and infant at the end of a fortnight’s lying-in
time is to lose what might be made the greatest lesson in his medical
course of the care of the national health and physique.
The last point to which I would draw attention is the “ psycho¬
logical aspect of preventive medicine hitherto greatly neglected ” [142].
This neglect is largely due to the preponderating influence both on out¬
work and on our mental attitude of the striking advances in surgery
which have characterized the last few decades. We have become so
absorbed in operative work, and hospital accommodation has been so
48 Fairbairn: Teaching of Obstetrics and Gynaecology
monopolized by operation cases, that our teaching material is in no
way representative of the future practice of our students. Our mental
attitude towards our patients and their symptoms has lost balance and
swung too far towards mechanical explanations — displacements and
kinks and hypothetical local affections — and mechanical cures by
operations of the “ pexy ” and “ ostomy ” type, in the devising and
carrying out of which much ingenuity and manipulative skill has been
expended. The resulting tendency has been to overlook the most
common of all factors in the production of disability, overstrain and
mental stress, and we must redress the balance. In women with pelvic
symptoms such causes as domestic worries, family anxieties and marital
and sexual troubles play so important a part that Sir'George Newman’s
words are specially applicable. He says: “ . . . the whole man
must be dealt with, for he is something more than animal. His body
is, in greater or less degree, the instrument and expression of emotion,
intellect and will. . . . Nor is the individual, taken at any one
moment, the whole of the issue. There is his life-history, his heredity,
his family, his domestic life, his personal habits and customs, his home
as well as his workshop. In short, preventive medicine to be effective
must deal with the man, the whole man, as an individual as well as
member of the community.”
We must, therefore, see that our gynaecological beds are occupied
by cases more closely representative of general practice, impress on our
students the necessity of considering the psychological factor and teach
them to study and treat not merely the disease but the individual
patient and the special problem she presents.
In concluding this paper the gist of my argument is that we must
acknowledge the special responsibility on us to create an atmosphere
of preventive medicine round our teaching, and for this purpose every
medical school must provided with a complete maternity and child
welfare centre. By co-operation with the pediatric side instruction
covering a period of six months should be continued from midwifery
into child welfare, so that the student, while acquiring the practice of
obstetrics, gynaecology, and pediatrics, is made to feel that he is playing
at any rate a minor part in a scheme of preventive medicine, the
complete working of which he can visualize. As the study of obstetrics
and gynaecology brings to the student “ new applications of his clinical
experiences, new social relationships ” [117], it is incumbent on us not
only to teach the actual practice of these subjects but to give the
Section of Obstetrics and Gynaecology
49
student a wider outlook and to teach him to apply his professional
knowledge towards increasing the resistance of the normal to disease
and arresting the progress ol incipient disease and so raising the whole
standard of the health and physique of the nation’s mothers and
children. This involves a fuller consideration of the social factor,
the psychological factor and other factors affecting the life and well¬
being of the individual patient and of the community as a whole.
The Teaching of Obstetrics and Gynaecology from the Point
of View of a General Practitioner.
By Lovell Drage, M.D.
This question is only a part of the whole subject of the education
and training of the medical man; and is one of very great importance
not only to students but to the community. The first point to which
I draw attention is the increasing demand made upon the time of the
student by the teachers of special departments. At no period have
heavier demands been made for the inclusion of new special subjects
into the curriculum than at present: and if every professor in special
subjects were to be humoured, I would not envy the lot of medical
students. Examiners, where work is very specialized, it is needless to
observe, are usually hard taskmasters in the examination room.
In what way, then, can the time of the student be saved ? It can
be saved- by the exclusion of the preliminary subjects of study:
chemistry, physics, .morphology and physiology. These subjects, of so
great importance to the basis upon which the structure is to be raised,
should be undertaken previously to registration as a student; and,
until a sufficient test has been applied, registration should be denied.
When a student has obtained a sufficient grasp of the main elements
of these sciences, and has shown that he can work intelligently in the
laboratory, he will be a comparatively easy student for the professors
of the early professional subjects to teach, and a great alteration can be
made in the teaching of those subjects.
At the present time a student begins the study of obstetrics and
gynaecology with a course of lectures and instruction in the wards,
after a course of lectures and instruction in the wards in medicine
and surgery.
F—5 '
50 Drage.: Teaching of Obstetrics and Gynaecology
A very large part of gynaecology is purely surgical and should be
treated as part of the course in surgery. There does not appear any
reason why a surgeon who is a first-class operator should not perform
operations in the pelvis just as well as he performs them elsewhere.
The conclusion which is drawn is, thlt the subjects to which the
teachers of diseases of women and midwifery should devote themselves
should be just those which were theirs before surgery arrived at its
present state of perfection. The special importance of a knowledge of
the various infective agents should never be out of the mind of the
student—and I cannot believe ever will be if the course in general
pathology has been sufficiently appreciated. If practitioners would but
consider it a disgrace when they have a case of infection after delivery,
there might be a chance of the practical banishment of puerperal fevers
caused by infection.
In the by-gone times of studentship and early practice these infec¬
tions were very much in my mind. But the knowledge which I possess
of them was not obtained by courses of pathology, but was gained by
subsequent hard work. The paper which I wrote and published on
puerperal fevers in 1894 1 (or rather the work which I put into it) has
saved many women from suffering at my hands as an accoucheur.
Knowledge of the infections of the genital tract of women is of more
importance to the general practitioner than a knowledge of anything
else in the whole of the subject of obstetrics and the diseases of women.
There is now no reason why the student should not have instruction to
begin where I leave off. The knowledge of pace in a jockey is the
knowledge which gives him pre-eminence in his calling. Quite other
characteristics majse him a good jockey; but in a tight place it is the
knowledge of pace which pulls him through a, winner. What training
produces this knowledge it is difficult to state ; and so it is with the
practice of midwifery—the judgment which determines the action of
the practitioner makes all the difference in success to his efforts. I must
confess that I do not know what course of training will produce this
desirable quality, except such a course as will make a- practitioner go
over in his mind all the details of his procedure after the conclusion
of a case in which difficulties have arisen, even if a satisfactory issue
has been arrived at.
A great teacher such as Matthews Duncan could produce this sort
of method in the mind of a student. But I do not suppose he could
1 Lancet, 1894, i, pp. 461, 523.
Section of Obstetrics and Gynaecology
51
have explained how or why he achieved it. A teacher is either great
or he is not. C. B. Lockwood was a great surgeon, and was successful
as a teacher because he made students think by asking them questions,
and by his insistence on the necessity of using eyes, hands, hearing,
and finally, reason, before making a diagnosis. He often said, “ We
enter the temple of science through the portals of doubt,” and he quoted
Buckle: “ Without doubt there will be no inquiry, and without inquiry
there will be no knowledge.” Again he has said : “ The true teacher
may be known because he tries to educate, but not to instruct; educa¬
tion teaches to think. But it is not enough to know what words mean
to yourself; try and learn what they mean to others.” It would be well
if many of the followers of vaccine therapy would adopt the method of
Matthews Duncan, when discussing puerperal fevers in 1880 : “ The
ideas suggested by the researches of Pasteur, of Toussaint, of Green¬
field, and Buchner may prove to be igne,s fatui; but they may prove, on
the contrary, to be true guides.” Well, they have proved true guides,
but Duncan, as well as Lockwood, entered the temple of science through
the portals of doubt. The late Professor Kanthack was a great patho¬
logist and a great teacher. I did not know him as a student, but came
across him some years after I was in practice. His success as a teacher
resulted perhaps from a sympathy which enabled him to listen to
anyone who took an interest in his subjects ; and he would not dismiss
a questioner because he talked what was possibly nonsense, or some¬
thing like it, to him. His sympathy was great, his knowledge
greater; and he was always ready to assist the inquiring mind. His
was a personality of the most charming kind. Much depends upon
the teachers of the subject and much less on schemes of teaching.
Machine-made schemes of the most copper-plate variety look well on
paper—very well. They attract the attention of prospective students ;
and the students pass their examinations with credit to the copper¬
plate scheme. But what happens to the students afterwards ? Pro¬
fessional gentlemen they are turned out, and professional gentlemen
they will remain—no doubt a credit to the scheme of training, but as
practical scientific men they may be very deficient.
If students have been sufficiently grounded and have been, not
trained only, but educated, a very short time will enable them to grasp
sufficiently all the details of obstetrics and gynaecology. The subjects
are not large in themselves, and three months will be sufficient time for
them to expend before examination at the final Board.
The question now arises—especially in view of the prospects held
62 Drage : Teaching of Obstetrics and Gynaecology
out by the promotion of a Ministry of Public Health—whether all
students should be compelled to undertake the subject before registra¬
tion as practitioners. As a matter of fact, I was placed on the Medical
Register having passed the final examination of the Royal College of
Surgeons and was not examined in midwifery. I do not think my
knowledge of midwifery was less because I was not examined in the
subject. Be this as it may, a great many men do not intend to practise
obstetrics or dabble in gynaecology; and there does not appear to be
any reason why the time and energy of such should be wasted in
cramming up sufficient knowledge to pass an examination. The fetish
of examinations and titles has obsessed the mind of the medical pro¬
fession to an extent which obtains in no other profession.
I have seen it stated that the Ministry of Public Health will make
many jobs connected with maternity and childhood, and that it will be
the duty of medical schools to train people to undertake them. I have
been trying to think of the nature of the work which will be demanded
of these practitioners; and it appears to me that the work will be such
that any sufficiently trained midwife would be able to undertake and
that it will be work which will lead the practitioner who undertakes
it to a dead-end. There would be no need for a scientific education
such as I have tried to delineate, any more than there is for such
a performance as that of school inspection of children. It will be
ordinary hack-work, conducted under red-tape rules and regulations
issued by officials. There will be an immense amount of clerical work
and a life of destructive stagnation. It is impossible to imagine a more
horrible position for any educated man. If teachers in obstetrics were
compelled to train students for such work, courses of instruction must
be made for two separate groups: the first course, in which real
education is attempted; the second, in which no more than training is
given. Under these circumstances:—
(1) Students who intend to practise in obstetrics will pursue the
first course.
(2) Those who intend to take up hack-work at Maternity Centres
will pursue the second.
(3) And perhaps, students who do not intend to practise obstetrics
will attend neither.
The basis for the demand to the medical profession that it should
take up the work of supervision over Maternity Centres appears to be
that it is impossible to manage an A1 Empire with a C3 population.
One reason for the statement that we are a C3 population is that the
&Mtion of Obstetrics', and■ O-ijtim-atogy 63
medical profession for many years past bau successfully prevented the
desUnefioo of the class which in Daruc Nature's scheme is classed. a »
imfib y^h addition, ,bI h my sanitary
district in !««(} there wore 220 berths, foe the- five years before the war ■
the average was UK) with an increase of popolauon of. nearly- 2.000.
The proportion -of ihh Jit to the unfit who are bora into the world is
probably abont the same as it has always been, hut we have by our
ftttontjbjv id the ajetense^ the #mubet-s.yf 'the unnto/vvh,areach
maturity.
Nature provides,'. if left aimm, a large .excess, of increase ia our
species in order to pondde for the ires ,•»{ the unfit. The medical pro¬
fession prevents to a considerable extent the \cm amongst the unfit, and
Other factors have diminished the excess':in'proiIucf.ioth
It does not, appear that there is any reason to suppose that the
supervisMjri »>! pregnant mothefa will pifiHjti.ee any other result than
that of raifpng up to maturity more unfit aduite,:
The prod fiction of a healthy stock .depends upon the healths con¬
dition ofthe parents, and the resistanco to'disease dependsupon factors
Wlhioh, at presimi are little understood.-' Thy practical remaiWft,
ha large expenditure of public money justified in the .absence of any
reason for suppoxiog that a larger stock of healthy children, who have
strong. resistance to disease, will result?
Tlit! President.
T’Oi-O ;:l* -ov.0 O' Si-O.O'- •> --i lii-
Hi iitiy wchp.rao of rwmhum'fioa is that- mum/.: are •••!<••!>!d-or/ made *0 too
tjiioffiicihf*'. jiUtOUXtfy of' ehft,h;4l matonal trt: spec-sat hospl tals. - Thkre %■
: - ivt-i.i w-iuiXim reaching, but the vhmad ibkiorwi in' ihtxw hosi.ljaU.
' f.4 altogether ''ichityd' ; &>r'i.i'QJcw..l‘-ifeM4ii.n|j. of 1 sluriems ‘
J->1'. '• ' . - ■ ’ • , M I ,1.
rinst is a well'Utoed iTisoclHfhunt as- fur the first time m our ontionut
history. H is recorded by the licgistswr-y;'oomi idmi. donltg the ptwc
ye# .< Pu.'.bsud I \\ .-'do-- ill. ovtiren d-. ■ “!. . i.., ’ni 1 - ; ;•/.
bu’kh-yaia. Sy that nutural jnoitssH of. Wit* popnitifho Jjft-s Wim<h4i.i!?,v
at a'U sfyhiii*.. ceased«
CTyufecoIogy.vfflilij lac tAv^btdbife. '..mbpreiem rkpahtjiijfjKt, i-he Wards
54 Routh: Teaching of Obstetrics and Gynaecology
and the operating theatre more easily than obstetrics, and care should be
taken, as Dr. Fairbairn says, to reserve a due proportion of the beds for
minor and plastic operations and not to fill all the beds with tumour
cases.
Dr. Lovell Drage’s proposal that general surgeons should perform
the operations which are now performed by gynaecologists would be a
retrograde step. Does he mean that the general surgeons should teach
as well as practise gynaecology, and does he propose definitely that the
teaching and practice of obstetrics and gynaecology should be in separate
hands ? If so, surely he fails to realize that, apart from tumours and
infections, almost all gynaecological operations are required for condi¬
tions complicating pregnancy and labour, or due to injuries from faulty
or difficult labour, the prevention or removal of which conditions must
remain in the hands of obstetricians. Where can the line, be drawn ?
Obstetrics covers a very wide range. In private practice the patient
may have needed occasional advice from puberty to the date of her
marriage. Her subsequent pregnancy is supervised and labour is con¬
ducted carefully, whilst lactation and weaning, and the periods between
pregnancies may need attention.
The children should be supervised, not “ from the cradle ” as used
to be taught, but from conception, and the child's “ infant welfare ”
should be the aim of the family doctor to the end of the first year and,
if opportunity offer, to adolescence. Such continuous supervision is
impossible in hospitals, but there should be a following up of the
pregnant mothers, not as individuals but in groups representing succes¬
sive stages involving ante-natal, natal, neo-natal, as Dr. Ballantyne calls
the first month of life, and post-natal periods to the end of the first year,
during which time the mother and child can be usefully seen together.
The student would then realize that unrecognized or delayed removal
of abnormal conditions in one stage tends to difficulties or functional
disorders in the next.
In a lying-in hospital the ante-natal clinic should be obviously an
important part of the training of the students and midwives, and would
there be attended by those actually engaged in their practical midwifery.
In general hospitals where district midwifery cases are attended, or
where special maternity wards are provided, the ante-natal clinic would
take the place of the old registration of expectant mothers, except that
now an expert would be in attendance. If such cases were few, they
would be more easily seen in the out-patient gynaecological department.
Obviously, students who have acquired some knowledge of general
Section of Obstetrics and Gynaecology 55
medicine would be better able to appreciate the complications of preg¬
nancy. A clerk Who has served for a month in the gynaecological
department could usefully serve another-month in the ante-natal clinic
and then serve another period in the ward.
Teaching in the ante-natal clinic is the most useful for future
practice. Amongst the subjects there taught the following may be
named: the recognition of venereal disease and the recently proved
safety of dealing with syphilis by salvarsan during pregnancy or after
birth; the recognition of tests for early toxaemia, especially now that
“accidental haemorrhage,” with its 75 per cent, foetal mortality, is
believed to be often toxaemic in origin, and may be preventable ; pelvic
contractions, both the major and minor varieties ; the previous maternity
history of the mother and her children, such complications as heart or
bronchial troubles, old kidney disease, diabetes, Graves's disease, or preg¬
nancy pyelitis. Ante-natal cases requiring further investigation or treat¬
ment would be admitted to the ante-natal ward or to the reserved beds of
the maternity ward; venereal cases would be admitted to the reserved
beds in the venereal wards. Labour, whether natural, prematurely
induced, manipulative or operative, would be used for teaching in the
maternity ward, together with knowledge regarding lactation, and
hand-feeding where lactation fails. Useful practical experience may be
acquired by attendance on cases in their own homes, after holding office
in the ward.
After the first month of the puerperium mother and child should
visit the gynaecological and the infant welfare departments, which should
be held at the same time, so that both could be seen during one
attendance. This would enable early, pelvic troubles in the mother
and beginnings of constitutional disease in the child to be detected.
Students should be taught to assist in laboratory research of all sorts,
such as examination of milk, special urinary tests for toxaemia, exam¬
ination of all expelled products of conception for detection of spirochaetes
and other causes of death, attempts to unravel the mysteries of toxaemia
and of the functions of the syncytial ferments.
Opportunities should be found for giving students information on
the causes of sterility due to malformations, gonorrhoea, or results of
operations, plumbism or X-rays, &c.; on the causation of the low birth¬
rate, such as sterility or criminal abortion, and methodical, chemical or
mechanical restrictions of child bearing. The responsibility of doctors
in cases of criminal abortion and infanticide are also useful subjects to
learn before private practice begins. A doctor should also know how
56 Blacker: Teaching of Obstetrics and Gynaecology
the expectant and nursing mothers can obtain extra diet and extra
pecuniary separation allowances and pensions benefits.
Iu urging the necessity of better obstetrical teaching, it is important
to contemplate the fact that out of 1,000 conceptions probably 250 infants
die during gestation and before their first birthday, and that this
proportion of deaths is doubled in illegitimate cases.
Dr. Drage’s statement that “ medical supervision would do no more
than raise up to maturity more unfit adults ” is extraordinary. Does
he mean that the 200,000 lives saved by a reduced infantile death-rate
in the last seven years are to become “ unfit adults ” ? Does he think
the children saved from craniotomy ‘by induction of labour a fortnight
before full term, or those delivered by a pre-arranged Caesarean section
are going to be “ unfit ” ? There is surely strong evidence to the
contrary. There seems every reason to believe that if the methods
advised in the first two addresses to-day should be carried out, at least
half the ante-natal and early post-natal infantile deaths would be
avoided, for doctors will be thoroughly equipped in the preventive
hygiene of pregnancy, parturition and the puerperium.
Dr. G. F. Blacker.
We should seek an answer to two questions: (1) Why is the
standard of teaching in midwifery not at so high a level as that of
medicine and surgery ? (2) Why is the reputation of the London
school of obstetrics for research so relatively poor? .
The answer to the first question is to be found in the fact that
most of the practical teaching is done by junior registrars and house
surgeons who often have become qualified only recently. From
the very nature of the work it is generally impracticable for one
of the honorary staff to be present when patients require operative
interference in their confinements, and a student may well pass
through the whole of his midwifery training and never see one of the
senior staff conducting an ordinary confinement or performing any
one of the common obstetric operations. It is impossible to arrange
for practical teaching in midwifery at the bedside or in the theatre
at set hours, and therefore a great deal of this part of the teaching
has to be done by junior men with but little experience. It is quite
easy for senior members of the surgical «nd medical staff to carry
out teaching at the bedside, but it is very difficult for the senior
Section of Obstetrics and Gynaecology
57
obstetricians to do so. In my opinion, then, it is necessary not to
consider what the student should be taught, but how he should be
taught and what changes are possible to overcome the present unsatis¬
factory state of affairs. There is only one way out of the difficulty—
namely, the provision of four or more large lying-in institutions in
different parts of London, in which the student could receive his
practical teaching fti Midwifery, Gynaecology and Maternity and Child
Welfare under the same roof.
These institutions should be large enough to provide for all the
medical students in London, and must be officered, if the students
are to be taught properly, by resident whole time properly paid senior
teachers. They should be either whole time or full time: by the first
I mean debarred from private practice altogether, by the second compelled
to devote so many hours a day to their work and not allowed during these
hours to undertake any other work. They should further have the
services of whole time paid assistants, and all the laboratory facilities
necessary for the proper carrying out of the pathological work concerned
in the treatment of their patients and also for research work. The
present lying-in hospitals have not, in my opinion, justified their
existence so far as teaching is concerned; they phould be closed or
' amalgamated with these larger institutions. The student should be
required to spend four months in the practical study of midwifery and
gynaecology, two Of which should be devoted to gynaecology and two to
midwifery. During his term of duty in midwifery he would be resident
in the institution while on duty in the wards, and then would spend
the second month of his attendance doing duty in the extern maternity
department. In these circumstances students would receive their
teaching from teachers of equal standing and experience to those
engaged in the teaching of practical medicine and surgery, they
would have ample opportunities of seeing large numbers of gynaeco¬
logical and obstetrical cases, and at the same time would be able to
attend in the Maternity and Child Welfare Department.
It would further be possible to carry out the students’ practical
training in the best possible surroundings. The present small number
of lying-in beds in most of the general hospitals are of very little
value, and are wasted in most cases, as it is impossible for the students
to live near or in the hospitals, and they are therefore not available
when wanted to attend at emergency operations.
Arrangements of this kind would enable any man who desires to do
so to carry out research work with credit to himself and his School, and
58 Eden : Teaching of Obstetrics and Gynaecology
such a development would be in keeping with the schemes which are
on foot at the present time for the appointment of whole time paid
teachers in medicine and surgery. I do not think that anything
short of this very radical change would ever succeed in improving
the present unsatisfactory methods of teaching practical midwifery
in London.
Dr. T. W. Eden.
Speaking of the London schools, I think that the obstetric
teachers need reconstructing quite as much as their methods of teaching.
Teachers should be men with a fair amount of leisure, and teaching
ought to be their principal occupation. In the case of too many of us,
our teaching is only an incident in a very busy life. This is largely due
to the system of holding multiple hospital appointments which prevails
in London. This, again, is diie largely to the fact that the teaching
hospitals, at any rate the smaller ones such as that to which I belong,
are overstaffed. In consequence the junior members of the medical
staff cannot obtain the clinical opportunities which they require,
and they take other appointments at non-teaching hospitals in
order to obtain them. It is not uncommon for men to hold three or
four appointments at hospitals scattered over various parts of London,
and thus they become overwhelmed with routine work, and their
teaching inevitably suffers. Conditions which do not admit of the
younger teachers concentrating upon their teaching hospitals are
necessarily disadvantageous.
And, further, it must be admitted that many men holding “teaching”
appointments do not take their duties as teachers very seriously. Dr.
Fairbairn well said that the clinical material in our wards ought to be
fairly representative of the future practice of our students. On looking
over the ward of a general hospital we might often find that the greater
number of the cases, and sometimes all, were there, not because of
their value for teaching purposes, but because they had previously been
seen in consultation with general practitioners. Or they may be
practically all cases of the same kind, admitted because the surgeon or
the specialist has gained renown in the performance of a particular
operation. Such conditions as these really constitute an abuse of our
trust as teachers, and no mere alteration of the syllabus will effect the
changes which are necessary.
In general I agree with Dr. Blacker that large central institutions
Section of Obstetrics and Gynaecology
59
are necessary, which must be staffed by teachers of experience, who
will be adequately remunerated and will devote their whole time to
their work.
Dr. Eardley Holland.
All teachers of obstetrics will entirely agree with the openers of this
discussion that the present system of teaching and practice of midwifery
in the medical schools is totally inadequate to the needs of students and
patients alike. The present system implies the extern midwifery
district unsupported, or feebly supported, by in-patient maternity beds.
Many of the public think it more than inadequate; they think it
scandalous. The pity is that we have not moved in the matter until
forced by the pressure of public and official opinion.
Amongst factors contributing to the neglect of proper teaching to
the student may be reckoned (1) the claims of the midwife, who absorbs
nearly all the teaching maternity, beds in London ; (2) the apathy of the
modern gynaecologist to “ common or garden ” midwifery, and his
absorption in the purely surgical aspect; and (3) the bad conditions of
midwifery practice for the doctor in all but well-to-do families. The
time element is the important one in midwifery, and a doctor cannot
afford to give the. necessary time, especially the waiting and watching
during labour, for the little fees that poorer patients can only afford. I
think the feeling has been subconscious that it is hardly worth while
training a man to a standard he can scarcely ever hope to keep up in
after-life.
I am very glad two of the opening speakers have emphasized the
need for obstetrics and gynaecology being treated as one subject for
teaching and research; their division into separate departments, under
separate heads, would be a great disservice to both. I hope this Section
will pronounce officially on this point, as there is a small body of
opinion which favours their separation in order that the infant may
receive more attention from the obstetrician. This brings me to a
point I wish to emphasize. There is no doubt the infant has been
neglected. I know no obstetrician who is really interested in the
diseases of the infant, and who knows much about them. The
psediatrician is not much better; any paediatrician I have seen faced by
a very sick infant was a perplexed man. The reason is quite obvious :
he has never had a chance to study the infant, which has always been
regarded as the special property of the obstetrician and his female
60 Fletcher: Teaching of Obstetrics and Gynaecology
satellites. The study of the infant should be taken out of the hands of
the obstetrician and placed in those of the paediatrician. The problem
of the infant is a problem of general medicine and pathology, and a very
complex one too; if the obstetrician wishes to study the infant as he
ought, then he had better give up surgery and take to pure medicine.
The infant is linked to obstetrics by the function of lactation, and by a
few transmitted diseases; beyond this, it lies quite outside the things
that make up the science and art of obstetrics, and belongs to a different
branch of medicine. In an obstetrical and gynaecological unit, such an
academic unit as it is hoped will be formed for teaching purposes, I
should like to see tfip whole of infant study and teaching, normal and
pathological, taken over by a paediatrician, who would work in con¬
junction with the unit.
Dr. Drage states there is no reason to suppose that the supervision
of pregnant women will have any other result than that of raising up
to maturity more unfit adults. No statement could be less true or
could display a greater lack of knowledge of what is done for the
foetus, quite apart from what is done for the mother, by the super¬
vision of pregnant women. There is a great deal of confused thinking
about the ante-natal care of the foetus. Some credit it with being
able to do too much; others, like Dr. Drage, think it will do harm.
What actually can be done for the foetus by the supervision of
pregnant women? The list of things is a small one, but each one
is of vast importance, and proper management after diagnosis means
an immense saving of foetal life and infant disease. The’ correction
of malpresentations, the treatment of contracted pelvis, syphilis,
albuminuria and pelvic tumours almost exhausts the list. There is
no reason to suppose that foetuses, saved from death by the induction
of premature labour or by Caesarean section in cases of contracted
pelvis, or by ex'temal version in cases of breech presentation, will
grow up into unfit adults, or that the same fate awaits a series of
foetuses born of a mother cured of syphilis.
Sir Walter Fletcher, K.B.E., M.D., F.R.S.
In the first place, I do not like speaking of “ defects ” in regard to a
body of teaching which has done so much in the past. • Within the
present conditions and limitations, it seems to me, on the whole,
admirable. But I agree heartily with Dr. Blacker, who urged so
■S&Uwsof Ohsteincs timl SynMmlogy
61
forcibly that, there is ne»?d now for a vast change. pr. Fairbairn was ;
t ight, I thiiils, when he said that the chief defects of the present ay-stem
are. in the ibsfcfiigt kin gtv£ii fet’frftef ba* ‘strtiek
rue as a teacher—away from London,—as a teacher of. physiology, is
that the normal physiology of the process of icpcoduetioh, tiiken in a
wide sense, is not inefficiently brought to the student's yo tide That, I
fKtv.ly fVtrt A V «V» ft i « «rU ,1 ^ T'f ,* iv’n *•»
the oorative. gt’njess the physiology.' M the whole Kequgdep: of the
blame. for this fiafdet iB to be shaved, perhaps, erjuivily .l>y physio-,
logical teacher in. the earlier part of the course and the .gynaecologist*
k .' i il': J *C'' j*4v.' LV. £ ^ :• icL:U''1< 1 ‘3 - r liJi 1 ■ XL _ ' - „• • - — 'Jo : -
•b ■ .: ■ ■.;>:<■■ ibb,
gi;haV}yv,l ttuoliy % riot fhft.&saiuplff& 'Sve, might get
from’gyna^itKvii’Cjg't;Vpr" wiiwdlei*-. af>igv iu the stvidiKhp'tv.U.fe, Tho
■uterine: hifnacln ;: rpig&t- $F{ij<ly-iddhhF»*iJP 'tdtBVbaS »«.' the. of
riiiojel*?, -^nii'feurttihi);:|||jjssrtj*ajty>n. *;d ff.ee few* af
v..,ct-'ii)( : p't! v-.g,. These should ho. uuigitt, again when tin* yi.ude.ui is
•»ir.^^-^yi*feodog{&a* inslytule, How iuart'y dido, M. y«4liCcaSivrn.:hayo’
: 3By-rd w «V idha of the phySidlogiea) bfyya of the itfr-ydf: pi the
ifikfiodj! wti atfesfcftd-
fag't that if i
a!h- gland h*-
- e:
Qiptieiiy {fa ,
itfc
fVity otQoietrcy dgi
dirn-s ?;V Also,
firat flu* late
t j v.'U't-
idM -bf-tbLifi
• lod;. con turn t,.ijf- c.piof part of fbi- fat ? And what tbo $jginfi«an***-:'<&;
that i*> •'! v.jKi i.,.;ii', t.o >.j»c .si.eo<'H*fH-y fobd hteiorr toi flit; diet
1 ; • ft tlte • ■'-■■:■■ pitii i <•■ ••'■■<'■■•■■•'. df' phttiidg t.V c/uid d:
lh£ I |h«5t}t d■ iis thytethat thpjtc tkipgs are 'rarely, ft ev*iv,'
.pfes<*»'fc id -IIkc ■'minds* of the. -mon • an Onal;fece.t;on, • wod 5 &.»afcr'fcbej’*
a,ie; Vafgfiiy Hteeut in the prof^d*nis 4 birth of. medical practitioners
••aid pi mif'c; I think ilcii i-ii'i!<:i. <.'i,>*H.*<'iiniii.»c.*. lot "..each itx j ,mb
ic.'.-ro-:!.- cun oil)'. )-.- I idly *i:v«w*<i i. : bv • h -•.■■•■■
rndWAtisd by I?r. Blacker.
62 McCann: Teaching of Obstetrics and Gynaecology
Dr. F. J. McCann.
I agree with what Dr. Blacker has said about maternity hospitals.
London, the greatest and richest city in the British Empire, and,
indeed, in the world, does not contain a single large maternity hospital.
It is true that there are several of small size, Queen Charlotte’s Hos¬
pital being the largest, but they are totally inadequate in proportion
to the size and importance of this great metropolis. There should be
State subsidized maternity hospitals not only in London but throughout
the country. These hospitals should not be State controlled or con¬
trolled by parochial authorities, but subsidized by the State. I suggest
that this Section should urge upon the Government the desirability of
providing these hospitals without delay.
This question of the teaching of obstetrics has been brought into
prominence largely through the increasing numbers of women who,
as midwives or nurses, are desirous of receiving instruction, and for
whom facilities must be found. Obstetrics must be taught either in a
maternity hospital or in a well-equipped special department of a general
hospital. In addition to a small visiting staff there should be a whole
time official or officials with assistants comparable to the “ Chef de
Clinique ” in French hospitals. This official should be appointed for
five years at a salary of not less than .£*500 per annum. He should
assist in the teaching and should do research .work. He should have
a knowledge of modern languages, and for one month in each year
should be obliged to visit clinics both at home and abroad, and bring
back a report to his hospital or department. From the nature of
obstetric work a resident teacher is required who will be at hand to
demonstrate to and instruct, the students when complications are
encountered.
The present system of training the specialist and future teacher
is a bad one. The house surgeon of to-day may settle down in
practice in Wimpole Street or Harley Street to-morrow. He then
proceeds to learn his work and becomes attached to different hospitals
in order to gain clinical experience, with the result that he cannot do
the work of any one appointment really well. Moreover, many of the
most brilliant intellects are lost to the schools because of financial
reasons; the poor man is forced to join the services or to go into
general practice in order to earn his living. By providing well paid
appointments such as I have suggested our future specialists and
Section of Obstetrics and Gynaecology 63
teachers would have a thorough training, and would have the oppor¬
tunity of showing whether they were capable of teaching and able
to do research work. In this way I believe we should have better
specialists and more inspiring teachers. The teachers, too, must be
better paid. As a result of the recommendations of the Haldane
Committee a Ministry for Research and Information is about to be
formed. From this ministry funds will be provided for the encourage¬
ment of research, and will be given to those who are capable and
willing to do the work.
For the purpose of providing increased practical facilities for obtaining
a knowledge of obstetrics and gynaecology in London it is proposed to
amalgamate Queen Charlotte's Lying-in Hospital with the Samaritan
Free Hospital for Women. Thus 140 beds will be available for clinical
instruction, and I hope to see established herewith a department for
after-results. Such a department should exist in every well-equipped
hospital. Consider what a wealth of material is lost both to the
student and the teacher from the absence of such a department. For
example, we should realize what permanent disability and suffering
may result from what is termed normal labour, and thus be enabled
to carry out Sir George Newman’s “ preventive idea ” to the fullest
extent.
In conclusion, in order to provide increased clinical opportunities
special departments must be enlarged or affiliated with existing special
hospitals. It is only a question of time before the teaching of obstetrics
and gyna*cology will pass into the hands of hospitals specially equipped
for the purpose, and then, and then only, will London become an
important centre for the study of these subjects, and attract students
and graduates from the four quarters of the globe.
Dr. E. L. Collis.
I desire to deal with only one aspect, that of the woman industrially
employed. During the War the nation suddenly discovered that many
women worked. Women worked before and will continue to work in
the future to even a greater extent. The duty devolved upon me in the
Ministry of Munitions of replying, or trying to reply, to such questions
as : (1) What work may a young girl or woman, i.e., a potential mother,
be allowed to undertake? (2) What weights may she lift? (3) For
what hours should she be allowed to stand ? (4) What risks are entailed ?
64 Bonney : Teaching of Obstetrics and Gynaecology
(5) What is the effect of industrial work upon menstruation ? (6) What
work may the expectant mother do ? (7) At what period of pregnancy
should she alter her work ? (8) How soon after confinement should she
be allowed to resume work ? and, again, What sort of work ? (9) How
can such women carry on breast-feeding ?
May be the great teachers here present have looked into these
matters, and can reply with full scientific knowledge. 'If not, I urge
you to acquire this knowledge; while, if you have it, I even more
urgently desire you to impart it to the coming generation of practitioners
who most assuredly will have to reply to such questions. In April, 1918,
there were in this country 4,800,000 women employed in industries and
professions, and normally we may probably expect in the future about
4,000,000 to be so employed. But female employment cannot be
estimated to last for each individual for more than ten years on an
average ; and if the expectation of female life at 15 years of age is forty
years, then each employed person represents three others who have
been so employed. That means that in this country some 16,000,000
females at any one time are either going through or have already gone
through the occupational mill. Employers of labour are more and more
coming to retain the services of medical officers. What answers are you
teaching them to give to these rudimentary questions ? What answers,
that may prevent the need for the practice of gynaecology, that may
promote health, lower infant mortality and increase the birth-rate ?
Mr. Victor Bonney.
As a teaching system must be judged by its end-results, it is obvious
that there is something fundamentally wrong with obstetric teaching in
this country. The Registrar-General’s returns for England and Wales
show that the maternal death-rate due to pregnancy and labour has
remained at somewhat over four deaths per 1,000 children born alive
for the last seventy years ! The Scottish figures are rather worse.
Over a period during which enormous advances have been made in
every other branch of the medical profession, obstetrics, as judged by
the results of obstetric practice, has remained nearly stationary.
The reason for this is that midwifery is neither regarded, taught, nor
practised as a branch of surgery, whereas it is in fact a pure surgical art
and moreover, of all the branches of surgery, it is that in which the
surgical attitude of mind and the scrupulous observance of surgical
technique is most essential.
Section of Obstetrics and Gynaecology
65
The failure on the part of the teachers to adopt this conception of
the art they teach is reflected in the practice of the profession at large,
and as a result the public, who take their tone from the profession,
habitually underrate the dangers of pregnancy and labour, and thus
there persists a great ignorance of the necessity for proper supervision
during the carrying of the child and of the need for pre-arrangement
against the time of its birth in the way of securing surgical environment
for the labour. A study of the deaths shows that the greater proportion
can be prevented by the vigorous application of the principles of modern
surgery. The remedy lies in nothing less than a radical change in the
conception of midwifery and a complete revision of the attitude of
thought that dominates the teaching of the art.
Dr. Eardley Holland is right in stating that the teaching of, and
the attendance upon, the diseases of the new-born child is the province
of the physician and not’of the obstetrician.
Dr. Herbert Williamson.
What type of education produces the most competent medical
practitioner ? Two systems are in vogue at the present time. The
first instructs the undergraduate mainly by lecture-demonstrations,
systematic lectures, laboratory work and tutorial classes. In the second
system clinical work is paramount, and after passing his examination in
anatomy and physiology, the student is taught at the bedside of the
patient; he personally examines the patient, keeps the records of the
case and is made to assume a certain responsibility for the investigation,
the diagnosis and the treatment of the patient. Clinical work is the
foundation and the keystone of his education. I believe that the latter
system produces the better man and that we should therefore hold
firmly to it.
Looking back after seventeen years’ experience as a teacher and five
years as examiner, I see what appear to me defects and weak spots in
our curriculum. In the first place, the majority of teachers of clinical
subjects have to earn their living by the practice of their profession
outside the hospital and are compelled strictly to limit the hours they
devote to hospital work and teaching. It is almost impossible for them
to devote much time to research, or even keep abreast of the researches
of others, and they have none of the leisure which is essential to those
f—6
66 Williamson: Teaching of Obstetrics and Gyncecology
who aim at the highest kind of teaching. The only remedy I see for
this defect is the adequate endowment of clinical teaching.
A second weak spot is the haphazard way in which the student is
allowed to conduct his midwifery cases. In my opinion a lying-in ward
forms a necessary part of the equipment of every medical school, and
no student should be allowed to take cases on the extern district until
he has clerked for a month in that ward and has personally conducted
at least five cases under the immediate supervision of a competent
instructor. This instructor should be a qualified man or woman who
knows the subject well and knows how to teach; the teaching should
not be left to a midwife. The subject of obstetrics is essentially a
branch of preventive medicine ; most of the disasters which still
unfortunately attend its practice are preventable, and for this reason the
pre-maternity work upon which Dr. Fairbairn has rightly laid so much
stress should form part of the teaching of every student.
The next thing that strikes me as wrong is the examination system ;
it cramps education and is injurious both to the teacher and to the
student. The time devoted to the study of obstetrics is short, and
the teacher has to meet the requirements of examining Boards and is
not free to consider solely the educational value of his teaching. It acts
injuriously upon the student, who is too apt to base his work entirely
upon examination requirements and is unwilling to devote time and
attention to matters of great importance which are not of direct value
to him in the examination room. The principle of determining a man’s
fitness to practise obstetrics simply upon one examination paper and
a twenty minutes' viva voce examination is altogether wrong. Students
ought to be examined by their own teachers, possibly in the presence of
an assessor, and the granting or withholding of the licence should
depend largely upon the way in which he has done his clinical work and
upon the opinion formed of him by those who have watched his work
week by week and month by month.
The last defect to which I shall draw attention is perhaps the
gravest defect of all. Every student should be brought up in an
atmosphere of research, and in our medical schools this is too often
lacking. Research is the very soul of medical education : the spirit of
doubt, the spirit of observation, the spirit of inquiry, constitute the
atmosphere in which the student should live and move and have his
being. This research, this true education, can be cultivated in a small
ward ; it does not demand a large institution, and the degree in which
it obtains in any institution is the measure of the education value of
Section of Obstetrics and Gynaecology
67
that institution. Let every student during his clerkship be encouraged
to look up original papers upon some point, let him see for himself the
process by which the statement of some particular point in his text-
. book was arrived at, let him see the art and science of obstetrics in the
making. Then let him be encouraged to work out some particular
* point for himself. Teach him to observe, teach him to think, then you
have laid the foundation truly and well.
Dr. Lai’thorn Smith.
My long experience as a teacher has convinced me that the best
place to teach gynaecology is in the out-patient department of the
hospitals, because there alone would the student see the kind of case
that he would meet with in practice. But attendance at the subsequent
operation, if one is necessary, would greatly increase the knowledge
gained in the outdoor clinic. It is equally important that the students
should be taken to the wards to learn the after-treatment. With regard
to obstetrics, which in many countries is under the direction of the
professor of gynaecology, I have always felt that London should be the
greatest centre in the world for teaching it. But the enormous amount
of material for teaching is made very little use of, so that it is frequently
said that the young doctor goes out to begin practice with very little
experience in that department which will form the bulk of his work.
As several speakers have pointed out, there is room for improvement in
the way of reducing the still large number of deaths from puerperal
fever and eclampsia, and it is to be hoped that the pre-natal and post¬
natal clinics being started all over the country will not only save many
mothers, but many more children. There should be a great Rotunda
Hospital for London, with several branches, where thousands of poor
women could be delivered under skilled and aseptic surroundings who
would otherwise be confined at home under most unfavourable condi¬
tions. In time private rooms should be available for the rich, the
revenue from this source as well, as from the middle class, and even a
little from the poor, would go a long way towards making these institu¬
tions self-supporting. The deficit could be made up by bequests and
donations. The master would perform the deliveries in the day time,
and the assistant would attend to those taking place at night, but each
delivery would be carried out in the theatre under anaesthesia so that
every student in a few months would have been present at a hundred
68 Barrett: Teaching of Obstetrics and Gynaecology
cases instead of at half a dozen, and would have had the opportunity of
observing the methods of the very ablest exponents of the art. Each
medical school might in turn be responsible for the service under the
supervision of the master, who would be elected by all the schools, for.
three or five years. His reward would be a large consulting practice.
Lady Barrett, C.B.E.
The two most distinct features of the debate have been Dr.
Fairbairn’s paper calling attention to the need of the teaching of the
preventive side in obstetrics and gynaecology, and Dr. Blacker’s plea for
a whole time professor in the subject whose chief work in life is teaching.
Might not, however, some immediate influence be brought to bear upon
the students now in our schools by reform in the examination regula¬
tions, or rather in the demand made upon students as to work per¬
formed before they are allowed to present themselves for examination ?
I would also suggest that the student might be afforded practical
acquaintance with the preventive side of our subject as well as the
more modern type of work by allotting part of the time devoted to
obstetrics and gynaecology to pathological work associated with the
subject. I should like to see regulations passed that np student might
present him- or herself for examination in this combined subject without
at least a six months* course—three months in gynaecology, including
in-patient and out-patient work and attendance at infant clinics, one
month in the wards of a lying-in hospital and one month in the out¬
patient district of the hospital and one month in the obstetrical patho¬
logical department—-Jthe student at the same time to attend the ante¬
natal and infant clinics throughout the whole three months. This
would at least be the first step towards improvement on the present
slight demand in midwifery, viz., the attendance at twenty cases.
Dr. E. W. Johnstone (Edinburgh).
I was a little disappointed that the earlier speakers confined their
remarks so largely to the special difficulties of the London schools,
because I am most immediately interested in obstetric teaching in
Edinburgh, and the wider aspects of the subject under discussion are
applicable to all schools. I was not aware, until I listened to some of
Section of Obstetrics and Gynaecology
69
the speakers to-night, how much was apparently lacking in the teaching
of obstetrics and gynaecology in London; and I was beginning to think
that we managed these things better north of the Tweed, when Mr.
Bonney disillusioned me by indicating statistics for Scotland of the
maternal mortality following childbirth. Still in some ways we are
more fortunate in Scotland. For one thing, the Scottish schools have
grown up under the tradition of the systematic lecture, and while I am
not prepared to maintain that a six months’ course of systematic lectures
on midwifery is either necessary or desirable, I am still less prepared to
agree that systematic lectures can be abolished and the subject better
taught by clinical meetings and demonstrations only. In Edinburgh,
and in the other Scottish universities as far as I know, the student has
a full six months’ course of midwifery and gynaecology lectures. During
that period he has the opportunity of attending daily cliniques at the
Maternity Hospital, for one month, where he conducts one or two cases
of labour under the supervision of the teacher or the house surgeon
before going out into the district for his practical experience. Similarly
he attends the gynaecological wards of the infirmary for a month, where
he is taught practically how to examine a gynaecological case, and sees
the ordinary minor and majoi\ operative work.
Previous speakers have justly emphasized the great value of clinical
teaching being given by the senior teachers, who have the greatest
experience/ In Edinburgh this is customary. I would also enter a
plea for more attention being devoted to the minor cases, which after
all form the greater part of the gynaecological work with which the
student will meet in actual practice. Too much attention is apt to
be paid to tumours and the more interesting cases from the operative
point of view. The same thing applies to midwifery. One or two
cases adequately taught and demonstrated may be of more value, even
if they be normal cases, than less adequate teaching on a large variety
of pathological cases.
I do not agree with Dr. Blacker’s advocacy of whole-time teachers,
at least not for the teaching of undergraduates. In the first place it is
not to be expected that the salaries offered would attract the best type
of man, and in the second place there is the danger that such a teacher
would in the long run become so immersed in hospital methods and
the hospital point of view, that his teaching would not be best adapted
to the conditions of general practice.
70 Wilson: Teaching of Obstetrics and Gynaecology
Dr. T. G. Wilson (Adelaide, South Australia).
As an Australian graduate I have often remarked on the fact that
graduates and students of Australian universities, who very frequently
proceed overseas for further experience before commencing practice,
though they generally come to London to do surgery, medicine,
pathology, &c., almost always plan to go to other places to do obstetrics
—to the United States, to work at the Johns Hopkins Hospital or the
Sloane Maternity Hospital; to Ireland, to work at the Botunda or
Croom Hospitals, or to the Continent—before the war especially, to
, Vienna or Paris. As a teacher on these two subjects I have often
been asked to advise old students as to what they should do in their
post-graduate courses. Naturally it cannot be that there is any lack of
clinical material in London, or that the recognized teachers in the
London schools are not on a par with those in other places. What,
then, is the difference in the teaching of obstetrics in London generally
and in some of these other schools? Dr. Blacker indicated some of
these differences, and the main one is that in these other schools the
actual clinical teaching of obstetrics is. given by more experienced
men, who, for the time being at any rate, are whole time men and
willing and able to give up their whole time to the instruction of
students. The actual delivery of the bulk of ordinary obstetric cases
in many of the London hospitals is done by the house surgeons—men
who have just qualified, and who are themselves getting practical
experience in this work, or in the extern departments especially, often
by midwives.
In a school like the Johns Hopkins, on the other hand, this work is
done largely by qualified men who are in process of being trained to be
specialists in this branch. The same applies to a hospital like the
Allgemeines Krankenhaus in Vienna—to the Sloane Maternity Hospital
in New York, or to the Botunda Hospital in Dublin. At the Johns
Hopkins Hospital the assistants are men who have done a year or more
as general house surgeons or house physicians, and have then taken up
gynaecology and obstetrics as a speciality—starting as fourth, fifth, or
sixth assistant in the clinic, and working their way right up through all
the departments, and definitely spending four or five years at this work.
During this time they are for six months to a year definitely detailed to
the pathological and research department of this speciality, and when
they reach the position of first assistant, are fully competent specialists,
Section of Obstetrics and Gynaecology
71
and generally apply for a teaching appointment in one of the smaller
universities. During this term of training they are adequately paid,
and are not doing private practice, and consequently can devote the
whole of their time to the actual hospital work and teaching. The
students and attending graduates who come under them naturally have
the advantage of their greater experience, and even though these
students do not get actual demonstrations from the honoraries or heads
of the clinic (except in special cases) they have the immense advantage
of being taught by far more experienced teachers than the ordinary
house surgeon, who is very often doing obstetric manipulations for the
first time himself. The question as to whether the teaching hospital
is one large one or a number of smaller ones is of less importance
than the actual type of teaching personnel in the hospital.
The procedure outlined definitely seems to serve the double purpose
of providing better opportunities of being taught practically in ordinary
obstetrics for the ordinary pass student, and also of providing a
thorough and systematic training for those men who intend to take up
this particular speciality in their after life. Naturally I am speaking
only of the actual teaching of practical obstetrics, and not of the
systematic course of lectures on this subject.
The amount of clinical material at the various special hospitals
for diseases of women in London, as has been emphasized by Dr. Eden,
is enormous, and it has often struck me how little this is utilized for
teaching purposes. If it were possible for all students to have a
period as house surgeons or clinical assistants at one of these hospitals,
it would be a great thing for the future general practitioner, but as this
is not practicable, it seems that the next best thing might be obtained
by some such method of ensuring more experienced teachers for the
students in the conduct of the ordinary obstetric cases. And if some
such procedure can be carried out in the proposed amalgamation of the
Queen Charlotte and Samaritan Hospitals as a teaching school for
obstetrics and gynaecology, it may be a boon for the future London
medical students and general practitioners, whose work in private
practice is after all largely made up of ordinary obstetric work and its
complications.
72 Andrews: Teaching of Obstetrics and Gynaecology
Dr. H. R. Andrews.
I fully agree with the general proposition that obstetrics - and
gynaecology must be taught together: a* gynaecologist is inadequately
equipped, if he has not had a thorough training in obstetrics. Many
“ interesting ” gynaecological 'specimens have been exhibited which
would have remained fairly harmless parts of the patient’s body while
she was increasing the size of her family if her attendant had been an
obstetrician as well as an operator.
Old-fashioned, set, formal lectures are not of great value except to
advanced or post-graduate students, but courses of lectures as informal,
chatty, suggestive and practical as may be, are of considerable value,
especially if the students attending them will do some reading between
the lectures.
•The old method of learning practical midwifery, entirely or
almost entirely in the patients’ own homes, has one advantage—viz.,
that of teaching the student something of “ responsibility ’’ and self-
reliance, but in many cases he was not ready for responsibility and
had no Solid ground-work on which to base self-reliance. This advan¬
tage was overwhelmingly outweighed by many disadvantages. Some
men got into slipshod, haphazard, trust-to-luck ways as the result of
want of knowledge and want of supervision, and kept to these ways
throughout their practice in after life. A student must be drilled into
conducting labour on modern lines, investigating each case as thoroughly
as any medical or surgical case, and suiting his treatment to the indi¬
vidual case instead of going simply on general principles ; and he must
be taught what rigid asepsis means. He will learn a good deal about
the puerperium and about the baby in the ward which he could not
pick up for himself on the district unless he was an exceptional man
and an unusually keen observer. When he has learnt that it is dis¬
graceful to be slipshod and careless he will never relapse completely,
if he is worthy to be a doctor. One of the most important lessons
which he will learn is that, having found that all is well, even if progress
is slow, his duty is to “ stand by.” When he has finished his training
in the ward he is fit to go out on the district, and is ready to profit
greatly by his experience there.
I agree with Dr. Lovell Drage that “ the medical profession
prevents to a considerable extent the loss among the unfit,” but a
thing which distresses me every month, if not every week, at the
Section of Obstetrics and Gynaecology
73
London Hospital is that the medical profession does not prevent a
large unnecessary loss among the fit. The only way to prevent this
unnecessary loss is by improving the teaching of midwifery. There is
one sentence in Dr. Lovell Drage’s paper which must not be allowed to
pass uncriticized: “ It does not appear that there is any reason to
suppose that the supervision of pregnant mothers will produce any
other result than that of raising up to maturity more unfit adults.”
I suspect that Dr. Lovell Drage meant to exaggerate, and knew that he
was exaggerating, but, to my mind, he has gone much too far. Take
the first two examples that occur to one—maternal syphilis and minor
degrees of contracted pelvis. Supervision of pregnant mothers may
result in the production of A1 citizens in either of these two conditions.
French authorities stated many years ago that thorough treatment of
babies with congenital syphilis resulted in their being as good in every
way as children who had not had syphilis, and I do not believe that
Dr. Lovell Drage or anyone else has any evidence to show that children
of syphilitic mothers who were adequately treated by more modern
methods during pregnancy suffer any ill-effects in after life. If minor
degrees of pelvic contraction are discovered only during labour the
result is often that the mother is badly torn and the child dead or
damaged. If, on the other hand, the mother is admitted into a lying-in
institution because the contraction was discovered before labour, in the
large majority of cases she will be undamaged and the baby will be
born alive and well, either after induction of premature labour or by
the exercise of patience and masterly inactivity which characterize the
management of labour by a whole time medical officer who is always
available. The general practitioner, in far too many cases, cannot give
up the time necessary for watching the course of labour for many hours
as would be done ip a hospital, and terminates the labour by forcible
traction with disastrous results. I consider that an ante-natal depart¬
ment is an essential part of the equipment of a modern teaching
hospital.
Dr. W. S. A. Griffith (in reply).
I am sure that the discussion will be of great value in stimulating
all who are responsible for the teaching of these subjects to press for
the improvements which have been suggested and so generally approved.
I hope visitors and others present who are not conversant with the
excellent instruction afforded in London will not accept the condemna-
f— 6a
74
Griffith: Teaching of Obstetrics and Gynaecology
tory statements of certain distinguished teachers as entirely justified.
It is inconceivable that they who are responsible for these departments
in their medical schools could allow them to be so completely
unorganized.
Mr.‘Victor Bonney’s argument based on a continued 0'5 per cent,
maternal mortality is hardly fair, when it is realized that two-thirds of
midwifery practice is in the hands of midwives, and that there are still
in practice a considerable number of senior practitioners who have not
received the advantages of modern training, and for whom the present
teachers are not responsible.
The most important suggestion made is one to which most teachers
will agree—namely, the establishment of a central maternity and
gynaecological hospital in the principal teaching centres, thoroughly
equipped with laboratories for pathology and research, under the control
of a professor or director, adequately-remunerated, whose whole time
should be devoted to his work, with the necessary assistants, and, as
Sir Walter Fletcher has suggested, associated with an expert physi¬
ologist to link up the teaching as well as the investigation of problems
which are at present carried out in widely separated institutions.
The development of infant welfare schemes, which Dr. Fairbairn so
strongly advocated, ia one which each maternity department and
hospital can do much to carry out, and will prove of great value.
Section of ©botetrlco anb (B^naecoloap.
President—Mr. J. D. Malcolm, C.M.
The Continued High Maternal Mortality of Child-bearing:
The Reason and the Remedy.'
By Victor Bonney, M.S.Lond., F.R.C.S.Eng.
Some Statistics.
The yearly reports of the Registrar-General for England and Wales
show that the death-rate directly and indirectly attaching to pregnancy
and labour has diminished woefully little in the last seventy years.
England and Walks.
Year
1917
Births
608,346
Deaths
attaching to
childbirth
3,236
Proportion
per 1,000
live births
4*8
Deaths
by
sepsis
916
Proportion
of deaths
by sepsis
per 1,000
births
1*3
Proportion of
deaths by
sepsis to
total deaths
Per cent.
... 28
1916
785,520
3,978
50
1,147
1*4
28
1915
814,614
4,259
5-2
1,253
1*5
29
1914
879,096
4,498
51
1,422
1*6
31
1913
881,890
4,295
4-8
1,173
1*3
27
1912
872,737
4,321
4-9
1,280
1*4
28
19U
881,138
4,322
49
1,334
1*5
30
1910
896,962
4,277
4*7
1,274
1*4
29
1909
914,472
4,600
4,521
5*0
* 1,429
1*5
31
1908
940,383
4*8
1,395
1*4
30
1907
918,042
4,672
5*0
1,465
1*5
31
1906
93i,681
4,944
5*2
1,640
1*7
33
1905
929,293
5,164
5*5
1,734
1*9
33
1902
... *
940,509
4,205
4*4
2,003
2*1
47
1892
897,957
5,194
5*7
2,356
2*6
45
1880
881,643
3,492
40
1,659
1*8
47
1870
792,787
3,875
4*9
1,492
2*8
38
1860
684,048
3,173
4*6
978
1*4
31
1859
689,881
3,173
5*1
1,238
1*8
39
1858
655,481
3,131
4*8 ...
1,068
1*6
34
1857
663,071
2,787
4*2
836
1*2
30
1856
657,453
. 2,888
4*4
1,067
1*6
37
1855
635,043
2,979
4*7
1,079
1*7
36
1854
• M
634,405
3,009
•/ •
4*7
954
1*5
31
1853
612,391
3,063
5*0
795
1*3
26
1852
624,012
3,247
5*2
972
1*5
30
1851
615,865
3,290
5*3
1,004
1*6
30
1850
593,422
3,252
5*5
1,113
1*8
34
1849
578,159
3,339
5*8
1,165
2*0
35
1848
563,059
3,445
6*0
1,365
2*4
39
1 At a meeting of the Section, held May 1 , 1919.
jc— 9
76 Bonney: High Maternal Mortality of Child-bearing
The ratio between the number of deaths directly due to pregnancy
and labour, and those returned as merely associated with pregnancy and
labour may be exemplified by the returns of the Registrar-General for
England and Wales for the five years 1911 to 1915.
Thus in 1911 there were 3,413 “direct ” deaths, or 3‘87 per 1,000
births, and 909 " indirect ” deaths, making a total of 4,322 deaths
“ direct ” or “ indirect,” or 4‘91 per 1,000 births.
In 1912 there were 3,473 “direct ” deaths, or 3'98 per 1,000 births,
and 848 “ indirect ” deaths, making a total of 4,321 “ direct ” and
“ indirect ” deaths, or 4'95 per 1,000 births.
In 1913 there were 3,492 “ direct ” deaths, or 3‘96 per 1,000 births,
and 803 “ indirect ” deaths, making a total of 4,295 “ direct ” and
“ indirect ” deaths, or 4'87 per 1,000 births.
In 1914 there were 3,667 “ direct ” deaths, or 4’17 per 1,000 births,
and 831 “ indirect ” deaths, making a total of 4,498 “ direct ” and
“ indirect ” deaths, or 5'12 per 1,000 births.
In 1915 there were 3,400 “ direct ” deaths or 4‘18 per 1,000 births,
and 881 “ indirect ” deaths, making a total of 4,259 “ direct ” and
“ indirect ” deaths, or 5'27 per 1,000 births.
It is to be noted that the ratio is between the number of maternal
deaths and the number of live births and not the number of labours or
pregnancies.
The Scottish statistics are as follows :—
Scotland.
Year
Birth*
Deaths
attaching to
Proportion
per 1,000
Deaths
by
Proportion
of deaths
by sepsis
Proportion of
deaths by
sepsis to
1915
114,181
childbirth
... 698 ...
live birth*
6*1
sepsis
262
per 1,000
births
2-3
total deaths
Per cent.
37 f
1914
123,924
... 746 ...
6*0
288
2-3
38
1913
120,516
... 708 ...
5*9
201
1-6
29
1912
122,790
... 675 ...
5-5
231
1-9
34
1911
121,850
... 699 ...
57
214
1-7
30
1910
124,059
... 710 ...
5*7
229
1*8
32
1909
128.669
... 699 ...
5-7
214
1-7
30
1908
131,362
... 676 ...
5*1
241
1*8
35
1907
128,840
... 686 ...
5*8
285
1-8
34
1906
132,005
... 717 ...
5*4
275
20
38
1880
124,570
... 620 ...
4*9
204
1*6
33
1870
115,390
... 583 ...
5*0
202
1*7
34
1864
112,333
... 628 ...
5*5
254
2-2
40 *
1863
109,341
... 571 ...
5*2
195
1-8
34
1862
107,069
... 435 ...
4-0
130
1-2
30
1861
107,009
... 511 ...
4-7
203
1*9
39
1860
105,629
... 564 ...
5*3
236
2-2
41
Those are disappointing figures, though they cannot be taken
entirely at their face value, first because a somewhat different method
Section of Obstetrics and Gynaecology
77
of computation has been adopted of recent as compared with more
remote years, and secondly because there has undoubtedly been, over the
period under consideration, a progressive improvement in the thorough¬
ness and accuracy with which certification has been carried out.
Thus for some years past, deaths certified as directly due to
pregnancy and labour have been classified separately from those
certified as merely associated with pregnancy and labour, whereas
before the “ direct ” and “ indirect ” deaths were all included together.
Moreover, in recent years, deaths from certain diseases, not previously
held to be the direct outcome of pregnancy, such as pregnancy nephritis
without eclampsia, have been included under the head of deaths directly
due to pregnancy.
These amendments in the method of computation and the improve¬
ment which has probably taken place in the accuracy of certification
operate unfavourably towards the figures of recent years.
The excessive maternal mortality from child-bearing in the United
Kingdom and its scanty diminution was forcibly commented on by
Sir A. Newsholme in a report on the subject in 1915. 1 He therein
showed that a high maternal mortality is associated with a corresponding
increase in the number of stillbirths and of infant deaths in the early
weeks after birth. He gives the following figures
In England the present average is 1 maternal death for every 250 registered births
In Ireland ■ ,, , t 1 M ,, >, 191 yt ,,
In Wales „ „ „ 1 „ ,, „ 179 ,, „
In Scotland ,, „ ,, 1 ,, „ „ 175 „ „
and states that “ on general grounds there can be no reasonable doubt
that the quality and availability of skilled assistance before, during,
and after childbirth are probably the most important factors in
determining the remarkable and serious differences in respect of
mortality in different districts.”
The following tables are also given by him:—
Death-bates peb 1,000 Bibths fbok Puebpebal Sepsis.
Wales
Years
England
(including
Monmeuth)
Scotland
Ireland
1881—1890
2*56
8-11
2-42
2-88
1891—1900
2*22
2-99
2*01
2*62
1901—1902
2 10
3*24
2*29
2*22
1903-1910
1*62
2*05
1*93
2*04
1911—1914
1*89
1*67
1-44
2-01
* A Report on Maternal Mortality in connexion with Child-bearing : Forty-fourth Annual
Report, Local Government Board, 1914-15.
78 Bonney: High Maternal Mortality of Child-hearing
Death-rates per 1,000 Births from Accident and Diseases of Child-bearing
other than Sepsis.
Walts
Years
England
(including
t Monmouth)
Scotland
Ireland
1881—1890 ...
2 08
2*99
3*03
4*24
1891—1900 ...
2-74
3*95
2-71
398
1901—1902 ...
2-33
3-66
2*66
3 99
1903-1910 ...
213
3-21
2-37
. • 3*41
1911—1914 ...
2-47
3-91
4-26
3*19
from which it will be seen that though some diminution has occurred
in the mortality due to puerperal sepsis, in England particularly, yet
the mortality due to diseases and accidents of child-bearing other than
sepsis has, except in the case of Ireland, risen appreciably.
He further gives the following table dealing with the total death-
rates in different periods of years:—
Total Death-rates per 1,000 Births from all Causes.
Wales
Years
England
(including
Monmouth)
Scotland
•Ireland
1881—1890 ...
4*64
6-10
5*45
7*07
1891—1900 ...
4-96
6*94
4*72
6*60
1901—1902 ...
4*43
6-89
4-95
6*21
1903 —1910 ...
... • 3-75
5-26
5*30
5*45
1911—1914 ...
3*86
5*58
5*70
5*20
from which it appears that comparing the period 1881-90 with 1911-14,
the total mortality has declined 17 per cent, in England, 9 per cent, in
Wales, and 26 per cent, in Ireland, whilst in Scotland it has remained
much about the same.
Now whichever way these figures are viewed they are thoroughly
unsatisfactory, for they show that over a period during which enormous
advances have taken place in every other branch of our profession,
obstetrics alone, as judged by its results, has advanced very little.
Something is wrong somewhere, and this applies not only to British
obstetrics but to obstetrics all over the civilized world.
In a very exhaustive and important report by Dr. Grace Meigs, of
the Department of Labour of the United States of America, 1 it is shown
that during the twenty-three years ending 1913, no definite decrease
in the death-rate of child-bearing can be demonstrated in the death
registration area of the United States.
Further it is shown from a study of the death-rates of fifteen foreign
countries, that only five of them—England and Wales, Ireland, Japan,
1 “ Maternal Mortality from all Conditions connected with Childbirth in the United
States and certain other Countries,” 1917.
Section of Obstetrics and Gynaecology
79
New Zealand and Switzerland—have effected any diminution in the
mortality of child-bearing in recent years, and of these, England and
Wales, and Ireland, are the only ccrantries which show a falling off in
the percentage of deaths due to puerperal sepsis.
It is to be remembered that of the total deaths an undue proportion
follow first pregnancies and labours, because puerperal sepsis and
pregnancy toxaemia, which as we shall see are the two chief causes of
death, are conditions which specially afflict women bearing children
for the first time. The death risk of these, therefore, is considerably
greater than the general averages given.
The Chief Causes of Death.
What are the chief causes of death directly due to pregnancy and
labour ? A perusal of the English and Welsh figures for 1912, 1913,
1914 and 1915, which may be taken as characteristic of all years, show
that in importance they rank as follows:—
(1) Sepsis, including phlebitis.
(2) Pregnancy toxaemia, including nephritis, eclampsia and vomiting.
(3) Haemorrhage, either before, during, or after labour.
(4) Embolism and other causes of sudden death.
The numbers of deaths due to these causes in the years named are
as follows:—
ID 12
1913
1914
i y i f>
Total deaths directly due to pregnancy and labour
Deaths from—
3,473 ..
. 3,492 ...
3,667 ..
. 3,408
Sepsis
1,280 .
.. 1,173 ...
1,422 ..
. 787 ..
. 1,253
Pregnancy toxaemia
662 .
.. 797 ...
. 663
Haemorrhage
610 .
.. 616 ...
696 ..
556
Embolism and sudden death
298 .
.. 267 ...
276 ..
242
Sepsis .—Puerperal sepsis, including under that term septicaemia,
pyaemia, phlebitis and all its other manifestations, is thus seen to be still
by far the commonest cause of death. The figures would probably be
higher still did they include every case in which bacterial infection of
the birth canal determined the fatal issue. For in the tables of deaths
not directly due to, but associated with, pregnancy it is seen that
pneumonia and influenza figure largely, a suspicious circumstance, seeing
how often pneumonia is the most striking feature of puerperal sepsis
and how frequently in septic cases the mistaken diagnosis of influenza
is made. Moreover surgical experience has shown that embolism after
operations is probably in most cases due to slight sepsis; for if the
charts of patients thus dying be examined it will usually be found that
80 Bonney: High Maternal Mortality of Child-hearing
the temperature has been slightly abnormal for some days preceding the
catastrophe. Further the frequency of sudden death after operations
by embolism has diminished of recent years concurrently with the
improvement in rapidity and smoothness of convalescence which modern
surgical teehnique has achieved. Septic infection of the wounds caused
by labour will probably never be entirely abrogated because in a certain
proportion of the cases the process is one of auto-infection. Nevertheless
in by far the greater number the infection is carried into the birth canal
by fingers or instruments, a largely preventable occurrence. During the
ten years 1906 to 1915 the mortality from septic infection in England
and Wales has remained very nearly constant, but with a slight tendency
to fall. In Scotland, however, although the material difference is small,
the figures indicate a slight tendency to rise. Comparing the years
between 1870 and 1902 with those between 1906 and 1915 we find,
however, that in England and Wales there has been some improvement.
Thus the mortality due to sepsis per 1,000 births was:—
In 1902 . 2 1 per 1,000
In 1892 . 2-6
In 1880 ... ... ... ... ... ... 1-8
In 1870 ... ... ... ... ... ... 2-8
whereas in the ten years, 1906 to 1915, it never exceeded 17 per 1,000
for any one year.
The year 1870 brings us back to the initiation of “ Listerism,” and
one would naturally suppose that in the years prior to this great event
the mortality from puerperal sepsis would be found to be considerably
higher than in the years after it. But—and this is a very striking
circumstance—the Begistrarial figures show nothing of the kind : on the
contrary, in the year 1860, the death-rate from sepsis is returned at 1'4
per 1,000 births, a figure as low as any of those of recent years, except
1913, when it was 1*3. Nq doubt it may be argued, and with justice,
that in these earlier times certification was much less accurately carried
out than nowadays, and that, in all probability, many deaths really
caused by puerperal septic infection were not recognized as being due to
such. But after every excuse has been made and every explanation
offered in the attempt to adjust to our satisfaction these jarring figures
the uncomfortable question still suggests itself: Have we so much
improved on the practice of pre-Listerian days that we have a right to
expect greatly improved results ?
It is true that devastating epidemics of puerperal septicaemia no
longer ravage our lying-in hospitals, and that from being the most
Section of Obstetrics and Gynaecology
81
dangerous places for labour to take place in they are now become
the safest. But, after all, the number of women confined each year
in lying-in hospitals forms such a trivial proportion of the yearly
total of confinements in the country at large, that even so great a
reduction in the institutional death-rate as has been accomplished in
the last forty years would not distinctly affect the death-rate of labour
in general. The diminution that has been effected in the death-rate
of ‘institution-conducted labour has been so dramatic that it has
obscured the voider issue, and most of us if asked whether obstetric prac¬
tice had not greatly improved in 1 the last forty years, would, thinking
in terms of the lying-in hospital, have returned an emphatic affirmative.
But the hard figures dispel this comfortable illusion. They show
that the great wave of progress initiated by Lister and swelled by
the host of workers in surgery treading after him, has passed over
obstetric art and left it not greatly changed.
Taking the conduct of labour in general, not much more than a
bowl of antiseptic lotion stands between the practice of to-day and
the practice of the sixties. But a bowl of antiseptic lotion is not
Listerism, though it was misconceived as such by many of the older
surgeons in the seventies and early eighties, and apparently, with the
addition of rubber gloves, is still misconceived as such by many
obstetricians up to the present day. The principle of antiseptic
surgery as conceived by its great founder was the creation of aseptic
conditions; in the wound primarily, and therefore as a corollary in all
that surrounded or touched the wound. Now the problem of how to
achieve such conditions is an exceedingly difficult one, even as regards
those regions of the body most favourable for its accomplishment; and
most of all difficult in connexion with labour ; and yet the immense
amount of thought and endeavour that has been expended on the
effective . application of the antiseptic principle as far as recognized
surgery is concerned, stands in marked contrast to the apathy on the
subject which distinguishes the practice of obstetrics. One reason for
this is that that method of infection of the birth canal wherein septic
organisms are conveyed from individual to individual has received
disproportionate attention, probably because it is the most obvious and
was responsible for the striking epidemics that afflicted lyingrin hospitals
in the past. But even in those days by far the larger proportion of
the cases of puerperal sepsis were probably due, as they are now, to
infection by the bowel organisms of the patient herself. For special
conditions of propinquity and rapid carriage are necessary for infection
82 Bonney: High Maternal Mortality of Child-bearing
from extrinsic sources and such only obtain in the minority of labours.
The problem of preventing extrinsic infection moreover is relatively
simple as compared with the prevention of infection from intrinsic
sources—for example, the wearing of sterile-rubber gloves practically
renders impossible the conveyance via the' attendants’ hands, of
organisms from one patient to another, but it in no way diminishes
the possibility of the carriage of anal organisms into the vagina.
Thus, although the antiseptic measures employed in lying-in hospftals
fall far short of those in use in general surgery they have sufficed
practically to abolish extrinsic infection, in spite of the fact that
the first requisite for its extensive occurrence, the collection of a
number of patients under one roof, remains as before. But intrinsic
infection producing more or less pyrexia is quite common still. The
symptoms are rarely severe, however, for the infection is probably
considerably modified by the antiseptic measures taken and moreover
the cases are promptly treated. In home-conducted labour, on the
other hand, in which extrinsic infection was probably always a
subordinate cause of puerperal sepsis, the adoption of antiseptic
measures on the average considerably less thorough than those
employed in lying-in hospitals, though potent to a certain extent
against extrinsic infection, has had little effect on the far commoner
intrinsic infection, against the occurrence of which nothing less than
a most elaborate antiseptic technique will suffice.
Besides the immediate loss by death of a number of fertile women
each year, the scarcely diminished prevalence of puerperal sepsis is of
national importance on account of the far greater number of cases of
acute illness that it occasions short of death. It is impossible to assess
accurately the mortality of the disease in relation to the number of
persons attacked because only the worst examples as a rule are
officially certified. Taking all cases of severe illness however caused
thereby, I believe that a death rate of 20 per cent, would not be far
from the mark ; that is, that for every one woman that'dies, four more
are very seriously ill. This morbidity is injurious to the nation in three
ways : first, the community is constantly deprived of the working
activities of a certain number of its members ; secondly, a considerable
proportion of these women are rendered sterile by the disease, whilst
others are discouraged from further child-bearing; and, thirdly, a
certain number of children perish because they have to be withdrawn
from the breast.
Pregnancy Toxaemia. —By far the larger number of deaths falling
Section of Obstetrics and Gynaecology
83
under this head are caused by pregnancy nephritis and eclampsia,
pernicious vomiting on the average only accounting for between thirty
and forty deaths per annum in England and Wales. There are rare cases
of eclampsia in which the onset is absolutely acute and without any
premonition whatever, but, in by far the larger number, forewarning
signs such as albuminuria, headache or vomiting are present for some
considerable time before the onset of the fatal seizure. Most of the
deaths from eclampsia are either the result of failure to observe the
premonitory signs, or to adopt the right treatment when the condition
is obviously declared, and the same applies to the deaths from pernicious
vomiting.
Haemorrhage .—About two-fifths of these deaths are due to placenta
prsevia, the remainder to other forms of ante-partum haemorrhage and
to post-partum haemorrhage. Deaths from haemorrhage in pregnancy
and labour are almost entirely preventable. In lying-in hospitals where
skilled supervision of labour obtains, practically the only deaths from
this cause are those hi which the patient is admitted having already lost
a great quantity of blood.
Embolism and Sudden Death .—The probable relation of embolism
to latent sepsis has already been commented on. Certain of the cases
classified under the above head may possibly be due to such disasters as
rupture of the uterus, but, beyond all gross physical causes, death from
sudden heart failure occurs occasionally after labour, not only in
women, but in the lower animals. These deaths from unexplained
cardiac failure must be looked upon as unpreventable in the present
state of our knowledge.
If it be true then, as it undoubtedly is, that of the number of deaths
directly due to pregnancy and labour the greater proportion could be
prevented, the scantily diminished yearly mortality constitutes a standing
reproach to the community at large and to the medical profession, and
in particular to the teachers of obstetrics. The remedy lies in nothing
less than a radical change in the conception of midwifery, both by the
profession and the public, and a complete revision of the attitude of
thought that dominates the teaching and practice of the art.
Midwifery a Surgical Art.
Pregnancy is a state induced by the growth of a neoplasm ; labour
is a process accompanied by self-inflicted wounds, and the puerperium
is the period of their healing. , .
84 Bonney: High Maternal Mortality of Child-bearing
Midwifery concerns itself with the treatment of these three, and is
a pure surgical art, for the diseases of the new-born child are the
province of the physician.
The product of conception causing hepatic breakdown or renal
disease or convulsions or menacing haemorrhage or pelvic impaction
is no less a life-endangering neoplasm than an hydatid cyst, an adrenal
tumour, a glioma, a uterine fibroid, or an incarcerated ovarian cyst, and
the problem of its treatment is a surgical problem.
Normal unassisted labour is an operation that the patient performs
on herself, and should have the environment proper to any other
operation that involves a breach of surface. Still more is this neces¬
sary in cases in which manipulative interference or operative assistance
may be required.
But not Recognized as such.
Unfortunately the conception of midwifery as a department of
surgery is still ^ery far from being established.. Let us examine the
reasons.
Founded on the art of the female midwife, obstetrics is the oldest
special branch of our profession, but, unlike the others, it arose not as
an offshoot, the result of the exuberant growth of medical knowledge,
but more or less as an independent subject, which in process of time
became grafted on to the main stem. That that process is not yet
complete is shown by the fact that medical art is still divided into
three primary divisions — medicine, surgery and midwifery — some
examining bodies even granting a separate diploma in the last named
subject.
The isolated position of midwifery is early brought to the notice of
the medical student. His text-books of physiology do not deal with
the function of reproduction; the diseases and disasters of child¬
bearing receive no mention in the lectures on general pathology; the
obstetric curriculum is divorced from the rest of his studies as though
the morbid processes with which it concerns itself were fundamentally
of a different nature to the rest of disease. He sees in some institutions
its exponents, though styled physicians, practising their calling almost
entirely by operative means. In the theatre attached to the lying-in
wards he witnesses labour conducted with the circumstances of modern
surgery, whilst in the extern department he finds the same procedures
carried out under conditions which would make any of the operations of
recognized surgery unjustifiable. He finds that at the London Uni-
Section of Obstetrics and Gynaecology
85
versity the M.D. degree may be taken in obstetrics, and that an essential
feature of the examination is a paper, not on surgical pathology, but
on general medicine, including tropical medicine!
What wonder, then, if, in the face of all these anomalies and contra¬
dictions, a conception of midwifery as a separate art, to which the tenets
of surgery only partially apply, grows up within the student, from him
passes on to the practitioner, and finally reaches the public.
The Consequences.
The ill-results that follow from this false conception are accentuated
by those flowing from another error perpetuated by the foolish reitera¬
tion of the word “ natural ” as applied to child-bearing, without compre¬
hension of all that “ natural ” implies.
Childhearing is a physiological process, but it stands alone amongst
such, in that while the rest of them are exercised on behalf of the
individual, reproduction occurs for the benefit of the race at the cost of
the individual. The toll thus levied on the female is exacted from
civilized and uncivilized women alike; animals, whether domesticated
or wild, whether high or low in the scale, do not escape it.
The analogy between reproduction and other natural acts has been
so much harped upon that the public has come to think little of the
dangers of pregnancy and labour, the latter of which, amongst the un¬
educated classes, is regarded as analogous on a larger scale to defsecation
or micturition. These two errors are responsible for maintaining great
public ignorance of the necessity for proper supervision during preg¬
nancy and pre-arrangement against the time of labour, and, as a
corollary, a disinclination to spend on these events an amount of
money commensurate with their importance.
In the practice of recognized surgery the medical man postulates
certain surroundings and accessories as a necessity for the successful
performance of his work, and without them, except under great
emergency, he refuses to undertake the case. Moreover, the public,
educated as regards recognized surgery, supplies his requirements
without demur, or being unable to do so, appreciates at once the
necessity of having the patient transferred to a hospital or home.
But in obstetrics a vicious circle obtains. The want of under¬
standing of the dangers of child-bearing and the “ surgicalness ” of
midwifery results in the public under-rating the requirements of the
art. Hence has been established a custom by which childbirth takes
86 Bonney: High Maternal Mortality of Child-hearing
place under conditions that sicken the surgical soul. The attitude of
the public in turn reacts on the medical man. He finds when he
begins practice that it is customary to conduct labour under conditions
that he feels to be faulty, but in the face of long usage, he hesitates to
undertake the task of changing them.
The conversion of the lying-in room into some semblance of an
aseptic operating theatre, efficient assistance, and an independent
anaesthetist are looked upon by many as academic ideals—unessential
and not to be pressed for in everyday work.
There are still in all great cities numbers of houses unfit for the
habitation of human beings. In such surroundings, with insufficient
material, scanty light, and inadequate assistance, the difficult operations
of obstetric surgery are frequently performed, and no vigorous voice is
raised in protest against the custom.
Most of us are familiar with the general surgeon who relates, in
tones of proud accomplishment, the occasion when he successfully
operated for, say, a strangulated hernia in a dirty cottage by the light
of a single candle and the assistance of only the anaesthetist and the
village nurse.
But what of the obstetric surgeon, who by evil custom amidst similar
surroundings, plays the part of operator and anaesthetist in his single
person, not on one exceptional occasion but over and over again in the
course of his professional life !
But the absence of the conception of the “ surgicalness ” of mid¬
wifery is by no means limited to the poorer classes. Consider the
average lying-in room in the average middle-class house. A double
bed, unwieldy and inconvenient, is the first object that strikes the eye.
By the side of it stands a commode. In one corner is the baby’s cradle,
in another is the cast-clothes basket, in the third is the washstand, and
upon it toothbrushes, bottles of hand and hair lotion, and the husband’s
shaving materials. The dressing table absorbs much of the floor of the
room and most of the light of the window. It is littered with brushes,
combs, hairpins, trays, boxes, photograph frames, wisps of shed hair
and such like rubbish ; in the midst of which a bowl of antiseptic solu¬
tion, in which some blobs of white wool have been immersed, stands
forlornly. A large wardrobe, three chairs, and a chest of drawers, the
top of the latter piled up with books, knicknacks and various odds and
ends, obtrude themselves on the already limited space. . The mantel¬
piece exhibits multifarious articles, none of them bearing any reference
to the matter in hand except a bottle of Three Star brandy, a feeding
Section of Obstetrics and Gynaecology
87
cup, and a cleaned soap bowl containing the time-honoured hut
ridiculous sheaf of threads for tying the cord. Under the dressing-
table are several pairs of boots; whilst airing in front of the fire, partly
on the fender and partly on the floor, is a heap of baby linen. Amidst
these surroundings lies the unfortunate woman on whom a surgical
operation, fraught with very definite risks, may presently be required to
be performed. Were the nature of it any other than obstetrical the
room would not be left in a state of such utter unpreparedness, but
would be cleared and converted as far as possible into an impromptu
operating theatre.
Pregnancy considered as an Abdominal Neoplasm.
The product of conception is as truly a neoplasm as any other uterine
tumour, and should be regarded as such. It differs from the rest of
them only in this, that it usually undergoes spontaneous cure. But
even in this regard it is not peculiar, for a uterine fibroid may be
expelled or be absorbed. It all other respects it is strictly comparable
with the other new growths. It may become malignant or be
malignant ab initio. It may become infected, impacted, or twisted.
It may rupture into the peritoneal cavity, or cause pressure symptoms
by its size. It may give rise to severe haemorrhage or undergo patho¬
logical changes as a result of which the possessor suffers from acute
toxic absorption, and its final expulsion may be accompanied or followed
by shock, haemorrhage or sepsis.
In the present state of our knowledge we have no specific treat¬
ment for the results of abnormal pregnancy beyond surgery. When
the neoplasm is endangering life, it must be got rid of, and at all times,
seeing its potentialities for harm, its possessor must be kept under
medical supervision.
It may be said that this is already common obstetric teaching, but it
is not. The student is instructed in the diseases and aocid,ents of
pregnancy and their appropriate treatment, but the big general prin¬
ciple is not taught him : he is taught to see the trees, but not the
wood. Nearly all the deaths caused by abnormal pregnancy are due
either to lack of medical supervision, whereby the menace of the
neoplasm is not discovered until it is too late to save the patient any¬
how ; or, the danger being discovered, to tardiness in ^applying the
general surgical principle that a life-endangering tumour should be got
rid of as soon as possible.
88 Bonney: High Maternal Mortality of Child-bearing
Labour considered as an Operation.
Labour, even normal labour, should be considered as an operation.
The first requisite for safety, therefore, is asepsis of the operation area,
or birth area, as we will call it. The vagina should be regarded as a
wound, into which the passage of anything unsterilized, in a fumbling
half-sighted manner, and without previous antiseptic preparation of the
surrounding skin, is a hideous transgression of the ritual of modern
aseptic surgery.
And under the term obstetric operation I would include not merely
the more obviously mechanical procedures such as forceps extraction,
craniotomy, and so on; but every manual assistance to delivery, even if
it run to no more than the hooking down of an arm, a single stitch in
the perinseum, or a vaginal examination.
The wearing of boiled rubber gloves during the conduct of labour
has become increasingly common of recent years. A layer of rubber
between the hand and the patient prevents the transference of organisms
from one 'to tjie other. So far, so good. But organisms from the
patient’s skin, or from bed-clothes, furniture, or any other unsterilized
surface, are carried as well by the gloved as by the ungloved hand, and
it is the organisms from these sources, and particularly the patient’s
skin, that are, and always have been, the chief agents of puerperal
sepsis.
With the anus as a centre there exists a zone over which intestinal
organisms are spread with a lessening intensity from centre to periphery.
That is the reason why the likelihood of infection of a wound increases
the nearer it is to the anus. This was. strikingly exhibited, to my own
observation, in the wounds in the late war. All must have noticed that
when a game bird or hare is hung it is the inner and upper thigh which
first becomes “ high. Now nature has made the mistake of placing
the birth area almost in the middle of this danger zone. The problem
set us is how to prevent or minimize the results of this mistake.
To prevent the conveyance of organisms from the adjacent skin into
the wound, the up-to-date operator in recognized surgery prepares the
skin beforehand with powerful antiseptics and further attaches towels
or rubber sheeting in such a way as to cut the skin out of the operation
area altogether. It is urgent that such principles be applied to labour,
for the skin of the ano-perineal region is the most heavily infected
of any skin-area in the body. Could we achieve sterilization of the
birth area or only relative sterilization, the mortality of childbirth
Section of Obstetrics and Gynaecology 89
would be nearly halved right away and the morbidity much more
than halved.
The recent introduction of the non-irritant yet powerful antiseptics
belonging to the aniline group goes far to place at the service of the
obstetrician the means of achieving sterility of the birth area. The
investigations carried out by Dr. C. Browning and myself, showed that
sterilization of. the ano-perineal area could be effected by the use of
“ violet-green,” and I have suggested that during labour this antiseptic
should be applied by compress to the vulvo-perineal skin until such
time as the head is about to be born. Further I think that this anti¬
septic should be used as a lubricant every time a vaginal examination is
made, and before any operative procedure is undertaken within the
vagina the canal should be thoroughly swabbed out with it. It has
been objected that the baby’s head will be stained, but this is a small
price to pay for protection against sepsis. Instead of violet-green,
flavine can be used, the colour of which is not so aggressive, while
it is .nearly as powerful an antiseptic.
Such measures would go far towards sterilization of the birth area,
but a danger remains—namely, that due to. the eversion of the anal
canal and the expression of mucus or faeces during the last phase of the
second stage. Provided that the lower bowel has been thoroughly
emptied beforehand, I conceive it would be possible to insert into the
rectum a suppository composed of one of these non-irritant antiseptics
sufficient to sterilize a mere escape of rectal mucus.
As however absolute sterility of the anal region will probably never
be able to be effected, we must seek to cut the anus out of the birth
area. This can be done by fixing over it either by clips or stitches,
a large gauze pad soaked in a strong non-irritant antiseptic. It is
impossible to fix sterilized towels round the orifice of the vagina in the
same way as they are fixed to the edges of an operation wound.
Having created a state of asepsis in the birth area, the next point
is to keep it aseptic. This is attained by rendering sterile all that is to
come in contact with the birth area and all that environs it. The
problem is simple compared with that which we have just considered,
for we have only to copy the ordinary arrangements of a modern
operating theatre. The lying-in chamber should be cleared as in
preparation for a surgical operation. All maternity nurses should be
thus instructed. At the present time not one in fifty does so. This
is partly due to want of teaching, and partly to the ignorance of the
patient and her relatives who object to the removal of the bedroom
<)0 Bonney: High Maternal Mortality of Child-hearing
trumpery. This is a matter for education. The obstetrician must,
of course, be gowned and gloved as befits a surgeon engaged in an
operative procedure, in which the avoidance of sepsis is all-important.
At a cost of less than a sovereign a tin containing a complete outfit of
sterilized gowns, towels swabs and gauze can now be obtained. The
day will come, I hope, when public opinion will cause them to be at
the free service of the poor. Without such an outfit the aseptic conduct
of labour is impossible, and the layman, niggardly of all expenditure
where childbirth is concerned, must be made to realize that no money
is ever better spent.
And still considering labour as a surgical operation I now pass
to another necessity for its proper conduct: the birth area must be
accessible. In the second stage of labour the side posture is that
always adopted in this country but it is a bad one; for it gives a poor
exposure of the parts for purposes of sight and touch, and, by placing
the anus nearest to the attendant renders more likely the conveyance of
bowel organisms into the vagina. For all operative purposes, except
Caesarean section, even for examination only, the lithotomy position is
the proper one. If the patient is not anaesthetized she should be placed
across the bed with her feet on a couple of chairs or rests. But when
under an anaesthetic she should be secured by Clover’s crutch or the leg
rests of an operating table. The idea of a surgeon performing curettage
or ligaturing piles without an anaesthetist is admittedly ridiculous, but in
obstetric work the practitioner, still to this day, is frequently diffident
of asking for such assistance, because by custom the public expects him
to combine the offices. Now an absolute necessity, in the problem of
how to render aseptic the technique of assisted labour, is an independent
anaesthetist. Even where the anaesthetic is to be administered merely
for the sake of relieving the patient’s sufferings during the last phases
of the second stage it should not be given by the obstetrician, for at any
minute it may be necessary for him to turn his attention to the birth
area. Equally faulty is the practice of the nurse acting as administrator
and leaving the medical man to manage the delivery unassisted. Both
these methods are irreconcilable with an aseptic technique even in a
straightforward case, whilst in circumstances of difficulty or emergency
the result is hopeless chaos. Further it is impossible for the obstetrician
to guard his gloved hands against contamination, unless he has besides
the anaesthetist, efficient assistance. For the proper conduct of assisted
or operative delivery four persons are required—the operator, the
anaesthetist, the two assistants, one or both of whom may be nurses,
Section of Obstetrics and Gynaecology
91
provided they are properly trained. Finally, we have to consider the
action of the obstetric surgeon himself and the principles that we, as
obstetric teachers, need to impress upon him.
Given that every factor in the labour is normal, the safest method
of delivery is self-delivery free of any interference with the birth canal
whatever. Patients deploring the fact that the child was born before
the arrival of the attendant have sometimes reason to bless their good
fortune instead. Every manipulation within the birth canal, even the
single examination to determine the position of the presenting part,
carries with it a definite risk of conveying sepsis, which must be
balanced against the advantages of the interference. This does not
imply that there is no possibility of sepsis after absolute self-delivery.
Sepsis by auto-infection may, and does, occasionally follow such labours,
but it is rare. It follows, therefore, that interference in labour should
never be undertaken needlessly. But—and this is the point 60 essential
to be taught—when interference is necessary, either on account of
obvious abnormality, or doubt as to the exact state of affairs, it must
be carried out with surgical thoroughness. More harm has been done
by single, slovenly, internal examinations than by all the deliberate set
operations of obstetrics put together.
And, setting aside for the moment interference on account of obvious
abnormality, the teaching should emphasize the importance in obstetric
work of being sure; for of all departments of surgery there is none
in which cardinal decisions have to be reached and acted upon so
quickly. A mistake in judgment results in untoward happenings, at
the best to be palliated but never entirely to be rectified. Such
mistakes will of course at times occur, even with the utmost precaution,
for no one is infallible. There are, however, two axioms that should be
instilled into the student’s mind in this connexion.
The first is that a plan of action decided on and carried out in a
determined, thorough, and surgical manner, even though it be not
the best suited to the conditions of the case is better than wavering
measures, conceived in uncertainty, and performed in a timid and
unsurgical way.
The second is, that when it is realized that a mistake in judgment
has been made, that course should be immediately adopted which most
surely minimizes its ill results to the patient. And in this matter
I hold very strongly that the safety and well-being of the mother is the
obstetrician’s chief concern in all cases, and in difficult labour his sole
concern. I mean, that if two courses are open to him, both of equal
ju—10
92 Bonney: High Maternal Mortality of Gliild-hearing
risk to the mother, but one having a lesser risk to the child, he should
choose that one, but in every other case he should choose that which is
best for the mother. For in labour it is not only the patient’s life that
has to be preserved, but her health and her capacity for further child¬
bearing, and questionable gain it is' to deliver a living child by means
that rend the reproductive apparatus to pieces.
Such severe labour, especially when followed by sepsis, quite
frequently leaves the woman sterile, or although fertile, unwilling to
undergo the trials of childbirth again; while others, on account of
uterine displacement or weakness of the pelvic floor,' have their
usefulness as members of society permanently impaired.
Let it not be thought that I am imputing lack of skill to the
practitioner in general. Far from it. The skill is there but it is
discouraged by the absence of the accessories and conditions necessary
to make it effective.
The Puerperium considered as a Period of
Post-operative Convalescence.
The wound in the uterus left after the separation of the placenta is
entirely comparable with that left after the vaginal enucleation of a
large uterine fibroid, and the perineal wound caused by the child’s head
with that incurred in the performance of plastic enlargement of the
vaginal orifice.
The wounds of labour are more likely to become infected than those
of the gynaecological operations I have cited, because laboqr is a larger
operation involving more bruising of the tissues, and, under present
conditions, is not performed under anything like the same conditions of
surgical asepsis. Moreover sepsis, if it occurs, tends to run a much
more severe course, because of the enormous venous and lymphatic
hypertrophy that accompanies pregnancy.
The general management of puerpery should be conducted in the
same way as the convalescence after any other vaginal operation. The
wound in the uterus is inaccessible, and we have no means of dressing
it, but we can help to secure drainage by propping the patient up in
bed. The perineal wound, if it was aseptic when it was sutured, needs
no dressing. I believe that it is very rare for any wound to become
infected after it has been sutured. But to close an already infected
wound is disastrous.
The teaching that has for a long time obtained in text-books, that
Section of Obstetrics and Gynaecology
93
all perineal lacerations- should be sutured, urgently requires to be
supplemented by the proviso that, before doing so, they must be sterile,
otherwise it is far better to leave them open and at least secure
drainage. To close up with sutures an insignificant perineal lacera¬
tion which is already infected by the passage over it of fingers
recently contaminated by the anus, directly makes for serious sepsis.
That recently infected—even heavily infected wounds, can be sterilized
before suture by the application of antiseptics has been proved
conclusively during the war.
Septic perineal lacerations can be treated by the direct applica¬
tion of antiseptics, but for sepsis. of the placental site we have at
present no treatment beyond supporting the patient’s strength—and
he who thinks otherwise deceives himself. '*
The whole teaching on the subject of the treatment of puerperal
uterine sepsis needs to be revised. Consider the problem. The
patient is suffering from the effects of an acute toxaemia originating
from organisms sequestered in the uterine sinuses, veins and lymphatics,
and perhaps in other situations still more remote from the uterine
cavity. To remove or kill the organisms or neutralize their toxins is
the only solution of the problem, and we can at present do neither the
one nor the other. Instead, what is done ? The uterine cavity is douched
or explored with the finger and scraped—a futile proceeding, for the
organisms in the cavity are not those causing the symptoms. But
it is worse than futile, it is dangerous, for the necessary manipulation
frequently dislodges thrombi and liberates organism's into the blood
stream at large. The rigor that so frequently follows these proceedings
is characteristic of the entry of injurious matter into the circulation—
you see it in malaria when the stretched blood corpuscles rupture and
the spores escape; and after intravenous infusion, especially of foreign
serum.
I have over and over again seen cases of relatively slight puerperal
fever converted into examples of virulent sepsis by these mistaken
methods of treatment. They are perpetuated by the continued teaching
of that gross error that puerperal sepsis is commonly caused by fragments
of the gestation retained in the uterus.
It is astonishing how blindly unobservant we all are and how stiffly
we become obsessed with what is taught us, though it fly in the face of
the obvious. There are no gross retained pieces in the uterus in
puerperal sepsis; not once in a hundred times. A variable quantity
of soft debris can be scraped out of any puerperal uterus, septic or
94 Bonney: High Maternal Mortality of Child-bearing
not septic. We must get rid of all that German teaching about
“ septicaemia ” and “ sapraemia,” and the “ germs that flourish on dead
tissue ” which is so dear to the heart of the student, and start to think
for our selves.
The placental site infected by organisms originally derived from the
bowel is from the pathological standpoint exactly comparable with the
infected wounds of the late war. Gas gangrene is uncommon in puer¬
peral sepsis, because the muscle of the uterus is unstriped, and the
Bacillus aerogenes flourishes chiefly in striped muscle; while, more¬
over, the extensive bruising and laceration that in war wounds aids* the
development of this organism is absent. But in all other respects the
obstetrician has always been familiar with those results of profound
wound sepsis which have come as a surprise and a revelation to a
generation whose experience has been limited to the results of wounds
as modified by the practice of Listerism.
Owing to the anatomical position of the placental site, the
methods which in the later phases of the war were applied with such
conspicuous success to infected bullet and shell wounds, are only very
partially applicable to the major wound of labour. These methods were
of three kinds :—
(1) The immediate sterilization of the wound by strong antiseptics
before the infection had time to become profound.
(2) Progressive sterilization of wound3 already profoundly infected
by the continuous application of antiseptics until such period as the
wound became aseptic, after which closure might be effected (Carrel).
(3) Immediate excision of the whole wound before the organisms
implanted in it had time to multiply at all.
The first method has a scope in these cases in which it is known
at the time of the labour that the uterine cavity has probably been in¬
fected as the result of intra-uterine manipulation or instrumentation.
In such it is possible by the immediate application of a strong anti¬
septic to destroy the infecting organisms. The antiseptics of the
aniline group are peculiarly suitable for such immediate sterilization.
The second method which was developed by Carrel and Dakin with
most successful results is not capable of satisfactory application to the
profoundly infected placental site, for more is demanded than the mere
continuous application of an antiseptic. Previous excision of the wound,
or, if this be impossible, very thorough cleaning up of it, together with
removal of all damaged and dead tissue, and the freest drainage is
required. It is impracticable to do this in severe puerperal sepsis, for
Section of Obstetrics and Gynaecology
95
the placental site is too inaccessible to allow of thorough cleaning up,
whilst excision of it is impossible short of removing the uterus, and by
the time the patient is sufficiently ill to suggest such a drastic step the
organisms have, as a rule, spread beyond the uterine wall. Moreover
the technical difficulties of arranging irrigating tubes so as to be sure of
reaching every part of the infected uterine surface are great. The
method might be successful could it be carried out in the earliest stages
of puerperal infection, but the manipulations necessary to the pro¬
ceeding carry with them a risk of dislodging infected thrombi, which
probably outweighs the advantages to be gained.
The third method, which was the culminating achievement in the
treatment of war wounds, is utterly inapplicable to the major wound of
labour. It would necessitate the performance of hysterectomy at the
close of every confinement in which there was a possibility of infection
of the placental site.
The attempts that have been made to destroy the organisms of
puerperal sepsis or neutralize their toxins by antidotal sera, vaccines
and the intravenous injection of bactericides have all up to the present
been dismal failures. It is true that many patients thus treated
recover, but so do patients not so treated. All of us are a great deal
too much inclined to mix up post and propter hoc. My own opinion
after an extensive trial of all these methods of treatment is that they
are useless.
A method of curing puerperal sepsis will doubtless be discovered
in the future, but until then prevention is our only weapon. And
thus I come back to the urgent necessity for regarding labour as a
surgical operation fraught with risks of sepsis against which nothing
short of a very elaborate antiseptic technique will suffice.
Conclusions.
The conception of midwifery as a surgical art necessitating for
its successful prosecution the full gamut of modern surgical require¬
ments implies nothing less than a complete alteration of the conditions
under which it is at present practised, and until this change is accom¬
plished no satisfactory diminution of the mortality of child-bearing can
be expected.
The co-operation of the public is essential, and this will not be
secured until it is made to understand that the national and individual
advantage accruing from the change are worth the large sum of money
which will have to be spent on it.
96 Bonney: High Maternal Mortality of Child-hearing
In the present state of affairs the slight demands made on behalf of
his art have resulted in the public habitually underpaying the obstet¬
rician, though the outfit and skill demanded of him are at least as
great as those required in other departments of surgery, while the time,
trouble, and general wear and tear that attendance on a confinement
involves, is out of all proportion greater. Midwifery, in fact, does not
pay, except in so far as it serves as an introduction to other forms
of practice; a pernicious thing, for underpaid work can never be the
best work.
On the other hand it is essential that the monetary cost of child¬
bearing—cost to the husband and wife, I mean—shall not be so high as
to discourage reproduction. It may with much justice be argued that
the expenses of childbirth up to a certain equitable figure should in all
cases be born by the nation to whose advantage the child is brought into
the world.
The passing of the Midwives Act and the recent establishment of
ante-natal clinics in many parts of the country are both steps in the
right direction, but much more is needed.
A midwife single handed, still less than a doctor single handed,
does not comply with the requirements of labour, which like any other
operation demands “ team work ” for its proper conduct.
No figures are available giving the yearly number of recognized
surgical operations performed in this country, but the total must be
considerable. The larger proportion of them take place in hospitals,
a smaller proportion in nursing homes, and the remainder in private
houses.
When the public has been made to understand that labour itself is
a surgical operation there will be a similar distribution of confinements.
This will necessitate the establishment of large lying-in hospitals all
over the country, maintained out of public funds, either national or
municipal. Besides free beds there should be paying wards and separate
rooms for such as can afford them, the amount to be paid being arranged
according to the patient’s financial position, judged, perhaps, on their
rate assessment.
These hospitals should be the centres for the teaching of midwifery,
both to medical students and midwives, the former of whom should be
resident in them for at least three months.
Extern departments as they are at present carried on should be
abolished. They perpetuate all the worst features of midwifery as
practised to-day, the inadequate surroundings, the wretched light, the
Section of Obstetrics and Gynaecology
97
meagre assistance and the dirt, and lead the student to think that
the regime of the labour ward is an academic ideal unrealizable in
general practice.
Women unable or unwilling to enter the lying-in hospital would fall
into two classes: First, those whose means enabled them to command
the necessities for the surgical conduct of labour in a nursing-home,
or in their own home ; and, secondly, poor patients whose erftry into
hospital was impossible on account of domestic reasons or the sudden
onset of unexpected labour.
This latter class might be dealt with by having attached to the
central hospital an extern team—i.e., an obstetric surgeon, an anaes¬
thetist, and two nurses, with a complete outfit and a motor car to carry
them. The team should be able to be summoned free by the medical
man or midwife in attendance on the case, for given such a team the
requirements for the surgical conduct of labour could be constructed
in the poorest room, just as they can be for an emergency operation in
recognized surgical practice.
In the staffing of these large hospitals the medical men of the town
or district should take a large part and be paid for doing so, but a
certain number of resident obstetricians would also be required.
Patients taking private rooms should be attended by their own medical
man, and should pay him an adequate fee. The permanent resident
staff should be at his service and should co-operate with him in the
conduct of the labour, the routine of which he would already be quite
familiar with, having been trained in that or a similar hospital.
Such is a rough sketch of what is required before we can hope
to see a progressive diminution in the mortality of child-bearing
comparable with that already effected and continuing to be effected
in every procedure of recognized surgery.
Let me not be misunderstood. I want to see midwifery not
necessarily more “ operative,” but more “ surgical,” which is quite
another thing. I want to see it taught and practised as a branch of
surgery. The difficulties in the way of attainment are great, for we
have to undo the results of fifty years of cramped outlook and “ laissez
faire.” The whole edifice of obstetrics needs to be set in order, but the
foundations, the primary concept for which we, as teachers, are entirely
responsible, first of all.
98 Bonne) T : High Maternal Mortality of Child-bearing
DISCUSSION..
Sir FRANCIS Champneys : I notice that Mr. Bonney’s tables are based
upon the ratio between the number of maternal deaths and the number of live
births. "Why is this method adopted ? The results are somewhat strange to
me, and would seem to show that practically no improvement has taken place
since 1849. In 1910 I replied to a somewhat similar statement by Sir William
Sinclair from figures furnished from the Begistrar-General’s Beports, and
embodied in Appendix A of the Beport of the Departmental Committee on the
working of the Midwives Act 1902, p. 24, by the following quotations : “From
Table A, giving the annual death-rates from puerperal sepsis per million of
females living, it would be seen that the death-rate in 1902 was 118, and in
1907 it was 81. The census of 1901 showed that in England and Wales there
were 16,800,000 women. The saving of life in 1907, as compared with 1902,
was 37 per million. In other words, the lives of more than 621 women were
saved in 1907 which would have been lost in 1902. Table B, calculated in the
proportion of 1,000 births, showed the same thing, and these results were
graphically set forth in diagrams A and B. Diagram C, showing the death-
rates from puerperal sepsis and accidents of childbirth to 1,000 births, shows
that this rate prior to 1903 was never below 4*41; in 1907 it was 3*83.
Striking evidence was given before the Departmental Committee to the same
effect. As regards infantile mortality, Dr. Bobinson, of Botherham, stated
that while the death-rate in cases attended by midwives was 101 per 1,000 in
1907, the death-rate in cases not attended by midwives was 194; in 1908 the
mortality in midwives’ cases was 92, in non-midwives' cases 195.” I have
been favoured by Dr. Stevenson, of the General Begister Office, Somerset
House, with a continuation of the figures up to and including 1911, and now
give the calculation up to that date which is arrived at by substituting the
results of 1911 for those of 1907 : “ From Table A, giving the annual death-
rates from puerperal sepsis per million of females living, it would be seen that
the death-rate in 1902 was 118, and in 1911 it was 72. The census of 1911
showed that in England and Wales there were 18,672,986 women. The saving
of life in 1911, as compared with 1902 was 46 per million. In other words
the lives of 859 women were saved in 1911 which would have been lost in
1902. Table C, showing the death-rate from puerperal sepsis and accidents of
childbirth to 1,000 births, shows that this rate prior to 1903 was never below
4*41; in 1911 it was 3*67.” These figures show that the passing of the
Midwives Act was followed by a sudden and considerable fall, and that the
improvement since this has been gradual and comparatively slight. It would
seem that the great initial improvement in the puerperal mortality must
have been due to improvement in the midwives ; we may hope for still
further improvement not only in cases attended by midwives but by medical
Section of Obstetrics and Gynaecology
99
practitioners, but can hardly expect so striking a change in the future. 1 So
far from the subject being buried in a general gloom of despair three
things plainly emerge from the above considerations: (l) That the bringing
into operation of the Midwives Act was marked by a sudden and striking
drop in puerperal mortality; (2) that this must have been due to the
operation of the Act upon the practice of midwives only; (3) that no such
marked improvement took place in the mortality from accidents and diseases
of child-bearing other than sepsis. These facts are clearly evident also from
Sir Arthur Newsholme’s tables quoted by Mr. Bonney. In order to ascertain
where the defect lies it is important to know by what class of attendant
patients are delivered ; and, with this object the Central Midwives Board
some years ago asked the Registrar-General to allow a space to be left in
birth certificates for the name of the person actually delivering the mother,
but this application was not successful. I agree with Mr. Bonney that the
present loss of life and health is not satisfactory, and that we must do all in
our power 1 6 reduce it.
Mr. Bonney says : “ The year 1870 brings us back to the initiation of
‘ Listerism,’ and one would naturally suppose that in the years prior to this
great event the mortality from puerperal sepsis would be found to be
considerably higher than the years after it. But . . . the Registrarial figures
show nothing of the kind.” The history of antiseptics is one of the most
curious on record. The discoverer of antiseptics was not Lister in 1870 but
Semmelweis in 1847. The medical world would have none of him, and he
died in despair, insane. Had they not been so stupid and prejudiced obstetrics
would have been in the van, and surgery would have followed in the rear. As
it was, the order was reversed, and those who refused to enter the promised
land had to wander some forty* years in the wilderness. Now, although
Listerism was initiated in 1870, antiseptic midwifery was only started in any
London lying-in hospital in 1880, when it was set up at the General Lying-in
Hospital by Sir. John Williams and myself. The methods of Lister had to be
adapted to obstetrics, and we had to feel our way, but the results were immediate
and striking. Antiseptics in midwifery were only absorbed gradually and slowly
into private practice; I doubt whether they are even now thoroughly and
universally carried out. I should like to know the facts on which Mr. Bonney
founds his statements that: “ Even in those (past) days by far the larger
proportion of the cases of puerperal sepsis were probably due, as they are now,
to infection by the bowel organisms of the patient herself.” It is plain
that Mr. Bonney considers the anus the chief source of septic danger. How
does he account for the following facts: A ruptured perinaeum has no special
tendency to become septic ; it generally heals quickly and healthily ; operations
on the perinaeum and rectum have no special dangers from sepsis ? How could
these things be if the anus were such a plague spot as Mr. Bonney thinks ?
The presence of bowel organisms is undoubted, but they seem to do no special
1 Proceedings , 1910, iii (Sect. Obst. and Gynaecol.), pp. 231, 232 : see also Journ. Obst.
Gymecol. of Brit. Emp ., 1914, xxv, pp. 304, 305.
100 Bonney: High Maternal Mortality of Child-bearing
harm. The case with the other end of the alimentary canal is much the same.
The mouth of an average man is so septic that the rinsings from it if injected
into mice are generally fatal. And yet we do not get septicaemia from the
extraction of a tooth or from biting our tongues. I suppose that in this
case Nature has placed the dock-leaf near the nettle, and that a natural
immunity has been created and maintained by antibodies. Nature is not so
foolish as Mr. Bonney imagines.
I cannot agree with his condemnation of “ German teaching about
“ septicaemia ” and “ sapreemia,” nor that it should be got rid of. A case of
sapraemia is one of the most picturesque of medical experiences, though such
cases can usually be only suspected and not proved until they are over.
Innumerable times have I seen a patient gravely ill with the usual symptoms
completely and quickly convalescent after removal of retained products, usually
after a single and severe rigor.
With much of what Mr. Bonney says I agree. Midwifery needs developing
on a large scale throughout the country, with large and well-equipped lying-in
hospitals within the reach of all, and with the organization of team-work. As
to the delivery of every parturient woman in an institution I do not believe
that it would be feasible, even if desirable, but I believe that the nation is
determined that insanitary homes, in which a woman cannot safely be confined,
shall become a thing of the past. Finally, Mr. Bonney’s picture of the
“average lying-in room in the average middle-class house’’ does credit to his
imagination. I think it must be a “ composite photograph,” for I cannot believe
that he has ever seen all the articles enumerated in his inventory in the
same room at the same time.
Dr. Herbert Spencer : There are many points in Mr. Bonney’s paper
with which I am in agreement, such as the treatment of the septic uterus, the
need for an increased number of lying-in beds, and for improvement amongst
certain practitioners of their antiseptic and aseptic methods. But I think
Mr. Bonney, in calling labour a surgical operation, has been led into a some¬
what illogical position. His paper deals with maternal mortality and its
prevention by those antiseptic and aseptic measures which every student
learns, and his remarks about the modern conduct of labour are too sweeping
and are an unmerited aspersion upon the great bulk of practitioners and
nurses. The statistics given by Mr. Bonney are admittedly inaccurate, owing
to altered methods of registration in recent years; but it is also unfair to give
the percentage of maternal deaths to the number of live births instead of the
number of labours. In any case, if labour is a surgical operation (as Mr*
Bonney maintains), the obstetrician can congratulate himself, for a mortality
of 1‘3 per 1,000 from sepsis can be shown for no other surgical operation of
importance. Mr. Bonney is mistaken in regarding organisms from the patient’s
skin as the chief cause of death in puerperal sepsis. Is it true that Nature
has made a mistake in placing the birth passage near the anus ? It seems to
•mis more probable that there has been no mistake, but that Nature, in placing
Section of Obstetrics and Gynaecology
101
it there, has given woman fifteen years to become immune to the action of the
rectal micro-organisms. Everyone must have been struck with the uniform
success of plastic operations for old complete ruptures of the perinaeum, in
which no antiseptic is applied to the raw surface, which must be infected with
the Bacillus coli. The suggestion to disinfect the rectal contents during labour
by inserting a suppository seems to me to be unpractical in view of the action
of labour on the rectum. Mr. Bonney’s picture of the shortcomings of maternity
nurses in preparing the lying-in chamber is exaggerated, and only less highly
coloured than the antiseptic he recommends. I think British mothers would
object to have their babies’ heads stained green. Every obstetrician agrees
as to the importance of gloves, aseptic clothes and dressings and antiseptics
for the skin ; but the ordinary antiseptics, especially perchloride of mercury,
prevent deaths from sepsis in the practice of those who employ them properly.
However convenient to the obstetrician the clinic may be, I maintain that in
a decent private house a patient can be attended as safely as regards sepsis,
and, in some respects, more safely than in a clinic. No doubt there is a need
for more lying-in beds for patients with inadequate houses, but a large propor¬
tion of pregnant women will always have to be delivered at home. Outdoor
maternities show a very low mortality from sepsis, and are a valuable training-
ground for students. Mr. Bonney admits that the “ extern team ” could deal
with the cases in the homes of the poor, but the motor-car with its obstetric
surgeon, anaesthetist, two nurses, and complete outfit would not suffice for the
attendance of half-a-dozen women at the same time.
Dr. Amand Routh : The question of how to lessen the maternity and
infantile death-rate has been the theme adopted by most Presidents in their
inaugural addresses. In 1911 I took up the subject and showed that in the
previous twenty years the total maternity death-rate had gone down from
6*5 per 1,000 living births to 4*7, the deaths due to sepsis from 2*6 to 1*4,
and the proportion of septic deaths to total deaths had been reduced from
45 to 28 per cent. There seemed then to be reason to hope for further
progress, founded upon the better education of midwives and medical students
in antiseptic midwifery; the substitution of trained midwives for the 12,500
untrained midwives put on the Roll of Midwives by the Midwives Act of 1902;
and the enforced notification of cases of puerperal septicaemia throughout
England and Wales in 1911. This hope has not been justified, for the
improvement between 1892 and 1910 has not been continued. (The total
maternity death-rate per 1,000 living births in 1917 having been 4*8, and the
death-rate from sepsis 1*3, whilst the percentage of cases of sepsis to the total
deaths remained at 28 per cent., almost identical figures.) Mr. Bonney’s views
that obstetric examinations, manipulations and operations should be treated
as surgical cases is obviously correct, and his proposals, so far as they are
practical, are also entirely justified. His view that puerperal septicaemia is not
infrequently due to infection from intestinal organisms is however not proved
by him, nor do I think his consequential proposals to prevent such infection
102 Bonney : High Maternal Mortality of Child-hearing
are practical. The germs present in the bowels are : Streptococcus fsecalis ,
Bacillus bulgaricus , Bacillus coli communis , Bacillus acidi lactici , and Bacillus
enteritidis. What evidence is there that any of these ever produce septicaemia?
It would have been more convincing if Mr. Bonney h#d brought bacteriological
evidence to prove that normal intestinal organisms can produce puerperal
septicaemia. Mr. Bonney blames Nature for placing the birth area near the
intestinal exit. In all mammals, except monotremes and tnarsupials, the
allantois becomes attached to a definite region of the uterine wall, and a
placenta is formed in the higher mammals with interlocking of maternal and
foetal tissues necessitating a tearing of the foetal from the maternal portions
of the placenta at birth, whilst in the lower mammals there is a so-called
discoidal placenta where there is no such intimate interdigitate union, and the
foetal placenta separates easily from the maternal placenta. Boughly speaking
a common cloaca does not exist in placental mammals, except in some rodents
where the placenta is discoidal, so that Nature has deliberately placed the
recto-vaginal septum between the uro-genital and the intestinal exits wherever
there is a birth separation of the placenta which involves an intra-uterine
wound. This difference between amphibians, reptiles and birds, on the one
hand, and placental mammals on the other, proves that the question of a
“ danger zone ” was duly considered by the Creator, and no further separation
of the intestinal and birth areas was considered necessary than has been
provided. If intestinal organisms were as infective as suggested, hosts of
mammalian animals would die of puerperal septicaemia. Think of what
happens when a litter of pigs is born in a pigstye. Surely, too, the results
of operations in what Mr. Bonney calls “ the danger zone ” are prima facie
evidence that normal intestinal organisms do not infect w r ounds in the same
individual owing to natural immunity. One has only to name operations for
piles, fistulae, and for tom perinaeums ruptured even into the bowel itself.
Such operations prove successful even though faeces may be contaminating
the wounds during the operation. Operations on perinaeums ruptured into
the rectum, weeks after the occurrence, with intervening daily soiling of the
rupture area by faeces are frequent, yet the plastic operation is quite successful.
I believe that cases of auto-infection are very rare, and that the anal area
is not a source of infection apart from abnormally virulent organisms, or
organisms which have become virulent during acute intestinal affections-
Individuals are immune against their own normal organisms. As regards
treatment of early localized septicaemia, the prompt exploration of the uterine
cavity under anaesthesia, if the temperature is going up early in the puerperium,
and the gentle use of a blunt flushing curette or a bunch of gauze held in
forceps, followed by a free application of a 1 in 4 iodine solution all over the
mucosa, and especially over the raised placental site, will stop the large
majority of infections before the pelvic veins are involved and the septicaBmia
generalized. And in all such septic cases I strongly recommend twenty-drop
doses of liq. ferri perchlor. every three hours, even in apparently hopeless
cases, for I have seen many such cases recover in puerperal and other cases of
acute sepsis which had been given up by others.
Section of Obstetrics and Gynaecology
103
Dr. RUSSELL Andrews : There is one point on which I cannot agree with
Mr. Bonney absolutely—viz., that in septic cases there is seldom retention of a
piece of placenta. From a teaching point of view this is a dangerous statement.
In cases that come under my care retention of a portion of placenta occurs
much more commonly than in 1 per cent., sufficiently frequently to justify
a warning as to the danger of omitting to examine the placenta carefully in
every case of labour. I agree, however, that in the large majority of cases
of -puerperal sepsis the uterus is empty. Some such scheme as that which he
has sketched is necessary for the treatment of patients who cannot pay a fee
which is large enough it make it worth the while of their medical attendant to
devote, if necessary, many hours to their case. It is greatly to be regretted
that a doctor, who is going to receive a fee of a guinea, or 30s., for attendance,
cannot, from a purely business point of view, wait for the natural termination
of a tedious labour. Some do, but there is a great temptation to hurry the
delivery. It is not uncommon to have patients sent into hospital on account
of so-called obstructed labour, repeated attempts at delivery with the forceps
having failed, when the only obstruction is the incompletely dilated cervix.
Among the cases of puerperal sepsis which come under my care there is a very
high percentage of cases of forcible extraction with the forceps with tearing of
the cervix and vagina and perinaeum. A remark made to me some years ago
by a doctor who had sent into hospital a patient with eclampsia is pathetic
and instructive: “ I can't help feeling that I did the right thing in sending her
into hospital, although of course I lost the guinea ! ”
Dr. LAPTHORN Smith : I agree with everything Mr. Bonney has said.
Although there has been an immense improvement in the care of the parturient
woman since the Midwives Act has come into force much yet remains to be
done. Some of the most necessary things she requires she does not get; such
for instance as fresh air, sunlight, and plenty of water. And yet they cost
nothing. No one who has not actually seen it would believe the conditions
under which many thousands of confinements take place. In mentioning
the insanitary contents of the crowded room and the small amount of air
space, Mr. Bonney has understated rather than exaggerated the unclean sur¬
roundings. The windows closed to keep out the air, a shawl or shirt pinned
over the window to keep out the light for fear of giving the baby sore eyes,
the lack of pure cold water for fear of giving the mother a chill when her
system is craving for it to make good the loss by perspiration, respiration,
urination and defsecation, as well as the large amount required for lactation.
Another thing from which even the poorest might benefit but from which she
is debarred by prejudice, is drainage. The prehistoric nurse will not allow her
to lift her head from the pillow, and as a result large clots and decomposing
debris from the uterus remain for ten days in the vagina, as a most favourable
culture medium for bacteria, which are absorbed through the placental site or
leak through the tubes into the peritoneum. If she sat up on a chamber six
times a day to pass water and sat up in bed for meals and nursing she would
104 Bonney: High Maternal Mortality of Child-bearing
get drainage. Then again there are many very busy practitioners who are
opening abscesses and dealing with pus all day who are suddenly called to a
confinement only to find that there are no facilities for disinfecting their
hands. The untrained nurse may .just have left an infected case. The woman
runs a double risk from which two pairs of rubber gloves boiled in the tea
kettle would save her. I would like to hear that they were used at every one
of the thousands of confinements which take place every year. Then again
there is the large number of deaths from eclampsia, not one of which would
take place if every pregnant woman was instructed to have her water examined
at least once a month during the last four months. Doctors, midwives, and
ante-natal clinics should all combine to make this fact known. Then there are
the tears of the cervix and perinaeum due to the too early application of the
forceps, or as Mr. Bonney has said, before the cervix is half dilated. The
doctor who produces these tears will often tell you that he has never seen a
tear of the perinaeum ; and I quite believe him, for he does not look for them,
and even if he did he would not see them in the badly lighted room. But if
both tears of the cervix and perinaeum were immediately repaired under aseptic
conditions the mortality and morbidity of childbirth would be greatly lessened.
Why does the harassed general practitioner do those things which he should
not do, and leave undone the things he should do ? Mr. Bonney and several
other speakers have given the explanation. It is the pitiful fee of one guinea for
spending a night in such a place as has been described, and then making ten visits
free and paying for the cab and the chloroform out of his own pocket. Until
all women can be taught to look upon a confinement as a serious matter, not
to be entrusted to any inefficient practitioner, but to a well trained and decently
paid doctor, who alone should have the choosing of the nurse, and to put her¬
self in his hands during the whole of her pregnancy, there is not much chance
of abolishing the death-rate. It is not always because the people cannot
afford to pay a decent fee but because they have not been educated up to it.
I am sure that most of the deaths from puerperal diseases occur among the
class above described. Would it not be far better that all these women should
be sent into a hospital for confinement under aseptic conditions, where, if
they were sent in early, there would be no deaths. By so doing, senior
medical students and midwives would be able to gain valuable experience by
seeing them delivered by a master of the art, who would show them over and
over again how an ideal delivery should be conducted.
Mr. Harold Chapple : Like Mr. Bonney, I w T ish to see midwifery
conducted off modern surgical lines. In spite of the assurances of some
of the speakers that all is well, there is no question that many women
die annually and very many more are permanently crippled as a result of
childbirth. In the majority of cases the cause is sepsis. Nor is the reason
far to seek, as the circumstances under which labour is conducted are, to those
of us w T ho are trained in modern methods of asepsis, often pathetic in their
complete disregard of the requirements of modern surgery. The interior of
Section of Obstetrics and Gynaecology 105
the uterine cavity is sterile, as we have proved many times from swabs taken
from the uterus in cases requiring Caesarean section. The treatment of an
infected uterus is at its best so unsatisfactory that our utmost endeavour
should be to render it impossible for that organ to become infected. Yet
there are still many men who might hesitate to place an infected hand or
instrument into the peritoneal cavity, but show in practice no such regard for
the uterine cavity in the full knowledge of the tragic sequelae that are not only
possible but all too frequent.
Dr. F. J. McCann : This is a question of the greatest national import¬
ance. It must be confessed that in our war against puerperal infection we
have suffered a heavy defeat. The number of deaths has been largo and con¬
tinues to be large, whilst the number of wounded and permanently disabled
has never been estimated. The latter are numbered not by thousands but by
tens of thousands. Consider the loss to the community in wage-earning
capacity through chronic ill-health, and the expense even to the poorest
women entailed thereby. The remedy is hospitals, hospitals and again
hospitals. State subsidized hospitals should be established throughout the
country. I desire to see in every village a maternity hospital as well as the
village church, where the gospel of cleanliness would be taught. The great
advantage of a hospital in this regard cannot be overestimated, for it is no
exaggeration to state that some women are thoroughly washed for the first
time in their lives during their residence in the hospital. The question of
child-bearing mortality is closely bound up with the question of the housing of
the poor, for it is the environment of the parturient woman which so often
militates against her smooth recovery. Her surroundings are squalid, dirty,
and insanitary. An important housing scheme is about to be provided, but this
is not enough unless the householders are taught to be clean. The gospel of
cleanliness must be preached to the people, and here there is a fruitful field of
work for the clergy and the health visitor. These reforms require both time
and money, but two changes might be brought about without delay : First,
the provision of cheap obstetric outfits for the poor, say at a cost of ten
shillings. Now that there is a maternity benefit, this money is better spent
on an “ outfit ” than on beer to celebrate the occasion. When required,
additional funds might be forthcoming from the various charitable societies.
Secondly, accommodation should be provided at the hospitals for cases of
puerperal infection. It is a blot upon our hospital system that women
suffering from puerperal infection should be so often denied admission, and
left to die in their own homes without the skilled nursing and attendance which
they so urgently require.
Mr. S. G. Lukek : I endorse the opinions expressed by Mr. Bonney. With
regard to the origin and source, however, of the organisms causing puerperal
infection, I cannot entirely agree with him that the case against the bowel
organisms is a strong one, in acute septicaemia cases, at any rate. The result
of bacteriological investigations carried out mostly by Dr. Western on a largo
k
i
i
20G Bonney: High Maternal Mortality of Child-bearing
number of puerperal septicaemia patients admitted to the isolation ward at the
London Hospital shows that Streptococcus pyogenes is almost always the
organism found in acute generalized infection. On only two occasions has
Bacillus coli been found in blood culture. Further, on general bacteriological
principles, individuals are considered to be more or less immune to their own
organisms, as is shown by the rarity of general infection after operations on
the anus, rectum and abdomen, where injury to the gut is present.
Dr. R. A. Gibbons : Mr. Bonney says that there are no retained products
in puerperal sepsis, not once in a hundred times, and that we must get rid of
that German teaching about septicaemia and sapraemia. With this I cannot
agree. My experience shows that in certain cases where the temperature has
risen suddenly after confinement, judicious exploration of the uterus and
removal of retained membranes, or a piece of placenta, with subsequent
antiseptic irrigation of the uterus, is followed by a drop in the temperature.
If the uterus is found to be empty, internal manipulation is contra-indicated.
With the rest of Mr. Bonney’s paper, I am in full sympathy. I hope the day
will come when there will be established all over the country lying-in hospitals,
with men on the staff who are fully paid, and who can devote themselves
entirely to the work of the institutions, and to consulting obstetric practice
only, outside. I also hope that these institutions may be centres from which
a regular obstetric outfit can be sent to any house asking for it, and in small
towns and villages where there are no such institutions, charitable centres
may be formed for the distribution of these outfits, which should include
sterilized sheets, &c., to the poorest people. In my own practice, my nurses
are instructed to have sheets, nightdresses, towels, &c., sterilized before they
are likely to be required, and the tin containing these things is only opened
when the patient is in labour. In ordinary houses asepsis is almost impossible,
but I believe education is the only means which will bring about improvement
in the present method of managing the ordinary lying-in room in the vast
majority of cases. But although it is almost impossible to secure perfect
asepsis in the lying-in room, every attempt should be made to do so. Some
think that the mere fact of wearing india-rubber gloves seems to be sufficient,
whereas gloves are dangerous in giving a feeling of security unless every pre¬
caution is used during the time they are worn, and I have numerous small
sterilized towels with which to cover the glove if anything excepting the patient
has to be touched.
Mr. GORDON Ley : I cannot agree with Mr. Bonney that the vast propor¬
tion of deaths from eclampsia are preventable. I am of opinion that not more
than 10 per cent, of eclampsias have symptoms of more than thirty-six hours’
duration before the onset of the fits and in a very large proportion the
symptoms are of a much shorter duration. I am in complete agreement with
Mr. Bonney with regard to the extreme danger of clearing out a uterus. This
should never be done unless there is every reason to believe that there is
something retained. Further, I feel certain that if it is done it should be
performed on the earliest possible occasion, that is, on the advent of pyrexia.
Section of Obstetrics and Gynaecology 107
Mr. VICTOR Bonney (in reply): My paper was intended to provoke
criticism. I wanted to get obstetrics moved out of the rut in which it has
stuck so long. Some of the speakers have demurred to the elaborate technique
I advocate, but f the orthopaedic principle of “ over-correction of a fault ” is the
right one to apply in dealing with the backward condition of obstetric art.
The regime of a modern operating theatre supplies many examples of
precautions the direct effects of which on the operation are probably small,
but which are valuable in helping to keep the standard of asepsis up to the
highest possible pitch. In regard to the virulence of bowel organisms, a great
distinction must be drawn between tissues which are their normal habitat
and those to which they are entirely foreign. In the case of the latter the
results of infection are very serious. As an example I may cite the abdominal
wound in “interval” appendicectomy. If the stump of the appendix is allowed
to touch the wound suppuration results in a large proportion of the cases.
Still more striking examples are the radical abdominal operation for cancer
of the cervix, in which a wound of the bowel is invariably followed by sepsis,
so violent that the patient usually dies of it, and abdomino-perineal excision
of the rectum, in which the recovery of the patient almost entirely depends
on the care that is taken absolutely to prevent the implantation of bowel
organisms into the great cavity left after the extirpation. The investigation
carried out by Mr. A. Foulerton and myself fifteen years ago showed that
Bacillus coli communis is present in the uterus in most of the severe cases
of puerperal sepsis. I may also remind you that puerperal sepsis occurs
chiefly in primiparae, in whom a rupture of the perinaeum is invariably present,
and this creates a culture surface for intestinal organisms. The passing of
the Midwives Act was immediately followed by a fall in the mortality, but
that rate of. improvement has not been maintained. This is what one would
have expected. Most of the good to be obtained from the Act has already
been conferred, and further marked improvement can only be effected by a
radical change in the conditions under which midwifery is practised.
i
i
JU—11
Section of ©bstetnee ant) (B^naecoloa?.
President—Mr. J. D. Malcolm, C.M.
Report to Council on Teaching of Obstetrics and Gynaecology
to Medical Students and Graduates in London.
To the President of the Section :
Sir, —On March 6, 1919, the Council of the Section appointed
a Committee, consisting of Dr. Andrews, Dr. Blacker, Dr. Eden,
Dr. Fairbaim, Dr. McCann, and Mr. Gordon Ley, “ to inquire into
the teaching of Obstetrics and Gynaecology to medical students and
graduates in London, and to report to the Council upon the altera¬
tions which are required to make it more efficient." At the meeting
of the Council held on May 29, 1919, the Report of the Teaching
Committee was considered and adopted up to the end of Section E.
Differences of opinion arose with regard to Sections F and G, and
the Council referred back these portions of the Report to the Com¬
mittee for further consideration, instructing them to co-opt for this
purpose additional obstetric physicians in order that each teaching
hospital should be represented. Invitations in this sense were accord¬
ingly sent to the obstetric physician of each teaching hospital which
was not already represented on the Committee.
Two meetings have been held, at which the following, in addition to
the members of the Committee, were present: Lady Barrett, Dr.
Comyns Berkeley, Dr. Drummond Robinson, Mr. Bellingham Smith,
Dr. Spencer and Dr. Williamson. In addition Dr. Stevens and Mr.
Darwall Smith attended one of the meetings.
As an outcome of these conferences your Committee now beg to
submit revised proposals under Sections F and G, and Appendix C.
These revised proposals received a large measure of support, but it was
Section of Obstetrics and Gynaecology
109
found impossible to secure unanimity, and it was accordingly arranged
that an alternative report would be presented to. the Council by Lady
Barrett, Dr. Spencer and Dr. Williamson.
The Report of your Committee is therefore as follows:—
Under their terms of reference the work of the Committee falls into
two parts: (1) The present methods of teaching midwifery and gynae¬
cology to medical students and graduates in London; (2) the changes
which are required to make it more efficient.
The Committee desire to point out the great importance of the
subjects they were called upon to examine, not only to the medical
profession but through it to the women of the country and to the
community in general. The provision pf doctors more highly trained
in practical midwifery work, and the provision of adequate hospital
facilities for dealing with serious complications of pregnancy, labour,
and the lying-in period, are matters which are intimately related to. one
another, and are of equal importance to the public health. A large
increase in the present hospital accommodation for midwifery cases
in London is as urgently needed as an improvement in the training of
medical students. And further, if by suitable arrangements better
training in the management of infants could be associated with mid¬
wifery training, a great advance would be made in dealing with the
difficult problem presented by the high rate of infant mortality.
Four medical schools were directly represented on the Committee,
and in order to obtain the necessary information from all the teaching
hospitals, a series of questions covering all branches of teaching were
drafted and sent to each hospital. The answers were kindly supplied
by the obstetric physicians, and formed the groundwork upon which
the following account of the present methods is based. A list of the
hospitals in alphabetical order, and an epitome of the answers obtained
under each inquiry will be found in appendices A and B.
A— The Pbeseht System : Midwifery.
Systematic Teaching .—Systematic lectures are given in all the
hospitals by the obstetric physicians, usually in the summer term—i.e.,
once a year only: the number of lectures varies from twenty to
forty. A “practical midwifery” course, which includes operative
demonstrations on the dummy, is also given either by the obstetric
physician or by the tutor. In the latter case it is combined with
the tutorial class. In most hospitals the regulations provide that
students attend the systematic lectures and the practical midwifery
110 Teaching of Obstetrics and Gynaecology
course before being allowed to attend cases of labour. The Dean of
the school may, and sometimes does, suspend this rule.
The tutorial or revision classes are held each term by the tutor,
and are attended mainly by the students then preparing for the exami¬
nation in midwifery and gynaecology. Attendance at the systematic
and practical midwifery courses is compulsory under the regulations of
the Examining Bodies. Attendance at the tutorial classes is optional,
but in practice all students do attend.
Clinical Instruction in Normal and Abnormal Pregnancy .—
Systematic instruction is given in the gynaecological wards, and out¬
patients' departments of all hospitals on the diagnosis and management
of pregnancy, the clinical material consisting of such women as present
themselves from one reason or another during pregnancy. Pregnant
women who desire to be attended at their own homes are usually required
to present themselves at the hospital for examination beforehand.
They are seen, usually, by an obstetric physician or by the tutor, and
any students who care to attend are present and are allowed to examine
the patients; the attendance of students is however not as a rule com¬
pulsory, and in practice sufficient use is not made of this department
for purposes of teaching. Except "in the case of hospitals with a mid¬
wifery ward, this is all the provision which is made for instruction
in normal and abnormal pregnancy.
Clinical Instruction in the Conduct of Labour. —In four hospitals,
viz., Royal Free, St. Bartholomew’s, St. Thomas’s, and University
College, midwifery wards are established for the instruction of
medical students: others—viz., Guy’s, London, and Middlesex—have
a midwifery ward which is used chiefly for training mid wives; for
the purposes of this report these are of no value. The remaining
hospitals have no midwifery wards at all at the present time. In
every hospital serious complications of labour can be admitted to the
gynaecological beds, where they come under the charge of the obstetric
physicians; in many cases, however, the registrar actually deals with
them.
In the case of hospitals with no midwifery ward, the training of
students in the actual conduct of labour, normal and abnormal, is
practically non-existent. In order to attend the twenty cases required
by the regulations of the examining bodies the student is attached to the
maternity district of his hospital; previous to this he has attended the
lectures mentioned above, and in addition in some hospitals—e.g.,
London, St. Bartholomew’s and St. George’s—special demonstrations are
Section of Obstetrics and Gynaecology lit
given by the Tutor or the R.O.O. 1 to each batch of students before going
on the district. As a rule, however, the students of hospitals with no
midwifery ward have never seen women in labour before going on the
district to attend them.
Every hospital has a regulation that the student is to be accom¬
panied to the first case or the first two cases by the R.O.O., but this
regulation cannot in all instances be carried out, and the student not
infrequently goes to his first case alone. It is assumed that he needs
no assistance after the first two cases in conducting a normal labour,
but he is under instructions to report at once to the R.O.O. any
abnormal conditions which he may discover. His ability to detect
abnormal conditions is however very small from lack of training.
At one hospital (Charing Cross) a trained midwife in the service of
the hospital is also present at every labour, and gives the student
assistance ; as a rule the student conducts normal cases without any
assistance, even in respect of the toilet of the infant. Abnormal
conditions are frequently dealt with by the R.O.O. In the patient's
home; practically all hospitals have a rule that serious complications,
such as ante-partum haemorrhage or eclampsia, should be at once
transferred to the hospital, where they are admitted under the super¬
vision, usually indirect however, of the obstetric physicians. There
the student is able to take part in their management, and to see any
obstetric operations which are required.
The student continues to attend his district cases during the first
seven to ten days of the puerperium, under the same instructions to
report any abnormal conditions which may arise regarding either the
mother or the child. It must be recollected that unless he has
previously attended the midwifery ward, the student has received no
practical instruction whatever in the management of infants; as a rule
his work is done without any systematic supervision during the
puerperium.
In some hospitals the number of cases available in the district is
insufficient to allow twenty for each student: a certain number of
students from these hospitals are sent to the lying-in hospitals, where
they can be “ signed up ” for twenty cases in fourteen days (Queen
Charlotte’s), twenty-one days (York Road), or fourteen days (City of
London). In some instances the student goes for a fortnight to the
Lying-in Hospital, and then serves for a fortnight on the district of
his own hospital.
1 R.O.O. — resident obstetric officer.
112 Teaching of Obstetrics and Gynaecology
The character of the training given in the lying-in hospitals is
as follows: These institutions in London are primarily concerned
with the training of midwives; the fees of the pupil-midwives form
an important source of income to the hospital, and their presence
enables the trained nursing staff to be reduced to a minimum, which
forms an important economy in expenditure. The regulations of the
Central Midwives Board require that the cases they attend as pupils
shall not be shared with others; consequently the lying-in hospitals
must reserve for the training of their midwives an adequate number
of deliveries per annum. Only the surplus is available for training
medical students and graduates. From these conditions it results that
very few deliveries in these hospitals are actually conducted by medical
students, at the most four or five each; they are, however, allowed to
be present at all, which in the case of Queen Charlotte’s Hospital may
be as many as eighty a month, but they are present as spectators only.
The great majority of their twenty cases are “ attended ” in this way.
The students are in residence in the hospital, but they do not go
to cases in the district at all. Where the student, after a short
time at the lying-in hospital, proceeds to the district of his own
hospital, he has had the advantage of frequently observing the process
of labour conducted by others, and has gleaned some experience of its
management. There is no provision for the instruction of medical
students in normal labour at the lying-in hospitals, practically all normal
labours being supervised by the resident midwives. A certain amount
of instruction in abnormal labour and in the. puerperium is given them
by the visiting physicians. The students see a certain number of
forceps deliveries and any major obstetric operations that may take
place during their attendance.
In the case of the hospitals having a midwifery ward for students,
the conditions require separate notice. The number of beds in
these midwifery wards varies from eight at University College Hos¬
pital to twenty-four in the Boyal Free Hospital; the number of cases
admitted per annum varies from 180 in University College Hospital to
550 to 600 in St. Thomas’s; the number of cases admitted per student
trained varies from three in St. Bartholomew’s to eleven or twelve in
St. Thomas’s. The number of cases actually delivered by medical
students in the ward is limited, in all but St. Thomas’s, by the fact that,
not being in residence in or near the hospital, they only attend the
deliveries which occur in the daytime, except that, at St. Bar¬
tholomew’s, one student is always in residence and can attend night
8e-clum of Qhdrtrand Gynaecology
US
deliveries There l.fk g aUlSll r. mo her of ptjpil-iwichvivew at these hoepfo'C
0<ghi. k» ten por »wmta). If the midwifery ward tile Htudeiitg
are given practical dime&J any oayesof normal or
abnormal pregnahey which may lie ftva.il4.biei m the e/mree dud rriii wage-
merjt of uottiiu! labour ami the piit>xperitnn> •>!( the limiiagffiiient of
infanta, and op any csat** of .couiplfov. h^bour which occur during
the hohrs of their attendance, The i.aitifo$tfhfi j?. given m part by the
visitfog physicians,- bat tuaicly hy. fclfo rcgtstruj or the resident officers.
The period of attendance in the midwifery ward fa four weete, and the
■ student i& hot pet tiiittedV'begfp.. fttNfiftlag' casein until
he ha;;, conducted a oetiaUi .number of. iu-bvcci-.* ifl the ward and
received a certain Amount of. prantfoatinslTubtidtr After this ho
attends his district«w> 3 s. alone, .uh do the students of the other
hospitals
(>:,■ (a f;\jiwt Wfi/’jV': ('evlrcs. — These centres, where they
exist, proYide dpportuoftifcKfbi fusteuetion in the care of the nursing
mother, ip fofopt fedfonig'. aud fb the general management of the infant
during the first year of life The. rbidwifevy department of a hospital
'ceases to be concerned ydth the>'V«eag , e normal caie m ten to fourteen
.days after delivery tb*- work of these centres is a conticuatioD of the
work of thf* ob^tyjiUaD, and ife utility from the point of view' fit
preventive ^.^i^tt/ia^-geheraUy recognized as being very great. It
is of the href ihiphriahoa that these centres .should be made use of
ui training sindehift ih cen tin nation their midwifery work, yet only
five ht«pitel^-^i|^.,'^^ii»g Cross; Royal Pr.ee, St. Mary's, 6t, Thomas’s,
and UiiiYertftfy f^fe^^Mve a Maternity and Infant Welfare Centre
m connexion with them Othels are soon to lie started.
B—'I'liiv Ijkfkmw 0. -mv T" 1 - ■ ■ Ate ruoos or TtfACinxo
.;■ y.'. hfoiiwiKisiiY.
The $ijrttniari‘>: instruction given is'.,gpneth-ily: .speaking sxtfefaefory,
and is m the hand* of the obstetric physicians. The: jiMvtiiyJ .tejtttWe-
fion fenves very much to be desired, and in sorfie respcctR inetVts
emphatic condemnation 'We desire, however, to nvkuowU'dg.- tlie
great improvement which has followed, the estftbkshmifofc'bfomfovYifty'v
wards for the mstraction of medical students. This idiifogU•$» of recent
date, apjd is at present operating foe oftiy four. bdsSpibfc &% bp‘t ^s ^reat
I
114 Teaching of Obstetrics and Gynaecology
satisfactory ; the additional experience which may be obtained when the
student also goes to a lying-in hospital for a short time is most unsatis¬
factory. The following considerations must be borne in mind :—
(1) The Hospital without a Students' Midwifery Ward .—The grave
defects of this system may be set out as follows :—
(а) Students learn to deliver women only under conditions in which
surgical cleanliness is extremely difficult to secure. Under a satisfactory-
system the same principle should be followed as obtains in general
surgery—viz., they should be taught upon the highest plane of efficiency
which it is possible to attain/ not upon the lowest which can be reached
without unjustifiable risk to life. A not unfair analogy would be for
surgeons to teach students the technique of abdominal operations under
conditions where they would be deprived of adequate light, ventilation,
and the means of cleanliness. Unless difficult cases occur requiring
transfer to hospital, the student has no opportunity whatever of seeing
women delivered under hospital conditions.
(б) Students who are taught thus, under makeshift conditions, will
absorb the impression that careful and exact precautionary measures
are unnecessary. The effect of such an impression upon their future
work in private practice can only be disastrous, and may be related
directly to the incidence of puerperal fever in the country as a whole.
(c) The practical- clinical instruction which students receive in the
diagnosis and conduct of normal labour is of so perfunctory a character
that it may not unfairly be said that they are left to pick it up for
themselves, with the sole aid of the lectures they have attended before¬
hand and the books they may have read. In a considerable proportion
of cases the child is born before or immediately after the student’s
arrival, as the women like to .delay sending for the “ doctor ” until the
last moment.
(' d) Unless complications occur in his district cases, he will never see
the obstetric physicians dealing with labour at all; and even when patients
are transferred to the hospital, the control of the obstetric physician is
often indirect, and is exerted through the registrar or R.O.O. who
actually deal with the cases themselves after asking his advice. The
student, therefore, learns extremely little of abnormal labour; he may
not see a forceps delivery during his month, and in occasional instances
may go up for his final examination without having seen this procedure
except upon the dummy.
(e) It follows from (d) that the student learning clinical midwifery
is completely out of touch with his senior teachers; he does not see
Section of Obstetrics and Gynaecology
115
them actually engaged in the work he is trying to learn, and never has
the advantage of their supervision and guidance.
• (/) That a student' should conduct deliveries in the district is
undoubtedly useful, for the single-handed conduct of cases of labour
may be assumed to develop his sense of responsibility i a valuable aspect
of his training as a doctor. But this should come after and riot before
he has been made acquainted with the nature of his task. In the case
of the student of average ability, to thrust responsibility upon him
before he has been taught his work, will be more likely to hinder
than to help him in learning.
(g) Attendance upon twenty to thirty cases of midwifery ought to
afford invaluable opportunities of instruction and experience in the
management of the normal puerperium, of minor disorders of the puer-
perium, and of infant feeding. Under the district system these oppor¬
tunities are completely wasted, owing to the total lack of systematic
supervision of the students when at work.
(2) The Lying-in Hospital. —The great defect here is that no direct
provision is made for the instruction of medical students at these
hospitals. They attend the practice of the hospital in order to be
“ signed up,” but no one is responsible, for teaching them. The visiting
physicians pay regular visits to the lying-in wards where they are
followed by a mixed class of graduates, students and pupil-midwives, to
whom they give what instruction is possible in the circumstances, upon
the puerperium and the management of infants. They rarely, if ever,
conduct a case of normal labour, and are seldom in the labour wards
except for difficult cases which require their presence. “Waiting
cases ” which present abnormal conditions are usually seen by the
visiting physicians who may demonstrate them to the students; but
under the rules of the hospital the visiting physicians do not undertake
any responsibility for the instruction of medical students. It has been
already stated that the student does not actually deliver all the patients
he is certified to have “ attended.” The number he actually delivers is
variable and depends upon the goodwill of the R.O.O. and the resident
midwives, either of whom may supervise his work. Instruction of
students is however no part of their duty to the hospital and they are
under no obligation to take pains in giving it. Some students may be
allowed by the B.O.O. to conduct a forceps delivery under supervision ;
but this depends entirely upon the goodwill of the B.O.O. himself.
(3) The Hospital with a Students' Midwifery Ward. —This system
undoubtedly marks a great advance in the training of students, but
116
Teaching of Obstetrics and Gynaecology
certain defects are inherent in it. Only four hospitals have such a
ward in actual working; its size varies from eight to twenty-four beds.
The greater number of cases admitted are normal cases. Students are
attached to the ward, in all cases exclusively, for a period of four weeks.
They come into close touch with the obstetric physicians who demon¬
strate cases to them and give general clinical instruction on their regular
visiting days. The women are delivered by the R.O.O. or the resident
sister midwife, under both of whom the students work, and by whom
they are personally instructed in the conduct of normal labour. The
students are not in residence except in the case of St. Thomas’s, and,
as a rule, only the day-time labours are seen by them. It must be
pointed out, however, that the visiting physicians take little or no part
in teaching the conduct of normal labour, that the more serious cases of
abnormal labour are not all seen by them, and even when conducted
under their supervision, they are not necessarily delivered by them.
The small size of the midwifery ward is one of its chief defects. It
suffices to allow each student to conduct a small number of normal
deliveries before commencing his work on the district; this number
could with advantage be much increased. The more serious abnormal
cases from the hospital district are sent in to the midwifery ward, so
that Royal Free has a total of 530 cases, St. Bartholomew’s a total of
1,500 cases, St. Thomas’s a total of 1,500 to 1,600 cases, and University
College a total of 1,700 to 1,800 cases per annum, from which abnormal
cases are drawn. In this respect they all fall behind the largest
Lying-in Hospital, Queen Charlotte’s, which has an annual total of
.3,500 to 4,000 cases delivered in the wards and on the district. It is
impossible for these wards to deal with large numbers of abnormal
cases, and there is no doubt that the students’ opportunities of seeing
difficult labour dealt with are inadequate.
The non-continuous character of the student’s attendance, in all but
one hospital, is a grave disadvantage. A large proportion of all deliveries
occur at night, when the student is not there to see them. Compli¬
cated cases may occur at any time, and from their nature the great
majority must be dealt with promptly. As a rule they, cannot be
left over until the hours of the student’s attendance come round,
and thus invaluable opportunities of instruction are lost. To tell the
student all about a difficult case the day after it has been dealt with
is not a satisfactory method of clinical instruction. The time the
student devotes to the midwifery ward (four weeks) is quite inadequate,
if his attendance is only in the day time, and even that may be broken
up by other duties.
Section of Obstetrics and Gynaecology 117
The bulk of the practical teaching in the midwifery wards is given
by the registrar and the R.O.O., particularly in regard to the conduct
of normal labour ; whereas the student ought to be taught both normal
and abnormal conditions by senior obstetric officers of greater expe¬
rience and higher standing than the average registrar. The major part
of the student’s clinical teaching in surgery is given him by surgeons and
assistant surgeons, and this is universally regarded as being necessary.
It is equally necessary that he should be taught his clinical midwifery
by men of similar standing. In the nature of midwifery work this
would involve the presence in resident control of the midwifery ward of
senior officers, who would be always available, would personally supervise
the work of the labour wards, arid would themselves deal with abnormal
cases at whatever hour they might arise.
C—The Present System : Gynecology.
A certain small number of systematic lectures in gynaecology
are given by the obstetric physicians either as a part of the course
of midwifery or separately. As a rule the student clerks for one to
two months in the gynaecological department; although the regulations
of the majority of the examining bodies require him to spend three
months at clinical gynaecology the hospitals do not all enforce it. In
some instances his gynaecological clerking is done in the same month
as he attends his midwifery cases on the district. The number of
gynaecological beds in the various hospitals varies from eleven at West¬
minster to thirty-four at London, the average being about twenty. In
the wards the clerk is taught by the registrar or the R.O.O. to take
the history of a gynaecological case, and is usually taken over the
physical examination by the same officer. He follows the obstetric
physician in his rounds, and is present at the operations which take
place during his clerkship. His attendance in the wards may be much
. restricted if he is at the same time doing his midwifery cases on the
district. In the wards he gets certain opportunities of making pelvic
examinations under anaesthesia, and of personally assisting at operations.
The operations and the operation specimens are demonstrated more or
less fully, according to the custom of each operator, and the amount
of work he may have to get through. In the case of hospitals with only
ten to twenty gynaecological beds, the number and variety of cases seen
in a month is necessarily very limited, and is in fact quite inadequate as; j
a course of clinical training.
118
Teaching of Obstetrics and Gynaecology
Among gynaecological out-patients, the student usually sees a large
number of minor cases, and is allowed to examine a fair proportion
of them. He needs close supervision and a good deal of assistance in
learning to make the bi-manual examination, and in the case of a large
out-patient clinic the number of cases which have to be seen pre¬
cludes the out-patient physician from devoting close attention to the
student. In a small clinic the number and variety of the cases seen
by the student in one month is quite inadequate. As a rule the out¬
patient physician is assisted by the R.O.O., but it is rare to find any
system operating for the sifting of cases, so that those most suitable for
teaching may be passed at once to the out-patient physician. Usually
the B.O.O. sees all the old cases and the out-patient physician all the
new ones irrespective of their clinical importance.
Deficiencies in Gynaecological Training .—It is in the clinical training
of the students that defects are most apparent. These deficiencies can
be traced mainly to two causes: (1) The very inadequate number
of gynaecological beds in all the hospitals; (2) the very inadequate
amount of time which the student devotes to the subject. With regard
to the number of beds it must be recollected that midwifery and
gynaecology together form one-third part of the final examination,
and are associated on equal terms with medicine and with surgery.
The combined number of gynaecological and midwifery beds available
for teaching is less than one-third of the number allotted either to
medicine or to surgery. This policy of cramping the work of the
obstetric physician is due partly to the failure of colleagues to realize
the importance of these subjects to the medical practitioner and to the
community, partly to the relatively low level of the requirements of
most of the examining bodies. In both medicine and surgery the'
student is obliged to clerk for six months, while to clinical midwifery
and gynaecology combined he does not devote more than three months
at most hospitals.
D—The Consequences op Defective Training in Midwifery
and Gynaecology.
(a) The training of medical students is a matter of the first
importance to the S^ate, for efficient doctors are necessary to the
maintenance of the Public Health. In the early years of his private
: practice midwifery and the minor ailments of women and infants
•’form a large proportion of the young doctor’s work, and yet these are
Section of Obstetrics and Gynaecology 119
probably the subjects in which his practical training has been most
deficient.
(b) Since the great majority of students learn to conduct labour
only under conditions in which surgical cleanliness cannot be enforced,
they carry with them into practice the impression (perhaps sub¬
consciously) that surgical cleanliness is not of the same importance
in midwifery as in surgery. The makeshift methods with which they
begin their experience tend to become stereotyped in their minds, and
the effect of this upon their work in private practice must be very bad.
( c) The bearing of this point upon the incidence of death from
child-bearing in the country cannot be overlooked. During the period
1891 to 1914 this death-rate of childbirth for Great Britain and Ireland
was almost stationary, the fall being only from 5'8 to 5'08 per 1,000
births. This can only be regarded as extremely unsatisfactory for it
shows that during a period in which surgical training made such
rapid advances midwifery training made none. Indeed in all divisions
of the country except Ireland the death-rate actually rose in the
quadrennium 1911-1914. The conclusion cannot be avoided that both
medical students and midwives are being imperfectly trained.
(< d ) The student has been accustomed to pay only perfunctory
attention to the puerperium, for he has been left largely to himself
at this period while attending his cases on the district; he therefore
cannot be expected to realize its importance from the point of view of
the health and working efficiency of the mother.
( e ) The average newly-qualified doctor has had little or no clinical
training in the management of the infant and usually leaves it entirely
to the nurse. Even in the case of the well-to-do, the nurse often
regards the infant as her patient, and feeds it or doses it without
reference Jo the medical attendant. Mothers also come to think that
this is the proper arrangement and to prefer the advice of the nurse.
There is no doubt that many infant lives are lost owing to the fact that
medical students receive insufficient clinical training in this subject.
( (/) It is the personal experience of all the members of your
Committee that medical practitioners do not consider it necessary to
obtain the services of a specialist or of a hospital in the emergencies
of midwifery to the same extent as they undoubtedly do in the case of
general surgery. This is largely due to the fact that they have not,
during their training, seen such cases dealt with by the senior obstetric
officers in the way that they have seen serious surgical cases dealt with
by surgeons. Their custom is to call in a neighbouring practitioner
and to do the best they can.
120
Teaching of Obstetrics and Gyncecology
( 9 ) The lack of hospital accommodation for women in labour, and
the lack of public means of transporting patients to hospital, tend to
confirm the practitioner in this attitude.
(A) The close relation which subsists between bad midwifery and
pelvic disease in women is well recognized. A sound practical training
in the recognition and treatment of pelvic disease is as important as the
midwifery training itself. Young medical practitioners are probably
less able to recognize common forms of gynaecological disease than
they are common forms of medical or surgical disease. The results
are very serious in regard not only to the life but also to the health,
working efficiency and subsequent capacity for child-bearing, of the
women of the country.
E—The Bases of an Efficient Training in Midwifery and
Gynecology.
(1) Owing to their intimate relationships these subjects should be
taught, as is the British practice, by the same teachers and the training
of students in them should run concurrently.
(2) Midwifery training should be extended in one direction (ante-
natally) so as to comprise a fuller study of the whole course and
management of pregnancy, and in the other (post-natally) so as to
comprise the "management of the whole nursing period and the
management of the infant. Beference has been already made to the
opportunities offered by the Maternity and Infant Welfare Centres for
instruction in the care of the nursing mother, in infant feeding, and in
the general management of the infant. The work of these centres is
the natural sequence to the care of pregnancy and labour, and some
acquaintance with it is essential if the application of preventive medicine
to maternity and childhood is to be properly realized by the student.
The co-operation of the paediatrician in this work is very desirable.
(3) The management of labour should be taught as a surgical
procedure; this can only be done in hospital, under surgical conditions,
with adequate equipment, and a highly trained staff of teachers. Owing
to the peculiar nature of’the work the senior officers upon whom the
ultimate responsibility rests should be resident in the hospital, or
should be available at any time their presence may be required.
(4) There should be adequate hospital accommodation in all large
: centres of population to allow of all serious obstetric emergencies being
• •’immediately admitted for treatment; this is recognized as being
Section of Obstetrics and Gynaecology
121
necessary in respect of surgical conditions, and it is equally necessary
in respect of midwifery.
(5) From (4) it follows that the number of beds available for cases
of midwifery must be very largely increased, allowing due provision to
be made for the emergencies which so frequently arise.
(6) Medical students and midwives cannot be suitably trained in the
same institution, unless in separate classes.
(7) The proportion of beds allotted to midwifery and gynaecology is
quite inadequate to the importance of the subject from the point of view
of the public health; the number should bear a definite proportion to
the total number of beds in the hospital; at the present time the average
proportion is less than one-twentieth of the total in the twelve hospitals
shown in Appendix B; this proportion should be increased to at least
one-tenth. A considerable number of gynaecological cases are dealt
with by the surgeons in the surgical wards, which are largely lost
for teaching purposes.
(8) The requirements of the examining bodies in both subjects
should be strengthened, so as to enforce (a) an adequate period of
clinical training during which the student should be allowed to under¬
take no other work; (6) the provision of suitably arranged and
sufficiently large facilities for clinical work.
(9) In the system of training the following methods of instruction
should be followed, their relative importance being in the order named:—
(а) Clinical demonstrations upon patients, in out-patient depart¬
ments, Wards, operation theatre and labour wards.
(б) Demonstrations of specimens, fresh and preserved.
(c) Lecture-demonstrations, at. which surgical anatomy, the con¬
struction and use of instruments, the details of operative procedures,
&c., can be shown in detail. Under this head would be included the
present practical midwifery lectures.
(i d) Systematic lectures, which should be limited in number, and
concerned with principles rather than details.
(10) The extent to which the student’s training is influenced by
the nature of the qualifying examination must not be overlooked, and
the present system of examination in midwifery and gynaecology
urgently needs amendment. The examination of the Conjoint Board
for example is very unequal owing to the large number of examiners
from different teaching hospitals in London and from provincial uni¬
versities, who often set widely different standards. And the absence
of a clinical examination in both subjects leads the student to neglect
his clinical work and to underrate its importance.
122
Teaching of Obstetrics and Gynaecology
The examining authorities should be urged, whenever it is possible,
to recognize the principle that the student should be examined by his
own teacher with a second examiner as assessor, and that clinical
examinations should be accorded the same importance as in the case
of medicine and surgery.
F—Sketch op a Satisfactory Scheme.
(I) The inadequacy of the clinical facilities in the existing hospitals
not only for teaching midwifery, but also for the treatment of pregnant
women and women in labour, has been already emphasized. It is not
possible for the existing hospitals to allot the number of beds to mid¬
wifery which are required, in view of the deficiency of their present
accommodation in all departments, as is shown by the long waiting
lists which are found at all hospitals. Before long, additional hospital
space will therefore have to be provided to meet the requirements of
the community, and full use, for teaching purposes, should be made of
this new provision.
(II) There are two different lines upon which fully equipped
departments, of adequate size, for the teaching of midwifery and
gynaecology, could be organized :—
(a) Certain of the larger teaching hospitals might provide for a
great expansion of their existing midwifery wards, from which, with
their associated gynaecological, pathological and other services a mid¬
wifery department could be formed capable of providing for the
training, not only of their own students, but also, if necessary, of
students from other hospitals where there is no midwifery ward in
existence.
( b ) New centres might be founded in outlying districts where
there is at present no adequate maternity service. These new centres,
though not in proximity to existing teaching hospitals, might be
affiliated to certain of them which were unable to develop fully
equipped maternity departments of their own, and which might send
their students to the new centre for training. These new centres could
be made use of, for training not only students, but also post¬
graduates, and in addition they would afford much needed facilities
for research.
In the case of both (a) and ( b ) a small number of midwives could
also be trained for service in the institutions.
(III) Departments developed out of existing maternity wards at a
Section of Obstetrics and Gynaecology 123
teaching hospital (Subsection Ila) ought to provide a minimum of
seventy-five beds, of which fifty would be for midwifery and twenty-
five for gynaecology. Of the midwifery beds a certain number would
be allocated to ante-natal conditions and puerperal complications.
“ Departments ” developed in connexion with the larger teaching
hospitals, which have greater facilities for expansion, might exceed
these figures if students from other hospitals were received in addition
to their own.
In the opinion of the Committee a midwifery department con¬
taining less than fifty beds cannot be satisfactory for the teaching of
students, as it will not afford them an opportunity of seeing all the
ordinary difficulties and complications of pregnancy and labour during
the limited period of time in which they are attending the department.
It would be impossible for every one of the existing teaching hospitals
to supply such a large number of beds for midwifery. So it is obvious
that under this scheme some form of concentration would be necessary,
that is, that some of the hospitals should provide midwifery departments
which would be attended by their own students, and in addition, by
students from the hospitals which were /unable to provide such
departments.
(IV) Newly-founded Centres (Subsection 116) would probably be
much larger than the “ departments,” on account of the urgent public
need which exists for increased hospital accommodation for midwifery
cases. They could provide about 200 beds each, of which roughly
twenty would be for ante-natal conditions, 100 for labour, twenty for
infective cases (isolation), and sixty for gynaecological cases. The
provision of a certain number of such centres as these, in selected
outlying districts, would form a most valuable contribution to the
provision of an efficient maternity service for London. It is
obviously of great importance that full use for teaching purposes
should be made of such new centres when they come into existence.
The provision of a proportion of gynaecological beds in the centre
is an essential feature of the scheme. It would be needed to meet the
medical requirements of the district, and, further, it would allow the
student to do his practical work in the two subjects together, and
under the same teachers; knowledge of either subject is incomplete
without the other, and the student learns them together much more
readily than separately.
(V) The medical staff required to work the “ Centre ” also involves a
new departure. Reasons have been advanced for the view that a much
JU— 12
\
i
f
i
124 Teaching of Obstetrics and Gynaecology
larger proportion of the teaching in the conduct of normal and abnormal
labour should be given by senior obstetric officers, than is the case at
present. This involves senior officers being either in residence at the
Centre or on duty during certain definite hours of the day and night.
Such services could not be required of them without payment
upon an adequate scale. Next to them would be required assistants
in residence, of the status of the present registrar or tutor, whose
whole time would be required, and who also must be adequately paid.
(VI) “ Departments ” developing out of existing midwifery wards
at teaching hospitals (Subsection Ila) would probably be best staffed
as. follows:—
(1) A staff of two or more Visiting Obstetric Physicians (or surgeons)
who would, in rotation, undertake the duties appertaining to the
Director or Chief of the department, for definite periods as might be
most suitable.
(2) A resident 11 Clief de Clinique ,” appointed fQr a term of years,
who must' be a whole-time officer, and who would have charge of the
department under the visiting staff. His professional status should be
above that of an obstetric registrar, i.e., comparable with that of a
resident assistant surgeon or a resident assistant physician.
(3) One or two resident Senior Assistants of the status of a registrar,
who would direct the students personally in their work in the labour
wards, the lying-in-wards, and on the district, and a number of resident
Assistants (house surgeons). These would also be whole-time officers.
Departments such as these would probably eventually develop into
“ Units ” with professors of midwifery and gynaecology, on the lines of
the units of medicine and surgery which are about to be founded. Such
professors of midwifery and gynaecology should not be “ whole-time ”
professors but should remain in touch with consulting practice.
(VII) New centres formed'in outlying districts (Subsection Ili)
would probably be best worked by:—
(1) A resident Director or Superintendent, who might be appointed
for a term of say five to seven years. He would be of the status
of an obstetric physician at the teaching hospital. He would be
responsible for the control of the work of the institution generally,
and would take a large share in operative work, in teaching, and in
research. The Director should not be a “ whole-time ” officer, but
should remain in touch with consulting practice.
(2) One or more resident Assistant Directors.
(3) Working under (1) and (2) a sufficient number of resident
Section of Obstetrics and Gynaecology
125
Assistants to direct the students personally in their work in the labour
wards, the lying-in wards, the gynaecological wards, and in the district.
They would also be responsible for the clinical pathology of the centre,
and would carry out research under the supervision of the Director and
the Assistant Director.
These appointments when first instituted, would afford an oppor¬
tunity for the teaching hospitals affiliated to the centre to be represented
upon its teaching staff, and thus keep the students in touch with their
own hospital staff.
It must be borne in mind that outlying districts which are in need
of a midwifery hospital service require general hospitals as well; these
would, no doubt, eventually be established, and thus provide for the
association of pathological and other services with the new Centres.
Such schemes would involve such heavy expenditure that they could
not be put into operation without support from the State.
(VIII) In the opinion of the Committee the requirements of the
students’ training can only be completely met under the scheme of
new “ Centres,” on account of the necessity which has been already
emphasized of the senior teachers taking a considerably larger part
than at present in the work of clinical instruction. Under the alter¬
native scheme of “Departments” at existing teaching hospitals the
senior teachers would, in effect, not take any larger part in teaching
than they do now.
(IX) Students belonging to hospitals with a fully equipped mid¬
wifery Department (Subsection Ila) should be attached to the Depart¬
ment for a period of four months during which their whole time would
be devoted to midwifery and gynaecology, and they would be in residence
for, at any rate, a part of the time. Students from other hospitals
would probably come to the Department for practical midwifery only;
they would be in residence for at least one month. In the second
month they would attend their cases on the district of their own
hospital under the supervision of their own medical staff, and would, in
addition, continue to attend the Department for clinical teaching,
operations, &c. These students would receive their gynaecological
training at their own hospitals as at present.
(X) The midwifery districts of the teaching hospitals would there¬
fore be continued, for it is of great importance that the student should
have experience of district work during the latter part of his training,
as long as it is under proper supervision. In the case of certain
hospitals the district could not provide sufficient cases to enable each
student to attend the required number. Arrangements could perhaps
jtj—12a
126 Teaching of Obstetrics and Gynaecology
be made for a proportion of the students from these hospitals to do
their district work elsewhere—i.e., in the district of another hospital.
(XI) Each teaching hospital should provide means of properly super¬
vising its students in their work on the district. Under the present
system the assistant obstetric physician is in nominal charge of this
work, with the assistance of the registrar and the R.O.O. The control
of the assistant obstetric physician should be made effective under the
rules of each hospital, and the duties of the registrar should include the
instruction of each student in the management of his district cases
during the puerperium.
(XII) Students attending a new Centre (Subsection 116) would be
attached to it for a period of four months during which their whole
time would be devoted to midwifery and gynaecology, and they would
be in residence for, at any rate, a part of that time.
G—First Steps to be taken.
(I) While the Committee are of opinion that eventually the foundation
of new “ Centres” will be necessary for the proper training of students
in midwifery and gynaecology, it is recognized that it will probably be
some time before such a scheme could be put into operation. The
necessity of taking steps promptly to effect the most urgently needed
improvements is however obvious, and the formation of “ Departments ”
at existing teaching hospitals (F, Subsection Ila) could be put into
operation without prejudice to the later formation of new “ Centres.”
In this way the two schemes could be developed side by side, and there
is no doubt that the one found by experience to be best suited to the
special requirements of London would eventually prevail.
(II) The development of fully equipped “ Departments ” at existing
teaching hospitals, being the easier part of the scheme to put into
operation, it might prove practicable to make a start forthwith. 1 This
would be preferable to an attempt by all the hospitals to open midwifery
wards of about the same size as the existing ones, which would result in
too much dispersal of clinical material, and dissipation of effort on the
part of the teachers. Further, wards of twenty beds or under are too
small for the purposes required, which include beds for ante-natal and
puerperal cases, while large wards would not be fully utilized at the
smaller teaching hospitals except under some system of grouping
teachers and students from different schools together.
1 Suggestions with regard to the distribution of such Departments will be found in
Appendix C, p. 133.
Section of Obstetrics and Gynaecology 127
(III) It is of great importance that a 44 Department ” of the size
indicated, formed at a teaching hospital, should in addition to their
own students receive a certain number of students from one or more
hospitals which have no midwifery ward. If this plan were carried out,
the existing inequality of the training in practical midwifery in London
which results from the absence of a midwifery ward in many teaching
hospitals, would be to a great extent obliterated, and the general level
of midwifery training would be at once appreciably raised.
(IY) As hospitals without a fully equipped midwifery department
would continue to train their own students in gynaecology as at present,
an immediate increase in the number of gynaecological beds at these
hospitals is urgently required for the reasons which have been already
stated.
(V) The first steps to be taken would probably be to inquire into
the following points :—
(a) The possibility of the hospital designated being able to allot the
required number of beds to midwifery.
(b) The willingness of other hospitals to make use of the
“ Department ” for training their students.
(c) Suitable financial arrangements being made between the affiliated
hospitals, assisted by a Government grant.
(VI) Another development which might be put into immediate
operation is the much greater utilization of ante-natal and infant
welfare clinics- for the instruction of students.
(VII) It is also very desirable that all teaching hospitals should as
far as possible compel their students to give up a minimum of four
months solely to midwifery and gynaecology, and the Examining Bodies
should be moved to alter their requirements in this sense.
In considering the length of time the student should devote to the
subject, it must be recollected that the Committee propose that mid¬
wifery training should include work at ante-natal clinics and infant
welfare centres. The latter work especially will in the future form so
important a part of the duties of the practitioner of medicine that the
Examining Bodies must make some provision for it in the curriculum.
Obviously the best time is immediately after the study of obstetrics.
There is the further advantage in making the study of the infant
concurrent with, or immediately succeeding the study of midwifery,
that the two together afford a concrete example of the methods of
preventive medicine applied to the health of the community, which
must impress itself on the student. Experience may show that four
\
•
f
l
i
128
Teaching of Obstetrics and Gynaecology
months devoted solely to midwifery, gynaecology, and the study of the
infant, would not be long enough for the importance of these subjects
in the health service of the coinmunity, and some extension would be
then required.
H— The Teaching of Graduates.
Midwifery.
(1) There is no doubt that it is very desirable that provision should
be made for the clinical instruction of graduates in midwifery ; there is
a considerable demand for it now, and this demand is likely to be
greater in the future.
(2) The essential conditions for the practical instruction of graduates
in midwifery are: (a) An institution able to receive large numbers of
cases, and making special provision for difficult and operative labours;
( b ) resident teachers of status and experience.
(3) The case of the medical student is in our opinion more urgent
than that of the graduate and should be dealt with first. When large
central institutions on the lines indicated above have been set up, there
will be no difficulty, in addition to meeting the needs of the students,
to provide the clinical material, the teachers, and the laboratory facilities
which are requisite for the instruction of graduates.
(4) Under the conditions which exist at present it is practically
impossible to organize post-graduate instruction upon satisfactory lines.
Certain suggestions for improving the existing facilities at lying-in
hospitals will be found in Appendix D.
Gynaecology.
(1) The abundant clinical material of the special hospitals for women
is largely lost for teaching purposes under the present conditions.
A certain number of clinical assistants (qualified) are usually attached
to them who attend out-patients and operations, but there are no
systematic arrangements for clinical teaching upon a considerable scale.
(2) These hospitals would be of invaluable service in providing
clinical teaching for graduates, and this appears to be their proper
educational sphere.
(3) The three principal hospitals (Chelsea Hospital for Women,
Samaritan Free Hospital, Soho Hospital) should be affiliated, so that
graduates taking a course would be entitled to follow the practice of all
Section of Obstetrics and Gynaecology 129
of them. In this way graduates taking a course of clinical gynaecology
could be continuously employed in out-patient departments, wards,
operating theatres and laboratories.
(4) Courses of Instruction lasting for six to eight weeks should
be provided—viz., (a) clinical gynaecology; ( b) operative gynaecology ;
(c) gynaecological pathology.
Clinical Gynaecology .—Demonstrations on selected cases should be
given in the in-patient and out-patient departments, and the senior and
junior members of the staff should take part in the teaching in both
departments. Facilities should be afforded to each graduate to acquire
a knowledge of the bi-manual methods of examination by repeated
practice while the patient is anaesthetized; to acquire a knowledge of
the instruments, appliances, &c., used in the practice of gynaecology.
Case-taking cards should be provided in both in- and out-patient
departments.
Gynaecological Pathology .—Instruction should be given in (a) recent
specimens, (6) microscopic preparation, (c) bacteriology, (<i) specimens
in the Museum of the Royal College of Surgeons.
(5) Advanced courses might be arranged for those who desire to
specialize in gynaecology, and opportunities afforded them both in the
wards and in the laboratory for research.
(6) Clinical assistantships might still be available for those who,
having taken a post-graduate course, desire to continue their work at
the hospital.
Your obedient servants,
T. W. Eden (Chairman),
Henry Russell Andrews,
G. Blacker,
John S. Fairbairn,
F. J. McCann,
Gordon Ley (Secretary).
June 23, 1919.
Teaching of Obstetrics and Gynaecology
APPENDIX A.
Inquiries made on behalf of the Committee of the Council
of the Section of Obstetrics and Gynaecology of the
Royal Society of Medicine.
N.B.—It'is requested that answers be made on pre-war working, but that
additions or improvements (if any have been made during the War) be included.
Question I .—The total number of beds in the hospital ?
Question II. — (a) Number of gynaecological beds ?
(b) Number of obstetrical (including ante-natal) beds ?
Question III. —Number of deliveries per annum : —
(а) In the wards ?
(б) On the district ?
Question IV. —Total number of students per annum doing midwifery and
gynaecology ; also
Total number of midwives trained per annum ?
Question V .—Time given by students to training:—
(") gynaecological clerking J g} Qu't-paTient ?
(/») Midwifery . . . [ gj QuJpatlent ?
Do these run concurrently or not ?
Question VI. —What instruction is given to students :—
(a) In the midwifery department ?
(b) In the ante-natal department ?
(c) Or elsewhere ?
Before taking duty on the district.
By whom is it given ?
Question VII. —W 7 hat supervision of the students is provided in the out-patient
midwifery department ?
Question VIII. —Average number of cases delivered by each student:—
(a) In the wards ?
( b ) On the district ?
Question IX. —By whom are complicated cases of labour—e.g., eclampsia,
ante-partum haemorrhage, &c.—dealt with :—
(a) On the district ?
(b) In the hospital ?
Are all such cases admitted to hospital for treatment, and w r hat
arrangements are made for teaching in these cases ?
Question X. —Have you a maternity and infant welfare department? If so, by
whom is the work done, and is teaching given to students ?
Question XL —Are cases of puerperal infection admitted to the gynaecological
wards, or to a special department, and what teaching is
provided on these cases ?
Question XII. —What clinical instruction in gynaecology is given :—
(a) In the wards ?
(b) In the out-patient department ?
(c* By whom is it given in each case ?
Tabulated Answers to Questions in Appendix
Section of Obstetrics and Gynaecology
131
* Reserved for midwives. f Bun concurrently.
Q. C. H. = Queen Charlotte’s Hospital. C. L. M. H. = City of London Maternity Hospital.
132
Teaching of Obstetrics and Gynaecology
(II) Epitomized Answers to Questions in Appendix A.
No. VI. —The replies to this question indicate that three different systems are
followed in different hospitals :—
(a) Preliminary instruction in lying-in wards of the hospital, after
which the student is taken to his first one, two, or three
cases by the R.O.O.
(b) The preliminary instruction is given at a lying-in hospital; this
however in practice is nominal only and of little practical
value.
(c) No preliminary practical instruction, but special classes or
demonstrations given to students by the R.O.O. before
attending their cases on the district.
No. VII. —No details are furnished in eleven of the reports. St. Bartholo¬
mew’s is the only hospital which attempts to provide any systematic
. supervision.
No. IX. —In most of the reports it appears that there are no definite arrange¬
ments for the cases being in all instances seen and treated by the
visiting physicians; in three reports it is definitely stated that all such
cases are seen and treated by the visiting physicians (St. Bartholomew’s,
St. George’s, St. Mary’s).
No. XI. —Cases of general puerperal septicaemia are admitted:—
(1) To tlie gynaecological wards only—one hospital.
(2) Some to gynaecological wards, some to isolation wards—six
hospitals.
(3) Airto isolation wards—three hospitals.
(4) Refused admittance—one hospital (lack of accommodation).
Cases admitted to isolation wards are not as a rule available for
obstetric teaching; in three cases it is stated that such teaching
is given.
No. XII. —Gynaecological teaching in the wards is given as a rule by the
honorary officers either “ occasionally,” once, twice or thrice a week.
In two cases the obstetric registrar also teaches in the wards three and
four times a week. Clinical lectures, demonstrations under anaesthesia,
and teaching during operation are also mentioned in most cases.
In one hospital a course of “demonstrations” is given to “junior”
students by the visiting gynaecologist before they clerk in the wards.
Gynaecological teaching in out-patient departments is given usually
twice a week ; in one case four times a week ; as a rule the in-patient
obstetric physician is not engaged in this teaching, only one exception
being mentioned.
Section of Obstetrics and Gynaecology
133
APPENDIX C.
It is the larger teaching hospitals that would probably be able with the
least delay to develop fully equipped midwifery “ Departments ” on the lines
suggested in Section F, viz.:—
Guy’s Hospital
London Hospital
St. Bartholomew’s Hospital
St. Thomas’s Hospital
643 beds
925 beds
670 beds
592 beds
It is hoped that two others would also be able to take similar steps, viz. :—
Either Middlesex Hospital ... ... ... ... ... 480 beds
or University College Hospital ... ... ... ... 305 beds
and Royal Free Hospital ... ... ... ... ... 184 beds
Six fully equipped “ Departments” would be able, without difficulty, to receive
among them the students from the remaining six teaching hospitals which have
no midwifery wards of their own. The manner in which the hospitals were
grouped for this purpose would probably be mainly determined by proximity,
and the arrangements might well be left to the initiative of the hospitals con¬
cerned. The department at the Royal Free Hospital might prove to be
specially suitable for women students from other hospitals where women are
received for training.
According to figures prepared by the General Medical Council the total
number of medical students in London schools due to qualify annually during
the next four years is as follows: In 1920, 324 students ; 1921, 424 students;
1922, 463 students ; 1923, 546 students. The requirements of 600 students
per annum could be met if six “ Departments ” of fifty midwifery beds each
were established at teaching hospitals; this would probably allow an average
of over eight cases of labour for each student trained.
It is questionable whether financial assistance from the Government would
be forthcoming for the permanent establishment of so many midwifery
‘ 4 Departments ” in the central districts where, from the point of view of the
public needs, not all of them would be required, although they would perhaps
do so as a temporary measure. It is specially in the outlying districts that a
midwifery hospital service is needed, and before long this will no doubt be
established; there will not then be the same need for midwifery 44 Depart¬
ments ” in the central districts, and their number would no doubt be reduced.
Post-Graduate Teaching .—Advantage should be taken of the clpse proximity
of Queen Charlotte’s Lying-in Hospital and the Samaritan Free Hospital for
Women, to amalgamate these two hospitals and form a post-graduate school
of midwifery and gynaecology.
134
Teaching of Obstetrics and Gynaecology
APPENDIX D.
«•
The Clinical Teaching of Post-graduates in Midwifery
(Dr. F. J. McCakn).
(1) The existing lying-in hospitals should be utilized for the teaching of
midwifery to post-graduates as well as midwives, and arrangements made so
that facilities are afforded for acquiring a practical knowledge of the conduct
of labour and obstetric operations.
(2) Lecture demonstrations should be given on (a) the anatomy of labour,
(b) obstructed labour, (c) puerperal infection.
(3) Demonstrations should be given on the technique of obstetric
operations.
(4) Clinical instruction should be given in the wards and out-patient
department, and occasional lectures delivered on such subjects as the toxaemias
of pregnancy, cardiac disease complicating pregnancy, &c.
(5) Instruction should be given in the diseases and deformities of the
foetus, and for this purpose the valuable collection in the Royal College of
Surgeons Museum should be made available.
(6) Well equipped laboratories should be provided at the lying-in hospitals,
where instruction would be given by the pathologist, and opportunities provided
for research work.
(7) The courses of instruction in midwifery should last from four to six
weeks.
(8) A resident officer above the rank of a house surgeon should be
appointed at the lying-in hospital to assist in the teaching.
Section of ©betetrics anb <5\maecoloGip.
President—Mr. J. D. Malcolm, C.M.
A Foetus undergoing Spontaneous Evolution removed by
Laparotomy during Labour . 1
By Clifford White, F.R.C.S.
L. A., aged 34, had had four previous uncomplicated deliveries.
The average weight of these children is stated to have been 9 lb. Her
fifth labour commenced at term at 3 a.m. on October 18, 1916; at
10 a.m. on the same day a midwife ruptured the membranes. On
October 19 the pains ceased, but on the 20th strong contractions
recommenced, and at about 4 p.m. a doctor was sent for on account of
the left shoulder presenting. He failed to perform version under
anaesthesia, and sent her from Wood Green to Queen Charlotte’s
Hospital where she arrived about 9.45 p.m. One-third of a grain of
morphia was administered soon after admission. I saw her shortly
after 10 o’clock; she then complained of constant abdominal pain, her
pulse was 120 and her general condition bad. The uterus was in a
state of continuous contraction, the vulva was cedematous and there
was an offensive vaginal discharge. The pelvis was not contracted.
The left arm was the lowest presenting part, but both arms, the right
leg and the cord were prolapsed into the vagina. The cord was not
pulsating. The head was high up and quite out of reach, the buttocks
were at the fundus, which was displaced to the mother’s left side. The
lower uterine segment was tense and thinned.
It was obvious that an attempt to introduce the hand into the uterus
would rupture it, and it was equally obvious that abdominal section
must be attended by grave risk. Morphia had already been given, and
1 At a meeting of the Section, held April 3, 1919.
AU— 21
136 White: Foetus removed by Laparotomy during Labour
no farther relaxation of the uterus could be expected, so I amputated
both arms and made weight traction by attaching a 7-lb. weight to the
foot for three-quarters of an hour while waiting for the preparations to
be made for operation. The weight traction had little effect and so, at
11.30 o’clock—nearly seventy hours after the commencement of labour
—I opened the abdomen. The pouch of Douglas contained blood¬
stained fluid, the lower uterine segment was tense and thinned and the
uterus as a whole would not come up out of the pelvis during the
subsequent operation. The retraction ring of Bandl could not be
distinguished on the outer surface of the uterus but the bladder was
considerably drawn up. I turned the uterus forwards without opening
it and packed the intestines off and covered the upper part of the
incision with towels. The gravid uterus was then excised, curved
clamps being put on to the vagina (as far as the prolapsed arm-stumps
would allow) in an attempt to prevent infected fluid oozing from the
uterus. As the lowest clamp was about to be put on, the uterus slowly
underwent the process of rupture. It was possible to observe this
process, which was as follows : The peritoneum covering the right side
of the lower segment cracked into pieces about 2 cm. across, a little
blood appeared at the cracks and then the muscular tissue yielded
gradually and allowed portions of the foetus to be seen. Fortunately
the operation was nearly completed and so the vagina was cut across
and the uterus with contents removed without delay. I was surprised
to find that the left uterine vein was completely thrombosed and that
on the right side was partly thrombosed. The peritoneal flaps were
united over the vagina and the abdomen closed. The duration of
the whole operation was twenty-seven minutes and infusion of saline
solution was done throughout. The patient recovered consciousness
and power of speech and even drank some warm coffee, but died
suddenly three hours after the termination of the operation.
The specimen was hardened in formalin so that the original shape
was accurately preserved. The foetus is of the usual size of a child
at term, it is so bent on itself that the usual foetal oblong is replaced
by a more globular mass. The cervical spine is flexed to its fullest
extent so that the child’s head is embedded in the abdomen and the
right parietal eminence is in contact with the pubes. Both arms are
prolapsed below the neck and they are forced together so that there
is a space of only 2 cm. between the shoulder-joints. The right
leg is extended and the toes are on a level with the humerus of
the prolapsed arm. The left foot is in contact with the left ear.
Section of Obstetrics and Oymeeology
mmA
FuII-tiim* Icefcu? undergoing sjwJMatxeoa? ^volatioij. The gravid uterus
exceed uqox>ermd duvmg !&?»oor and the specimen hardened with the fretus in
^rignial
138 White: Full-time Pregnancy in a Uterine Horn
The arms have been amputated—the right above the elbow and the
left just below the shoulder.
The irregular mass formed by the contorted child measures 19 cm.
transversely from the vertex to the lower dorsal spines, 17'5 cm. from
before back and 27 cm. in its greatest length along the right leg.
The compression to which the child had been subjected was so great
that depressions have formed in places where foetal parts are in
contact. This is even the case where the, cord runs across the chest
and shoulder. On the outer surface of the foetus there is a groove
running round at the level of the axilla and another at the level of the
neck. These were probably caused by uterine action.
The specimen shows the condition of the foetus during spontaneous
evolution. The efforts of the uterus to overcome a transverse presenta¬
tion by this process failed probably partly because of the increased
difficulties occasioned by the prolapsed extended right leg and the fact
that both arms were in the vagina.
A Case of Full-time Pregnancy in a Rudimentary
Uterine Horn.
By Clifford White, F.R.C.S.
This specimen was given to me for investigation by Dr. Angus
Kennedy, my colleague at St. Mary’s Hospital for Women, Plaistow.
The lady from whom the specimen was removed was aged 27. She
had had one normal labour in 1915. Her periods were regular till
February 22, 1917, when they ceased suddenly. In October, 1917,
some blood-stained discharge was passed per vaginam but foetal
movements were felt up till, but not after, November. Pain was
never marked but as labour did not come on a. bougie was passed
into the uterus in January, 1918, and then the cervix dilated under
anaesthesia. It was found that the uterus was small and empty, but
. a mass as big as the gravid uterus at term could be felt above and
to the right. On January 30 Dr. Kennedy performed Caesarean
section and removed a dead male child, which was of full size and
well formed. The uterus was then removed by subtotal hysterectomy,
the appendages on the right side being removed with it. No signs
of impending rupture were noticed. The patient made an uneventful
recovery.
Ssctkjn of Obddrm <md Gynaecology J3&
When first given me the specimen was a good deal bigger than
it is now* ns considerable shrinking has takep place during 'hardening •:
it was originally about one>o4 a naif times the size of ». uterus after
au ordinary .Owsm^an section and the walls of the gestation ■ sat were,
more fiaefeid than usual. It consists ol the body of the uterus, the
gestatipa sac* the; right to be had ovary and, the stumps of both round
ligaments. The body of the uterus is pushed downwards and to the
left. In its present state it measures 9 cm. long , its cavity is 7 cm
long, it is not dilated, but only contains a small cpuiptity of reddish
l'teTUK 4ri(j ^f“gtfttvc*xT sac ffn>iV .^ ThfKer^ luIi-t'aru: eorrnj&) pr^iiRriTy reuinveil
bj operaitot) ‘two" lnbxiifcj?fclie tfoicv oj tbe of tjie |cwtlis<.
material which on section is found to be chiefly decidual debris. Above
and to the right oi the uterhk •» the gestation sae which measures
• 12 cm. by 13 cru. by 9 era.. The placental site is on the left or uterine
side of the cavity. Microscopic sections of the sac wall show little
decidual diAngto The wnib of the gestation sac measure from (Vb cm,
to, 2 r i cm. r:n thickness except on the ntcrine side where *2:3, cm, to
4*'o cm. of tissue separate the two cavities' The round ligauientgMto:
at the extreme tight and left limits of the mass; the point of insertion
140 Ley : Full-time Extra-uterine Pregnancy
of the right round ligament is just 4 cm. from the attachment of the
ovarian. ligament, and 3‘5 cm. from the insertion of the tube. The
right ovary contains a corpus luteum which measures 16 mm. hy
11 mm. The tube appears to be healthy and no peritubal adhesions
are present. Near the point of its insertion the wall of the gestation
sac is much thinned, but the peritoneum covering it is intact and there
are no signs of rupture. The position of the round ligament indicates
that the specimen must be either from a case of pregnancy in a
rudimentary horn, or else an interstitial ectopic pregnancy. From
the small size of the uterus and the proximity of the points of
origin of the tube, ovarian ligament and round ligament, it would
seem that the present specimen is one of pregnancy in a rudimentary
cornu.
I may add that in the last seventeen years Dr. Kennedy has operated
on five cases of full-time ectopic pregnancies with four recoveries.
Two Cases of Full-time Extra-uterine Pregnancy, with a
Tabulated Abstract of 100 Cases from the Literature.
By Gordon Ley, F.R.C.S.
In June of last year I had the good fortune to be able to treat two
cases of full-time extra-uterine pregnancy. These two cases, and the
conclusions drawn from them and from a study of the literature of
the subject, form the subject matter of my paper to-night.
I propose first to read the histories, notes of examinations and
operations, and to describe the pathological specimens of my two cases ;
secondly, to review tables based on 100 cases from the literature; and
thirdly, to open a discussion on the treatment of these cases. I hope
we may be able to lay down more or less defined rules along which
cases of extra-uterine pregnancy at term should be treated.
The first case came to the London Hospital out-patients early in
June and was admitted to hospital on June 15, 1918. Her notes are
as follows:—
E. L., aged 86. One child, fourteen years ago; no miscarriages.
Catamenia had been regular until December, 1911, after which she saw
nothing until October, 1912. In October, 1912, she had a period,
Section of Obstetrics and Gynaecology 141
during which the loss was excessive. There were no further periods
until January, 1913; since then she had been perfectly regular, the
flow lasting four days and occurring at monthly intervals. There was
no pain during the period from December, 1911, to January, 1913,
as far as her memory will serve. The abdomen enlarged between
December, 1911, and October, 1912, at which time she was much
bigger than she was with her first baby. Since October, 1912, she has
got smaller, but a lump has persisted ever since. It decreased in size
rapidly at first but has remained at its present size for years. She felt
the baby during April and June, 1912, but did not feel it after that
time. There was some vomiting during the early part of the period,
December, 1911, to October, 1912. She is doubtful if there were any
breast changes, but her memory is not good. During the last three
months, March to May, 1918, she has complained of pain in the back
and of considerable loss of weight.
On abdominal examination there is a stony-hard mass lying across
the mid and lower abdomen; it is somewhat of the shape of a foetus in
the normal attitude, lying transversely with the head to the left and the
breech to the right. The abdominal parietes grate against the mass on
palpation. The mass extends a distance of two fingers’ breadth above
the umbilicus, it rises out of the pelvis, the part of it just above the
brim and in the pelvis being considerably softer than that above.
On vaginal examination a normal cervix and lower uterine segment
can be defined; above this it is impossible to define the uterus. In
Douglas’s pouch there is a soft fixed mass, which completely fills it.
A confident diagnosis of full term, extra-uterine pregnancy was
made and was confirmed by an X-ray photograph which shows the
foetus clearly, lying with the breech to the right and its head to
the left.
On June 17 the abdomen was opened. There were many adhesions
of omentum to the front of a sac which was white, tough and pock
marked. The omentum was ligatured off and cut away. Apart from
these omental adhesions, the sac was free anteriorly with the exception
of one adhesion to the bladder and several slight adhesions to the
back of a small uterus which lay below and to the right of the sac.
The left Fallopian tube was identified crossing the front of the
sac well below the pelvic brim and apparently terminating in the sac.
Posteriorly the pelvic colon was firmly adherent to the back of the
sac crossing from the region of the left ovario-pelvic ligament to
the right side of the sac ; from this point the colon passed downwards,
142 Jurp: I^ui^Ume B^tra+nteritie Pregnancy
being adherent to the right posterior wait of the sac- in its whole depth.
'The: colon wasseparated from the sac without, much difficulty except at
one point low down on the right wheel the sac was opened and material
resembling placenta protruded. The sac was last separated from the
floor of the pelvis and waa Oven removed with the left tube and ovary,
Fio. I
a normal right tube and ovary being left,.- together with the atrophic
uterus,
The convalescence was abeokueiy undisturbed arid the patient
returned home on the sixteenth' day after her operation
V ^ •• \ 1 • >*» - •
Section of Obstetries, and Gynaecology
FATROLOGrCAl, L>tvs< if!:.'T.TO.\
Specimen from E. L ~—The specimen is a mv& s ■20 c-m. by 18 cm. by
t‘3 cm, Ifc isshaped like the African continent, the west side pointing
however to the east. Its surface is greyish■ white iu colour and is
irregular and pock-marked,..bet»g covered, by’plagues uf fibrin. To its
right enteciot and right posterior upper parts large, omental strands* are
attached. Lying at its equator, -m front of the mass, hsa structure
144 Ley: Full-time Extra-uterine Pregnancy
covered by vascular fibrous tags. This structure consists of the left
Fallopian tube, upper left broad ligament and left ovary. The tube
measures 7 cm. long by 0‘4 cm. in diameter, in its proximal 4 cm.;
beyond this it is intimately blended with and apparently terminates in
the mass. The ovary measures 2'2 cm. by 1'6 cm. by 1 cm. It contains
one small cyst 1 cm. by 1 cm. by 2 cm., the walls of which are lined by
laminated clot. On the right side of the posterior wall of the lower pole
of the tumour a process of soft papillary light brown tissue projects
from inside the mass. This measures 4 cm. by 3 cm. by 3'5 cm.
On opening the mass it is found to consist of a sac containing a foetus
and placenta. The sac wall varies from O'Ol cm. to 0'5 cm. thick.
The part above the equator has a comparatively smooth brownish lining.
Its wall is ridged, the ridges marking the site of the foetal folds. This
part of the sac contains the foetus. A rough area on the posterior wall
of the sac, measuring 3 cm. by 2 cm. and 2 cm. above the equator, marks
the point of insertion of the umbilical cord. The part of the sac
below the equator contains a dark brown papillary friable mass which
represents the placenta. This posteriorly and to the right has perforated
the sac wall and projects externally as formerly described. The foetus
weighs 3 lb. 1 oz. It is bunched into a position of extreme flexion and
compressed to the smallest possible bulk, the feet and hands being
flattened. The state of preservation is extraordinarily good. The hair
on the scalp is still present, and is light brown in colour. Here and
there are superficial ulcers floored by yellow gritty tissue.
The above description shows clearly that this was a case of
secondary abdominal pregnancy; the ampulla of the left tube being
the primary site of the gestation sac. The tube had apparently given
way posteriorly and the foetus and membranes had passed through the
rent into the peritoneal cavity. The placenta has in part remained in
situ and in part become attached to all structures forming the floor of
Douglas’s pouch.
The second case I saw at the Cottage Hospital, Walton-on-Thames,
on June 26, 1918:—
D. R., aged 28. Married three years and three months; no children
and no miscarriages. Her previous health had been good until two
years ago, since that time there had been pain in the left lumbar region
which was clutching in character. This pain was intermittent and was
usually associated with pain in the vagina. The pain persisted on and
Section of Obstetrics and Gynaecology
145
off until November, 1917, and since then she has not suffered from it.
It was sometimes absent for as long as six months. During the periods
of pain there was frequency of micturition. The condition was
diagnosed as a colon bacillus infection of the urinary tract. Her
menstrual periods were regular, lasting four to five days every month,
up to October, 1917, but since then she had not seen her periods.
On November 20, six weeks after the cessation of menstruation, she
had a very severe attack of abdominal pain, lasting three days; which
was felt all over the lower abdomen. The pain was exceedingly severe
and she fainted on two or three occasions; it was accompanied by a
slight show. She was in a nursing home for about a week at this time.
Her temperature ranged from 97'6° F. to 100° F., and the pulse
from 80 to 100. There were two less severe attacks in January and
again in April, 1918. Ever since the November attack there has been
slight pain in the right lower abdomen and the back, which has been
more of the nature of a sore feeling and has been practically constant;
it has been getting worse for the past few weeks. She first felt the
baby when /sixteen weeks over her time, and from that date onwards to
June 25. She has not felt the child since this time. Micturition has
been unaffected ; the bowels have been constipated for the past month.
Since June 26 she has felt ill and the pain in the back has become
distinctly worse. Her temperature has ranged from 98° F. to 100'4°F.,
and the pulse from 80 to 108. The breasts have increased in size since
November, 1917, and her abdomen has also greatly increased in size
since that date. There was a slight show on June 26 and it recurred
again on July 2.
On examination on July 2, the following points were noted: A
wasted ill-looking woman, anaemic and slightly jaundiced ; temperature
100'4° F., pulse 120; the tongue furred and dry. The abdomen is
distended and shows numerous striae gravidarum. A very large tumour
occupies the abdomen, rising out of the pelvis ; it is situated very plainly
to the right of the mid-line and reaches the costal margin. It extends
only about three fingers’ breadth to the left of the mid-line at the
umbilicus. The tumour is tender and is definitely cystic: it does not
contract on examination. No foetal parts can be felt and no foetal
heart can be heard. There is a uterine souffle in both iliac fossae.
To the left of the tumour attached to it, there is a mass rising out
of the pelvis to about the level of the umbilicus. This mass, to the
right, is continuous with the tumour in its whole length. It can
definitely be made to contract on stimulation and behaves in every
146 Ley: Full-time Extra-uterine Pregnancy
way exactly like a puerperal uterus on the day following delivery ; it is
also about that size. The examination is rendered extremely difficult
by a distended, transverse and pelvic colon and by general tenderness.
The breasts showed a well formed primary and secondary areola and
much milk can he squeezed from the nipples.
Vaginal examination: There is no discoloration of the vulva, the
parts are soft and vascular as at full term. The cervix is soft and
enlarged, it is extremely far up the vagina and is displaced very distinctly
to the left by a tender mass which pushes down the right side of the
vaginal vault.
With this history and these physical signs, the only possible
diagnosis appeared to be that of a full-term pregnancy in the right
broad ligament, and it was advised that the patient should be
transferred to a London nursing home. This was done on the
following day. An examination of the urine revealed a small
amount of albumin and a very large number of granular casts.
There were no pus cells but there were numerous staphylococci and
streptococci present. Her general condition was reported on favour¬
ably by a physician.
On July 3 there was a show, which was, however, extremely slight.
The physical signs on abdominal examination remained the same, with
the exception that the colonic distension diminished and allowed of the
more easy recognition of the two parts of the abdominal tumour. The
uterine mass gradually diminished between the 4th and the 16th, at
which time it was about the size of a ten weeks’ pregnancy. Contrac¬
tions and relaxations of the uterus were elicited at each examination.
Her general condition between the 4th and the 16th improved.
Vomiting, which had been pronounced from June 26 to July 4, ceased
on relief of the intestinal distension. The temperature, however,
remained from between 98'4° F. to 100° F., the pulse falling to 100 to
110. The pain in the back also persisted. These complications,
combined with the possibility of further adverse manifestations arising
at any time, seemed to indicate operative treatment.
After examination under an anaesthetic and still further confirming
the diagnosis, the abdomen- was opened on July 16, the child having
then been dead about twenty-one days. On opening the abdomen it
was seen that the condition exactly corresponded with the physical
signs. The uterus.was displaced to the left and was about the size of a
ten weeks’ pregnancy. The left tube was thickened and tortuous but
was apparently patent. The left ovary was normal. Attached to the r
"1
Section of Obstetrics and Gynaecology 147
right of the uterus was an enormous mass covered entirely by peritoneum
and showing large vessels coursing over it. The right round ligament
crossed the tumour passing from the right cornu downwards and to the
right. The right tube was lost on the surface of the tumour. There
were many adhesions of omentum to the upper anterior and to the
right and upper pole of the tumour. The pelvic colon was firmly
adherent to the back of the tumour as far down as could be reached; it
was also adherent to the hack of the uterus. The caecum was adjacent
to, and was bound by a few adhesions to the right side of the sac; the
right ovario-pelvic ligament being completely obliterated, the vessels
passing directly out from underneath the caecum on to the front of the
tumour. The union of the uterus to the left wall of the sac was
extremely firm and had a depth from before backwards of at least
2 in.—that is, it was too broad to clamp.
The right round ligament was divided in about its centre and an
incision was made from here, through the peritoneum to the right wall
of the uterus in one direction and to a point 1 in. below the ovarian
vessels in the opposite direction. The round ligament was then stripped
up to the uterine cornu and an attempt was made to get between the
uterus and the sac in the hope of saving the former structure. A large
blood sinus was at once encountered and bleeding from it was only
controlled with extreme difficulty. It was obvious therefore that the
uterus would have to be removed. The left round ligament, the left
tube and ovarian ligament were clamped and divided, and the left side
of the uterus freed in the ordinary way. The pelvic colon was next
separated from the back of the uterus, the left uterine vessels were then
divided between clamps and ligatured and the supravaginal cervix was
cut across. Some right uterine vessels were then clamped. Previous
to this, the bladder had been displaced downwards from the front of the
sac and from the uterus. The sac was next separated from the floor of
the pelvis, this part of the dissection being carried out satisfactorily,
many large vessels being encountered and clamped. The dissection was
carried backwards and to the right until the bowel was approached.
The caecum was then separated from the sac and the ovarian vessels
clamped as they passed out from underneath it. At this point the sac
ruptured and the baby was expelled. The cord was cut and the baby
removed. The sac was now almost completely free with the exception
of its posterior part which was firmly adherent to the pelvic colon. It
was cut away, a small area of its wall being left where the pelvic colon
and rectnm were adherent to its posterior surface. Complete hsemo-
!
14b- Lev : Full-time ■.’Bxtta-idemie. ■■Pregnancy
stasis was next secured, and the door pentoaeahzed, the edges of the
sac, which how formed the face of the pelvic colou aad rectum. being
sutured to the anterior and posterior leaves of the broad ligament, the
pelvic colon thus forming a horizontal lino stretching from right to left.
The abdomen was closed, a small drainage tube being inserted which
was removed twenty-four hours later.
The patient stood the operation extremely well. 'There was of
course severe shock and there was no small amount of blood lost. The
difficulties encountered were considerable owing to the absolute impos¬
sibility of controlling the blood supply before dissection. It had
beeh hoped that it would be possible to Save the uterus and to $lamp
the ovarian vessels before commencing dissection., but this, as has
been seen, was absolutely impossible.
Convalescence was undisturbed until the ninth day, When the
temperature rose and remained up until the seventeenth day. On
Bectum-pf Qhiiietrit:#- arid Qyn&'tology 140
the eleventh day the patient developed a right uretero^oervjeai fistula
which persists; at the present time Apart from th»; she m in perfect
health and will probably at a later date have a right nephrectomy
performed upon her.
Patuologh'aii Desobiction.
Specimen of £>. It-—A specimen measuring '27 cm. by 18 cm. by
0 eta. It constate ob two parts; (>fr a uterus, [b) a sac.; The uterus
has been amputate# through the tipper part of the cervix ; it- measures
Fid. 4.
Anterior vitw of ulurui mid .mv, Case 1, »hov. iu«r rigbi. rcutij (IgSMant,. right
Hue of jKU’ttonenl inois'fwo,
8'fi cm. by O'5 cm. by (» cm. Its surface,particularly* posteriorly and
superiorly, is covered by fibrous tags. The. wall is ‘.I'd cm. thick, the
inner' T,$ cm., consisting of a soft, grey or pinkish decidua in which
ace yellow dotted areas. The left appendages and left renrui ligament
are not included in the specimen, but their stumps aresecii•in the
region of the left cornu. Bunning from the right cornu is the stump
150 Ley ; Full-time ■E$&a~ufomie Pregnancy
of the right round ligament, measuring h*5 cm. by 1*5 cm. by 0 7 mu.
The fight J?a}|optan tube passes 'but on the suti.ace bf the sa& a.
distance of 3 cm.; it then turns '-upwards a further 2 cm., and is here
lost on the surface .of the sac. The fculje has a diameter of 1 tan.
and posteriorly ami mferiovly k incorporated - with the me. The sac
measures 1H cm. by 1H cm. by ti cm. If- is firmly attached to the
right and posterior-right wail of the uterus m the whole length of
the former and over a depth of 0 cm. The upper two-thirds of the
FlO. 5,
PosterjV/r view of uteciis and sit, Jf. Hi'H'id? jdfceenta, and stump of
urnbiti&M rord. / .
sac are covered by peritoneum to which a few omenta! are
attached, The lower third la devoid of -.peritoneum. Beneath the
peritoneum numerous blood-vessels can be seen. Posteriorly there is a
big foramen 15 ctu. ip diameter winch opens up the sac. The sac is
found to have, a wall varying from 0*2 eta. to 0*5 on;, in thickness. It
is lined by a rusty brown, soft, slightly wrinkled membiane. To its
right anterior, eytefua! add Upper wall, an irregular-placenta-is attached ;
this varies greatly so thickness, having a maximum thickness of }'.*<> cm.
’..Vv: *,M ',/: r w
Section, of- Gl&teirics and QyhMcology
The cord is attached id the region oi -the tipper and outer angle.
Accompanying the specimen is a. teumte feattts .i’ft an early-stage of
roaceration, weighitig-1 lb. 7 oz. It does not appear to be malformed,
and mbst certainly is not grossly so.
152
Ley : Full-time Extra-uterine Pregnancy
Comments.
In the first case, except that the separation of adhesions made the
work slow, no difficulties and no bleeding were met with. I feel,
therefore, that if it were safe to leave a dead, full-term, ectopic foetus
in the abdomen for months, this should be done in all cases in which
the child is dead at the time when the patient is first seen.
In the second case, the extraordinary vascularity and the inability to
avascularize the sac before freeing it, were the main difficulties. The
vascularity of the sac in this case was out of all proportion to that of
the sac in the first case, and was the real danger of the operation. Not
only was the blood lost considerable in amount, but the continuous
bleeding made recognition of structures very difficult, and resulted in a
division of, or strangulation of the wall of, the right ureter. If I met
this case again I should open the sac first in spite of the risk of
peritoneal infection, remove the foetus and then remove as much of the
sac as possible with the placenta, marsupializing and draining or
packing the remainder of the sac.
Discussion.
With a view to formulating a line of treatment,, I have collected 100
cases from the literature of the subject, dealing almost exclusively with
cases after the thirty-fourth week of gestation. On tabulating these
abstracts interesting points are brought out: (1) With regard to the
symptoms during pregnancy, (2) with regard to the symptoms of
labour, (3) with regard to the complications consequent on labour or
foetal death, and (4) with regard to the findings at operation.
Among the 100 cases collected—in 77 per cent, pregnancy went to
term, in 16 per cent, it was continued to between the thirty-fourth
and thirty-sixth week, in 2 per cent, it was continued to between the
twenty-eight and thirtieth week, while in 5 per cent, the history sug¬
gested that the pregnancy had progressed two to four weeks over
term.
The site of the pregnancy was thought to be: Primary abdominal,
3 per cent.; secondary abdominal, 37 per cent.; secondary broad
ligament, 24 per cent.; primary ovarian, 4 per cent.; rudimentary
uterine horn, 7 per cent. In the remaining 25 per cent, it was
undetermined.
I cannot in any way vouch for the correctness of these figures, as
Section of Obstetrics and Gynaecology
153
it is obvious that in many cases it will be extremely difficult to be
certain of the site of the pregnancy.
Pregnancy. —The pregnancy was normal in all respects in 33 per
cent, of the cases, this being a characteristic feature of rudimentary
horn pregnancies. Among seven of these latter, pregnancy was
absolutely normal in four, while in two others it was complicated by
severe vomiting in one and cystitis at the thirty-sixth week in the
other. There was a history of a more or less acute abdominal
catastrophe occurring between the sixth and sixteenth week in 50 per
cent, of the cases. This undoubtedly synchronized with the giving way
of the sac as the result of erosion, stretching or haemorrhage, probably
in the majority of cases the former. The attack was in a large pro¬
portion of these cases typical of the attack associated in one’s mind with
a ruptured tubal gestation. In 39 per cent, there were other symptoms
atypical of normal pregnancy. Fain was the most constant, sometimes
occurring in attacks, sometimes complained of as a continuous gnawing
or aching sensation. Irregular bleeding was also of frequent occur¬
rence, being rarely, however, severe. Vomiting, intestinal distension,
constipation and urinary troubles were not infrequent. The movements
of the child were violent and painful in a considerable proportion of the
cases; in 3 per cent., however, foetal movements were never felt. There
was evidence of toxaemia of pregnancy in 4 per cent, of the cases,
albuminuria in two cases, one commencing after the death of the foetus,
pernicious vomiting in one case and eclampsia, occurring during labour,
in one case. The uterine decidua was expelled during the early weeks
of pregnancy in 3 per cent, of the cases. Extra-uterine pregnancy
was associated with an intra-uterine pregnancy in 3 per cent, of the
series.
Labour .—A recognizable labour, consisting of intermittent pains,
with or without show, and frequently with dilatation of the os uteri,
occurred in 61 per cent, of the cases. In three of the cases a gush of
water occurred; this was possibly urine, it not being an infrequent
occurrence in the later weeks of normal pregnancy for a mother to have
a similar flow, which she attributes to the rupture of the membranes,
yet on examination these are found to be intact. In many cases con¬
tractions of the uterus synchronized with the pains, and in others
contractions of the sac were felt, these being cases of rudimentary horn,
pregnancy. The uterine decidua was expelled during false labour in
8 per cent, of the cases only. This is of interest as correcting a fairly
constant text-book description, a parallel of the shedding of vesicles
154
Ley: Full-time Extra-uterine Pregnancy
during pregnancy with vesicular moles, which rarely, if ever, occurs.
Death of the foetus during, or shortly after labour, or at, or shortly after
full time in those cases in which labour did not supervene, occurred in
60 per cent, of the cases, and in none did the life of the foetus postdate
the labour by more than ten days.
Complications following on Labour or Death of the Foetus. —This
must be regarded as of extreme importance as bearing on the treatment
of the cases. In 50 per cent, of seventy-four cases in which operation
was not performed at or shortly after term, there were no complications;
the sac shrank and the patient’s condition returned to or approximated
to and remained at the normal as in the first case described by the
author. In 33 per cent, there were symptoms more or less severe of
infection of the sac, pyrexia, rigors, pain, emaciation, vomiting, signs
of general peritonitis, or fistula formation usually in connexion with the
pelvic colon or rectum, the latter condition arising in 33 per cent, of
the septic cases, 11 per cent, of the total. The onset of these septic
symptoms occurred as early as ten days and as late as fifteen years
after labour or death of the foetus. Bleeding, more or less severe, was
a sequel of 12 per cent, of the cases; rupture of the sac, with peri¬
tonitis, of 2'3 per cent, of the series.
Treatment. —The ideal treatment would naturally be based upon an
analysis of the results of the preceding series. The results of analysis
of the tables may be grouped in two headings : (1) The time at which
the operation was performed, with the results to the mother and, if
living, to the child; (2) the method of dealing with the sac and
placenta with the results to the mother.
(1) (a) Operation at term, child alive, twenty-two cases. Maternal
results: Becovery, 73 per cent.; death, 27 per cent. Foetal results:
Foetus well-developed, 54'5 per cent.; foetus mal-developed, 45'5 per
cent.; children died shortly after delivery, 18 per cent. The maternal
deaths in this series were six. One of these deaths was due to
delirium, existing both before and after labour, possibly toxsemic in
origin; in the remainder, death was due to sepsis, but in two of these
the operation was performed before the year 1880. The foetal
deformities consisted of: Cranial asymmetry, six cases, which usually
righted itself; talipes, five cases, which responded satisfactorily to
surgical treatment; torticollis, four cases; umbilical hernia and con¬
genital dislocation of the hip, one case each. These latter also re¬
sponded to treatment. Many of the children had several of these
deformities.
Section of Obstetrics and Gynaecology
155
(6) Operation within eight weeks of labour or death of the foetus,
thirty cases. Maternal results : Recovery, 80 per cent.; death, 20 per
cent. The maternal deaths in these series were five ; they were due :
to pre-operative haemorrhage from rupture of the sac, one case; to
shock from rupture of the sac, one case; to haemorrhage, two cases;
to sepsis and secondary haemorrhage, one case.
(c) Operation after the eighth week following labour or death of the
foetus, forty-six cases. Maternal results: Recovery, 95'75 per cent.;
death, 4'25 per cent. The maternal deaths in these series were two.
There were due to sepsis and secondary haemorrhage, one case; to
sepsis only, one case.
(2) The Method of Dealing with the Sac and Placenta. —Four
methods have been adopted : (a) The whole sac, including the placenta,
has been removed; ( b ) the placenta has been removed and the sac
marsupialized and packed with gauze, or drained; (c) the placenta has
been left in situ and the sac marsupialized and packed with gauze, or
drained ; (d) the sac has been sewn up over the placenta and the
abdomen closed.
(a) Forty-five cases. The results to the mothers have been as
follows: Recoveries, 91 per cent.; deaths, 9 per cent* The deaths
were four in number. They were due to pre-operative haemorrhage
and shock, one case; to shock from rupture of the sac, one case; to
haemorrhage, one case; to sepsis, one case. The death from haemorrhage
occurred in a case operated on six weeks after labour. .
( b ) Twenty-three cases. The results to the mothers have been as
follows: Recoveries, 87‘5 percent.; deaths, 12'5 per cent. The deaths
were three in number. They were due to pre- and post-operative
delirium (? toxaemic) in one case, to haemorrhage in one case, to
septicaemia in one case. The death from haemorrhage occurred in a
case operated on fourteen days after labour.
(c) Twenty-six cases. The results to the mothers have been as
follows: Recoveries, 76 per cent.; deaths, 24 per cent. The deaths
were six in number. They were due to general peritonitis, one case ;
to sepsis and secondary haemorrhage, two cases; to sepsis only, three
cases. In the case of general peritonitis, the condition was present
before operation.
(d) Three cases. The results to the mothers have been as follows:
Recovery, 100 per cent. In one of these cases the sac had been drained
later by posterior colpotomy.
156
Ley: Full-time Extra-uterine Pregnancy
The Ideal Treatment .—That the child is worth saying is certainly
beyond doubt, as shown by a perusal of the first table. This statement
must be qualified by “if the life of the mother is not endangered
thereby.” The above figures show a maternal mortality of 27 per
cent, in twenty-two cases in the series where the child is alive. Of
these six deaths, three must be excluded, the delirium case and the two
cases operated on prior to 1880; this gives a corrected mortality of
16 per cent, in nineteen cases, which is less than the mortality of
those cases operated on in the first eight weeks after labour or foetal
death. It is considerably greater than the mortality in those cased
operated on after the eighth week, but there is little doubt that many
cases in this latter group died of septic complications without being
operated on, while many others had their health permanently ruined by
prolonged sepsis and recovered with a faecal fistula. It can, therefore,
be said with regard to the time of operation, that cases of extra-uterine
gestation at or near term, should be operated on during the life of the
child whenever possible, and in view of the great risk of septic in¬
fection of the sac, operation should not be delayed even after the death
of the foetus ; delay only resulting in increasing the risk of sepsis and
not ensuring anaemia of the placental site, as in Fairbairn’s case, in
which there was profuse haemorrhage six weeks after foetal death. With
regard to the type of operation, removal of the sac is undoubtedly the
ideal treatment whenever possible. In those cases where removal of
the sac is impossible, marsupialization of the sac, with removal of the
placenta and drainage of the sac or plugging of the sac with gauze,
should be carried out when possible. In those cases where attempts
to remove the placenta cause profuse haemorrhage, the sac should be
marsupialized, packed with gauze, and the placenta allowed to come
away piecemeal.
Abstract of 100 Cases of Extra-uterine Pregnancy advancing to the Thirty-fourth Week or Term,
with Resalts.
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Kieschneb, W., Term Severe pain and At term; decidua — Twelve days Sac incised; child removed; sac re- Recovery;
Trans. Amer. bleeding at eighth not shed ^ after labour moved; right ovarian pregnancy child no mal-
Assoc. Obst. and week; pain from ' developments;
Oyn. f 1910, xxii, eighth to sixteenth did well
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Idm ; ibid. (1888), Term Severe pain and Decidua not shed; — Eight months Sac incised; foetus removed; placenta, Recovery
1889, xxx, p. 480 j vomiting six- death of foetus after labour anterior, removed; sacmarsupialized
! teenth week followed and drained; left broad ligament
! pregnancy
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rebnberg, H., Term Pain and irregular i At term; decidua — | At term Sac incised ; child removed ; placenta J Rec ov cry ;
Jo urn. Amer. bleeding through-i not shed I removed; sac removed in part; child not
Med. Assoc., out uterine and ovarian arteries liga- malformed ;
Chicago, 19 10, tured did well
liv, p. 1517 1
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later; right secondary abdominal 10 lb.
pregnancy
faction of Obstetrics and • Gynaecology 171
Specimen of a Lower Limb of a Mature Foetus contained in
an Osseous Cyst, and remaining in the Abdomen of the
Mother ior Fifty-two Years.
Shown by Herplrt. Williamson, M.B.
This specimen'.is from the Museum of St. Bartholomew’s Hospital
and is thus described in the catalogue
dOtiS. " One oi the lower limbs of a'loans of mature growth,.which was .
coKtamsd in au osseous cyst and reiuamod hi the fthdotneo of the mother for
fifty -two years. A portion of the cyst ix connected with the limp; their
surfaces were perfectly adherent, hut have been partially sepurnted, The
several tissut® of the lih'h are dry pad compressed, hut are ofliealthy ■ structure.
Thu-patient vJ!>.set f ;nt;y yea; s- oiVi when she died; fifty -two years before she
bud signs of pregnancy ;ti:U risen of labour for lb*, delivery of this child.’'.’
If -was previously exhibited at n meeting of this Society, held one
hundred and fixe years ago. the paper was written by Richard Brown
Cheston, M.EL, of /Gloucester, and was communicated to the.
Society by §ir; William Lawrence. Its history- is as follows ; —
Mi;S; Cowles, in the month of Idecerufaer, 1708, was taken in labour
with her fourth child. The pains were lingering and went on for three
days, but without, any advances; towards dMiveryi I>r. Rogers, nL
Gloucester, -was railed - in, and declared that the child offered for birth,
but that, he non id not deliver, it without instruments. This kind of
assistance Mrs. Cowles positively refused .and declared that if sire could
not be delivered without, ■instruments; sheand the child should die
together. For so’ue days the |Ktin seemed to return at interval a. but
gradually abated and by the end. of the third week ell prospect of
delivery was over. Great uneasiness' continued in her- bally and she
ftuffbtsd much mental ansiety from her situation, Bhe .continued in a
weak state for fully three months' afterwards, but gradually recovered,
Mrs. Cowles died in the 80th year of age, fifty-two years after the
events just recorded ; the cause of death was a paralytic stroke, followed
by a (puck-spreading mortification of the leg.
A post-^didi^D. examination 'was made by iSc. Ghestoo. Cpnn
exgpaiijg the cavity of the abdomen, a tumour immediately presented,
.coveted by omentum and small intestines, which adhered to it firmly.
172
Williamson: Lower Limb of a Mature Foetus
When these attachments were separated it presented a complete
bony surface which yielded upon striking it the sound of a solid
bone. The tumour could be raised from the brim of the pelvis upon
which it rested and the uterus was discovered “ lying flat at the bottom
of the pelvis.” After removal, the bony tumour was divided through
its middle by a fine amputating saw, and the body of a full-grown foetus
was discovered “ in a state of wonderfully perfect preservation . . . the
skin, adipous substance and muscles retained much of their natural
consistence and characteristic appearances ... of the membranes,
placenta and navel string, I could not discover any remains excepting
the insertion of the latter into the body of the child.” Dr. Cheston
concluded “ that the child was contained originally in the uterus and
remained in that situation the usual term of gestation.”
On reading his account of the autopsy, however, it appears probable
that the gestation was either tubo-abdominal or ovarian. “ The
spermatic vessels were very evident on the right side attached to the
superior part of the elongated uterus, but no trace of the ovarium could
be discovered. It was only after a very attentive search that I found a
cord-like substance about the size of a crow quill, in its external appear¬
ance not unlike the vas deferens. Upon discovering that this was
tubular I slit it up and found by the elegantly plaited appearance of
its internal surface that it was undoubtedly the Fallopian tube, possess¬
ing, in every respect, its natural course and appearance and terminating
as usual in its fimbriated extremity.”
In the same paper Dr. Cheston records a second case of full-time
ectopic gestation. This account is based “ upon minutes made by
Mr. Newell, an eminent surgeon at Cheltenham, with whom I paid the
patient several visits.” Jane Hawes was a healthy, well made woman
about 25 years of age, the mother of two' very fine children. In 1795
when her youngest child was 2 years old she again became pregnant.
“ She went her full time without the smallest inconvenience and at the
end of nine months was seized with pain which was supposed to be
labour.” The pains continued for three days, and “ on the third day
fever and symptoms of inflammation took place, and the spasmodic
pains which had at times been very violent subsided and were succeeded
by tenderness of the belly and pain, arising evidently from a new
condition of parts. After ten days the inflammatory symptoms began
to subside and were succeeded by considerable discharges of a very
foetid and purulent matter.” After six months’ grave illness the
discharge began to diminish and the general health to improve, and in
Section of Obstetrics and Gynaecology
173
fifteen months she had regained her usual flesh and strength. Five
years later she became pregnant again and went into labour in
December, 1800. On examination, a solid bony tumour was discovered,
fixed firmly to the base of the sacrum, and between this tumour and
the pubis was felt the dilated cervix uteri, through which the foot of a
child protruded. With great difficulty the child was broken up and
delivered. “ Suppuration followed with immense discharges of foetid
matter with hectic fever and great emaciation. She lingered on in
this wretched state till ulceration took place, which extending down¬
wards in the course of a few months, destroyed the vagina and rectum,
and her stools, urine and discharges came seemingly out of one great
cavity. During the progress of this wretched case, various bones of
the former foetus were discharged and after lingering in the most cruel
sufferings for about ten months, the unfortunate woman died.”
Cases of Extra-uterine Pregnancy.
By H. R. Andrews, M.D.
In 1903 a patient, aged 37, nulliparous, married thirteen years,
came to me on account of persistent vomiting. She thought that she
was about three and a half months pregnant. Her history was that
nine years before the periods had ceased, and she had all the symptoms
and signs of pregnancy, with nothing to, suggest that it was abnormal
except that she had abdominal pain. She did not remember having
had any acute attack of pain. At the expected time labour pains came
on, lasting twenty-four hours, accompanied by a slight amount of
bleeding which lasted for a week or two. Foetal movements ceased
when the labour pains began. For the next eight years she had good
health and was free from abdominal pains. The abdominal tumour
became rather smaller. She sought advice after three months’ amenor-
rhoea, on account of vomiting. A very hard irregularly rounded tumour
was found, the upper pole reaching about 2 in. above the umbilicus.
There was a soft swelling filling up the pelvis below the fixed hard
swelling. Bimanual examination was impossible as the hard swelling
was fixed in the brim. Diagnosis : Lithopsedion impeding the growth
of the pregnant uterus. Operation: The right half of the peritoneal
cavity was comparatively free, the left half almost obliterated by
174
Andrews: Cases of Extra-uterine Pregnancy
adhesions between the lithopsedion and omentum and anterior abdo¬
minal wall. When the head of the lithopsedion was separated from its
adhesions in the pelvis a gush of blood came from the pelvis. A living
foetus of about three and a half months was hanging out of a rent
in the posterior layer of the left broad ligament. The lithopsedion
measured 17 in. in length and weighed 3 lb. 5 oz. It was enclosed in
amnion and chorion which embraced it closely. The placenta, 4£ in.
in diameter, must have been, attached to the anterior abdominal wall.
The patient did very well. 1
My second case, in 1906, was a primigravida,' seven months
pregnant, who had no symptoms except severe vomiting. Before
marriage she had had two severe attacks of vomiting lasting for several
weeks, said to be due to gastric ulcer. I was asked to see her in
consultation, to decide whether labour should be induced prematurely.
The foetal, heart was heard. The foetus seemed to be small for
thirty weeks. Bimanual examination revealed nothing abnormal. The
patient, who had formerly weighed 7 st., weighed only 4 st. 8£ lb.
I refused to induce labour and sent her into the London Hospital.
The vomiting soon ceased and the patient put on weight rapidly.
She remained in the hospital four weeks. Four months later I was
asked to see her again, as she had not been delivered, and was very ill
with a temperature of 102° F. Soon after leaving the hospital a blood¬
stained vaginal discharge began, and she had very severe abdominal
pain coming on every five minutes for about an hour. The doctor
examined her under an anaesthetic and found nothing abnormal.
The foetal movements ceased just before the abdominal pain began.
Four months after the occurrence of the abdominal pains she became
feverish and ill, and had extraordinarily offensive stools. On examination
the tumour could not be separated from the cervix, but a swelling
which felt like an unimpregnated uterus could be felt projecting from
the left side of the tumour low down. Diagnosis: Suppuration in a
pregnant right rudimentary horn. Operation: The whole uterus was
removed. The wall of the tumour gave way during removal and
horribly offensive pus escaped. The foetus which was much decomposed
measured 17 in. In 1907 I wrote about this case: “ My experience
in this case would make me unwilling to leave a full-time ectopic
pregnancy alone in the hope that no further trouble would result.”
The patient made a good though slow recovery. 2
1 Obstet. Soc. Trans. (1903), 1904, xlv, p. 461.
2 Obstet . Soc . Trans . (1907), 1908, xlix, p. 209.
Section of Obstetrics and Gynaecology 175
In 1911 a nullipara, aged 29, was admitted under my care with an
abdominal tumour. Eleven months before her periods had ceased.
After nine months’ amenorrhoea, during which time she had no pain
or discomfort, she had rather free uterine haemorrhage, and then slight
haemorrhage lasting two months. During the first fourteen days she
had pains coming on every half hour. A large smooth tumour of almost
stony hardness filled up the abdomen. On the left side of it and
behind could be felt the uterus, rather bulky. Diagnosis: Full-time
ectopic pregnancy. Operation: The undeveloped right horn was
removed, the uterus, both ovaries and left tube being left. The tumour
contained a full-time foetus, macerated, weighing 4 lb. 14 oz. The
patient did very well.
In 1902 I saw in consultation in the country, a patient, B. S.,
whose history was as follows : She was aged 40, had had five children,
the last thirteen years before. The periods ceased in February, 1902.
During May and June she had a good deal of pain in the abdomen.
Labour came on in October and lasted for two days, but no child was
bom. I saw her in December and found that the uterus, which was
slightly enlarged, could be felt apart from a large abdominal tumour.
There was no doubt that she had full-time extra-uterine pregnancy.
I was not then on the staff of the London Hospital, so 1 got another
obstetric physician to admit the patient into his wards. He considered
that there was no need to perform an operation, and the patient was
sent back to the country. For the next ten years she was quite well
and then began to have abdominal discomfort, with occasional diarrhoea.
In January, 1914, she passed some bones, chiefly ribs, per rectum.
Bones were passed at intervals up to November, 1914, when she was
admitted into the London Hospital under my care. Besides the
diarrhoea she had had two or three attacks of abdominal pain and
vomiting. • On one occasion she was thought to have intestinal
obstruction. There was a firm, tense, cystic, median swelling rising
up half way to the umbilicus. The upper part of it was definitely
cystic; the lower part, although soft, seemed to be solid. On bimanual
examination the mass was found to be about the size of a cocoa-nut.
It lay more in the left side of the pelvis than in the right. It had a
slight range of mobility. The uterus, which lay to the right of the
tumour, was continuous with it. The rectum was ballooned, and
nothing abnormal could be felt per rectum. I opened the abdomen
and removed a very adherent ovarian cyst, which formed quite half
of the abdominal tumour. The sac lay above and behind the uterus
176
Smith: Case of Extra-uterine Pregnancy
and was attached to the pelvic colon by a mass of fibrous tissue in
which a flat skull-bone could be felt. The adhesions were so dense
that I thought it best to close the abdomen without making any
attempt to remove the mass.
This patient has been unusually fortunate in not suffering more
severely from sepsis and in escaping intestinal obstruction. The
greater part of the foetal skeleton must have been passed per rectum, as
the mass left in the abdomen was not much larger than a foetal head.
(I have since heard from this patient’s doctor in the country that
she died two years after I had seen her last. “ She had several attacks
of intestinal obstruction and recurrent attacks of colitis, with passage
of mucus, pus, blood, and putrid fluid, sometimes with foetal bones.
She developed symptoms of pyaemia, hectic temperature, endocarditis,
pleurisy, and finally empyema.”)
Besides these, I saw two cases of full-time extra-uterine pregnancy
operated on by the late Dr. Herman some months after term. No
infection had occurred.. In one case the sac was removed as if it had
been an ovarian tumour; in the other the uterus had to be removed
as well, as the placenta was widely attached to it.
In some cases of living ectopic pregnancy, especially pregnancy in a
rudimentary horn, diagnosis may be difficult, or, rather, examination
unless very carefully made, possibly under an anaesthetic, will not
reveal anything abnormal.
I am impressed by Mr. Gordon Ley’s findings that thrombosis
'may not occur until many months after the death of the foetus. As
infection may occur within the first few months after the spurious
labour it seems doubtful that there is any advantage to be gained by
delay in operating.
Case of Extra-uterine Pregnancy.
By Bellingham Smith, F.R.C.S.
Attention should be drawn to the difficulties of diagnosis between
normal pregnancy, unilateral distension of the uterus, and pregnancy in
a horn. My patient, who was under my care for five months, went to
full time and had labour pains which passed off. About this time the
child died. Three weeks later the abdomen was opened, the sac exposed
and opened, and the child which was much deformed was removed.
Section of Obstetrics and Gynaecology
177
The placenta, which was in the lower part of the sac, was peeled off
with very little oozing of blood. The superfluous parts of the sac were
removed, the lower part drawn up and sewn in the lower angle of the
wound and the wound closed. The sac was packed for twenty-four
hours with gauze, which was then removed and the sac contracted up
and the wound closed without any sepsis or further trouble. In view
of the easy operation and the successful result I think that in any
future case I shall follow the same procedure.
Two Cases of Full-term Extra-uterine Gestation.
By W. Gilliatt, M.S.
Case I. —J. S., aged 58, was admitted to the Middlesex Hospital on
January 2, 1907, under the care of Sir Alfred Pearce Gould, to whom I
am indebted for kind permission to publish this case. I was fortunate
in being the dresser to this patient. The patient had five children,
aged respectively 30, 28, 26, 24 and 18 years. The first confinement
was terminated by forceps delivery, the remainder were quite normal.
The different medical men who attended her in her last four labours all
called her attention to an abnormal swelling in the abdomen. She
thought that the tumour resulted from an accident which occurred
twenty-eight years before, when she was carrying a bath downstairs,
and fell with it. Soon after the accident she noticed a lump in the
abdomen on the left side of the middle line, about the size of a hen’s
egg. The swelling had been growing ever since it was first noticed.
Questioned after the operation, the patient could not remember whether
she had any grounds for believing herself pregnant at the time of the
accident. There was no trouble until August, 1906, five months before
admission to hospital, when an abscess formed in the middle line of the
abdomen, above the umbilicus. Six weeks later this abscess burst at a
point 2£ in. above the umbilicus and 1 in. to the left of the middle line,
and pus had escaped freely from this sinus up to the time of operation.
On examination of the abdomen, a tumour arising from the pelvis can
be felt extending up to the umbilicus. The tumour is rounded and
irregular in consistency, the upper part being hard, and the lower
portion definitely cystic. Pressure over the cystic portion resulted in
the discharge of pus from the sinus above the umbilicus. Per vaginam
the tumour moved with the uterus, and was felt to be in front of the
178
Gilliatt: Full-term Extra-uterine Gestation
uterus. A sound passed 2£ in. Streptococci were obtained in pure
culture from the discharge from the sinus. The abdomen was opened
on January 12, 1907, and the tumour was found to be attached to the
left side of the uterus, between the layers of the left broad ligament.
The omentum and several coils of intestine were adherent to the
tumour. The tumour was separated from these structures and
removed ; in doing this the sac was ruptured, and a considerable
amount of pus escaped into the pelvis. The patient died, three'
weeks after the operation, from broncho-pneumonia secondary to a
pelvic abscess.
The specimen is that of a rounded swelling, almost as large as a
football. A window has been cut in the wall of the sac through
which foetal remains can be seen. On the opposite side of the Swelling
there is some flattening, and it is in this portion that the abscess cavity
was found.
Case II. —B. S., aged 25, was admitted to the Middlesex Hospital
late at night on December 7, 1915, having been brought in from the
out-patient maternity district by the obstetric resident. In the absence
of Mr. Berkeley I was asked by Mr. Bonney to see the patient. The
history that could be obtained was almost negligible, as the patient
herself spoke Flemish only, and her husband Flemish and a little
French. She had had one child, eighteen months previously; the
labour was normal. When first seen the patient had been in labour
seven hours, and the midwifery clerk, noticing that she had an ab¬
dominal tumour in addition to the fufl-term uterus, obtained her
admission to the hospital. By the aid of an interpreter it was subse¬
quently discovered that four years previously the patient was living in
Paris and thought herself pregnant, but the child was never born.
She saw many doctors, between twenty and twenty-five, some of whom
thought she was pregnant, and others who did not, and finally it was
decided that she was not pregnant. No history of any attack of
abdominal pain during the pregnancy could be obtained. On exami¬
nation of the abdomen a full term uterine pregnancy was found, the
uterus lying more to the right side of the abdomen than normally.
On the left side, rising out of the pelvis and resting in the left iliac
fossa, was a rounded tense swelling, which was pushing the uterus
to the right, and which appeared to be impacted in this position.
The child was presenting by the breech, which was resting in the
iliac fossa. Per vaginam the cervix was very high and about the
size of a florin, the membranes unruptured and bulging. The pre-
Section of Obstetrics and Gynaecology
179
senting part could not be reached. The abdominal tumour could be felt
bimanually, but could not be moved. A diagnosis of ovarian tumour
obstructing labour was made, and operation advised. The abdomen
was opened, and the tumour was felt to be a sac containing bones. Tha
sac was lying between the layers of the left broad ligament, and was
adherent to the omentum and colon. The adhesions were divided and
the tumour was removed. Caesarean section was done, and a living
female child delivered. Except for suppuration in the superficial
stitches the patient made an uninterrupted recovery and left the
hospital with her infant five weeks later.
The specimen on removal was not quite rounded in shape, and
measured 8 in. in one diameter and 6£ in. in another. Crepitus could
be easily felt through the sac wall. On opening the sac it was found to
contain the remains of a small foetus, probably of about eight months’
development. The soft tissues of the child had undergone pronounced
softening, similar to that seen in advanced maceration. The tissues of
the scalp had disappeared, and the foetus was surrounded by a viscid
fluid of brownish colour.
Case of Extra-uterine Pregnancy.
By J. D. Malcolm, F.R.C.S.Ed. (President).
A patient, aged 33, well nourished and generally healthy, was
admitted to the Samaritan Free Hospital, on September 25, 1915, on
account of an increasing swelling of the abdomen, noticed since the
previous April and causing some pain of recent date. Menstruation
was regular until February, 1915, after which there was amenorrhoea
for seven weeks, followed by slight bleeding every day for three months.
There was no further loss until a brown discharge began a fortnight
before the patient was first seen. Constipation and frequency of
micturition increased as the swelling grew larger. There was a medium
sized tumour, the size of a seven to eight months’ pregnancy, and the
breasts contained milk. No thrill was felt on percussion. No souffle
or foetal heart sound was heard. It was thought that the outline of
the buttocks of a child could be felt above, and something like a foetal
head was found in front of a very soft cervix with a slightly patulous os
uteri. In consultation differences of opinion were expressed, and as
the patient was not suffering seriously she was discharged and kept
180
Marriott: Case of Extra-uterine Pregnancy
under observation. Occasional slight haemorrhages from the vagina
occurred, and two months later the abdominal mass was somewhat
smaller. Otherwise the conditions were unchanged except that the
supposed foetal head was recognized as the body of the uterus. This
was verified by passing a sound which went in 3| in.
On December 20,1915, the abdomen was opened. The tumour was
redder than an ovarian cyst. There were some adhesions of omentum
and caecum and the vermiform appendix was spread out over the mass.
These parts were easily separated by rubbing and the tumour Was
gradually separated. It ruptured at one point where adhesions were
not very firm and some greyish fluid escaped. There did not seem to
be any definite base more adherent than other parts except at the side
of the uterus. The outer edge of the round ligament was stretched
over the upper right side of the tumour as a band which was divided.
The attachments to the uterus were close but offered no serious difficulty.
The Fallopian tube was divided and appeared healthy. The remains
of the broad ligament were drawn over the side and back of the uterus.
The patient made an uninterrupted recovery and was discharged three
weeks after the operation.
The specimen was set aside unopened for future examination and
was, unfortunately, lost, but a well-developed child’s hand protruded
from a rupture in its wall. Except for this and the colour of the part
removed and the merging of the Fallopian tube in the tumour there
was nothing to distinguish the operation from one for the removal of an
adherent ovarian tumour. On the outside of the mass the position of
the placenta could not be detected by sight although it was obvious to
palpation. The Fallopian tube, although healthy where it was divided,
soon merged in the mass which contained the foetus. No separate ovary
was seen on the affected side.
Specimen from Case of Extra-uterine Pregnancy.
By Cecil Marriott, M.Ch.
(Shown by the President.)
A woman, aged 41, who had four children, ceased to menstruate for
nine months, after which she appeared to be in labour, but she was not
delivered and the signs of labour passed off. During the following
Section of Obstetrics and Gynaecology
181
three months there was a red vaginal discharge, and at the end of
February the patient was sent as a case of degenerating fibroid tumour
to the Leicester Royal Infirmary, under the care of Mr. Cecil Marriott.
A large tumour occupied the pelvis and rose into the abdominal cavity.
The uterus was recognized in the right iliac fossa with a sulcus between
it and the abnormal mass. There was no uterine souffle and, of course,
no foetal heart sounds. The breasts were small, flabby, and altogether
atypical of pregnancy.
On opening the peritoneal cavity a mass was found in the left pelvic
region rising up into the abdomen and pushing up the sigmoid flexure
which lay along its upper surface, being very adherent for about 12 in.
and disappearing into the pelvis on its extreme right side. The uterus was
considerably enlarged and pushed out of the pelvis to the right. The mass
was easily shelled out from the pelvic wall and freed from the sigmoid
and uterus with some difficulty, many vessels requiring to be ligatured
at the attachment to the uterus. It was difficult to be sure about the
relations of the parts, but the placenta seemed to be attached to the left
side of the uterus and to the back of the broad ligament. The mass
appeared to be between the layers of the broad ligament. The Fallopian
tube lay upon the upper surface of the tumour. It was a little swollen
and curved round rather acutely towards the uterus. The left ovary
was not seen apart from the specimen. This consists of a sac which
has been opened and a foetus attached to the placenta. The foetus
shows signs of decomposition in the peeling of epithelium from its
back. It is much distorted, but possibly this is due to pressure only.
The amniotic fluid, of which there was no very large quantity, was of
brownish colour. The sac is well developed except where it covers the
placenta. At this part it has been separated over a considerable area.
The patient has made a good uneventful recovery.
The specimen has been presented to the Royal College of Surgeons.
DISCUSSION.
Dr. ARTHUR Giles : Mr. Gordon Ley’s paper has involved a considerable
amount of work, and the statistical tables will be of permanent value. I shall
confine my observations to three points:—
(1) The Ways in which a Full-time Extra-uterine Pregnancy can occur .—
My own view is that every case begins as a tubal or an ovarian pregnancy;
I am sceptical as to the possibility of an oosperm dropping free into the
peritoneal cavity and developing there. When a gravid tube ruptures the sac
182
Discussion on Extra-uterine Pregnancy
may be extruded towards the peritoneal cavity, resulting in what I regard as a
“ primary abdominal,” but what Mr. Ley has described as a “ secondary
abdominal ” pregnancy. If the rupture takes place into the broad ligament,
a mesometric pregnancy occurs and may go to term as such; on the other
hand, there may be a secondary rupture into the peritoneal cavity, resulting in
a true “ secondary abdominal ” pregnancy. Another possibility is a tubal
abortion of such a character that the sac is extruded from the fimbriated end
of the tube without disturbance of the placenta. This is probably the mode of
origin in a case that I recorded in the Obstetrical Transactions for 1905. At the
time of the operation it appeared to be a mesometric pregnancy; but on examina¬
tion of the specimen later by the Pathological Committee of the Obstetrical
Society, the tube and mesosalpinx were found almost unaltered ; and the sac
lay external to the ovary and the tubal ostium, between the broad ligament
and the lateral pelvic wall. As a rule, the surgeon in these cases has little
leisure or opportunity to identify the precise anatomical relations ; he will be
much more concerned to get through the operation as quickly and safely
as possible.
(2) Diagnosis .—I quite agree that in some of these cases the diagnosis
is most difficult. In others it is conspicuously easy. Before full-time a
diagnosis may be suggested by two points; the first is an abnormally easy
palpation of the foetus, in cases where it is lying free in the abdomen, covered
only by the amnion. Such was a case in which I assisted Sir John Bland-Sutton
at the Chelsea Hospital for Women ; the child was lying free enough to clutch
the mother's intestines. Sir John recorded the case in the Obstetrical Transac¬
tions for 1903. The second point of diagnosis is resonance over the front
of the abdomen right down to the pubes. This feature will never occur with
an intra-uterine pregnancy; and it was very noticeable in my own case.
When spurious labour takes place, the diagnosis seldom presents much
difficulty.
(3) Treatment. —Probably the most debatable question is the time when
the operation should be undertaken. Mr. Ley's figures seem to me to be
eloquent on this point, since he has shown that the maternal mortality is
about 4 per cent, in cases operated on later than eight weeks from the death
of the foetus; as against 26 per cent, in cases operated on while the foetus
is living and 20 per cent, in cases operated on within eight weeks of the death
of the foetus. Notwithstanding the fact that some extra-uterine children have
survived their birth, and perhaps even grown up, I still hold the opinion that
I expressed in reporting my case in 1905, that the extra-uterine foetus is not,
in insurance phrase, a “ good life.” Mr. Ley’s figures corroborate this view,
since he has found that no fewer than 46 per cent, of extra-uterine children
presented some deformity; and of those born alive 18 per cent, died within
a few weeks. The foetus is not, therefore, of such value as a “ prospective
citizen,” that it is worth while submitting the mother to increased risk to save
the child. Dr. Handfield-Jones, in discussing my specimen mentioned that
he had two children delivered alive, but both the mothers died. It appears to
Section of Obstetrics and Gynaecology
183
me to be demonstrated both by experience and by Mr. Ley's figures that it
is safest for the mother if operation be delayed a few weeks after the child's
death.
In conclusion, the variety of the conditions found justifies the warning that
a surgeon who meets with an easy case must not too lightly assume that the
next will be equally easy. Such an operation as Mr. Ley's second case, where
the sac and placenta had to be removed before the primary vessels supplying
them could be got at and secured, is among the most difficult and dangerous
operations in surgery.
Dr. HEDLEY : I think the greatest danger in dealing with cases of full-term
extra-uterine pregnancy is from haemorrhage, and in comparison the danger of
infection of the dead ovum is small. In midwifery the general rule is to
consider the mother’s life first: I therefore feel that operation in these cases
should not be undertaken until two or three months after the death of the
child unless there is some very urgent reason. By waiting two or three
months after the placental circulation has ceased there are good grounds for
hoping that thrombosis will have taken place in the maternal vessels supplying
the placental site, and this certainly is so in the majority of the cases recorded.
In cases which have to be operated upon while the chili is living or soon after
death I should advise leaving the placenta behind and’closing the abdomen
unless the placenta was attached in a position favourable for ligature of the
vessels leading to its site.
Dr. FAIRBAIRN : I have operated on three cases of advanced extra-uterine
gestation. Of these, two were fatal, and in one both mother and child survived.
As the first is reported in full in the Journal of Obstetrics and Gynaecology of
the British Empire , 1906, x, p. 599, I need only say that six weeks after term
the mere separation of the edge of the placenta was followed by bleeding so
severe that the patient was sent back to bed with the abdomen stuffed with
gauze and towels and that she collapsed and died shortly after a second attempt
to remove the placenta, made a week later, and with precisely the same result.
The second case (in 1911) was not full time but about seven months, and here
again the patient collapsed some four hours after operation as the result of the
severe haemorrhage which had occurred during the separation of the placenta.
The sac was adherent to omentum, intestine and fundus uteri, the placenta
being anterior. The abdomen was reopened as the patient’s condition suggested
further haemorrhage, but none was found. The third case (in 1913) I will
record more fully. The patient was a woman, aged 28, who had had one child
at the age of 18, had been a widow for seven years and remarried in 1912.
She had no history suggestive of salpingitis or other pelvic trouble. Her last
period was in November, 1912. In December and January she had morning
sickness and swelling of the breasts, attacks of epigastric pain but no history
of pelvic pain. In May and June there were three slight losses of blood, and
with the last what she thought were labour pains. At the end of June a
doctor was called in who sent her into St. Thomas’s Hospital. On admission
AU —24
184
Discussion on Extra-uterine Pregnancy
she was found to be somewhat emaciated and had been vomiting for some
days. She had intermittent fever up to 102° F., pulse-rate 116 to 124, some
albumin in the urine but no blood. There was a Bacillus coli infection of the
urine. The foetal parts as felt per abdomen did not suggest an extra-uterine
pregnancy and her condition was at first thought to be a pyelitis of pregnancy.
The vomiting continued, rectal salines were not retained, and abdominal dis¬
tension became marked. Vaginal examination at once raised the suspicion of
the pregnancy being extra-uterine, as though the body of the uterus could not
be accurately differentiated, foetal parts could be made out behind and below
the cervix. On the fourth day after admission (July 1) the continuance of
the vomiting with abdominal distension was suggestive of intestinal obstruction
and .together with the marked deterioration in her general condition made it
clear that something would have to be done at once. Examination under
anaesthesia made the diagnosis clear, the body of the uterus being identified
in front of the foetus. This was confirmed when the abdomen was opened,
when the uterus was found to be nearly the size of a four months* gestation;
behind it and to the right and apparently enclosed in the right broad ligament
was the sac containing the foetus. The sac was opened and the foetus removed.
The placenta vas situated on the right broad ligament, a small portion only
extending on to. the postero-lateral pelvic wall. Haemorrhage was easily con¬
trolled and the sac was removed by clamping and ligaturing the broad ligament.
Some haemorrhage from the area of placental attachment not the broad
ligament was controlled by underrunning it with sutures. A plug was left in
to control some oozing which continued. Intravenous saline infusion of 3
pints was given during the operation and the patient left the table in fair
condition ; pulse-rate 120. The child, a male, weighed 3 lb. 14 oz.; respiration
was soon established after a hot bath. From examination of the sac it
appeared that the pregnancy had been primarily tubal and either had ruptured
intraligamentarily with a secondary rupture into the abdomen or bad been
extruded from the tube and, obtained a secondary attachment to the broad
ligament. The patient’s convalescence was retarded by the Bacillus coli ,
pyelitis and cystitis, but she left the hospital in good condition on August 15
with her child now weighing 6 lb. 9 oz. The child was watched for a year in
the baby clinic and developed normally. From this small experience I would
say that the old instruction to wait for the death of the child is useless: the
most straightforward of my cases was the one with the child that survived;
the most difficult the one in which the child had been dead for six weeks.
The trouble depends almost entirely on the situation of the placenta. When
the sac and its attachments can be ligatured and removed the operation is
straightforward. When the placenta has to be separated from some irre¬
movable part the bleeding, even two months after the death of the child, may
prevent the operation being completed.
Dr. F. J. McCann : It would be easy to formulate rules for surgical
treatment if the exact conditions met with in the abdomen were known befqre
Section of Obstetrics and Gynaecology 185
the actual operation. There are, however, two important principles which
should be followed—viz., preliminary ligature of the chief vessels supplying the
placenta and foetal sac, and rapid separation of the placenta. In one of my
own cases the haemorrhage would have been difficult to control if these prin¬
ciples had not been followed. The ovarian vessels were ligatured high up, a
clamp was placed close to the lateral border of the uterus, and a large artery
coursing down the posterior wall of the uterus towards the placenta was
ligatured. The placenta was then rapidly separated from the floor of the
pelvis and the sigmoid colon, and a gauze pack at once introduced to arrest
the bleeding. The bleeding from the colon was arrested by over-stitching
with catgut, thus infolding the raw area on the wall of the bowel. The placental
sinuses bleed freely when the placenta is partially separated, or when they are
partially torn, whilst if the placenta be rapidly removed inr its entirety, it is
remarkable how soon the bleeding ceases. Many examples of extra-uterine
fcetation are described as being intra-ligamentary or broad ligament preg¬
nancies. I do not say that rupture into the broad ligament may not occur,
but it is relatively rare. It is easy in the hurry ot an operation to omit to
observe accurately the anatomical relations of the foetal sac, and to assume
that its position is between the layers of the broad ligament. In many of the
recorded examples the foetal sac was removed without difficulty. If the sac
had really developed between the layers of the broad ligament there would
have been considerable difficulty in its removal. These sacs have false capsules
comparable to what is found in certain “ broad ligament tumours,” and the
broad ligament is stretched over them like a hood. This arrangement favours
enucleation, and I have actually seen this false capsule in process of formation.
Mr. Gordon Ley has referred to an example of abdominal pregnancy which I
have recorded, and which I believe to be an example of primary abdominal
pregnancy. It is interesting to recall the fact that the older writers believed
in the existence of both ovarian pregnancy and primary abdominal pregnancy.
Now the existence of ovarian pregnancy, although denied for many years, has
been conclusively confirmed by numerous observers. I believe that this will also
be true of primary abdominal pregnancy. Mr. Gordon Ley further asks for
information regarding the rush of “ waters ” associated with the onset of
false labour in my case. 1 This was liquor amnii and not urine, and in all prob¬
ability it had escaped through the patent Fallopiaq tube or tubes as a result of
the Violent uterine and probably tubal contractions associated with the false
labour.
Dr. Lapthorn Smith : My operative experience of extra-uterine gestation
is limited to fifty-five cases, three of which died and fifty-two recovered. My
invariable rule has been to operate the very day and in some cases within an
hour of a reasonable evidence of the condition being present, which in most
cases was a furious abdominal hasmorrhage. One of my cases, not included
in the above because not operated on, occurred in -my first year of practice in
1 Proceedings , 1916, ix (Sect. Obst. and Gynaecol.), pp. 109-115.
186 Discussion on Extra-uterine Pregnancy
a woman in whom labour was going on violently at the expected date. The^
empty uterus could be felt quite distinctly as well as the child’s head pushing
it to the right. Upon my telling the people why the baby could not come and
asking for a consultation with an older man, I was promptly dismissed from
the case. Another practitioner who at that time had never heard of such a
thing, told them that there was nothing the matter, and the patient actually
got smaller and smaller for several years, when I lost sight of her and she
could not be traced. The second case, not my own, which made a great
impression upon me, occurred some twenty years later. One of my hospital
colleagues, a clever young general surgeon, operated in the case, which was that
of a full-time extra-uterine, in which the child was alive. The mother was most
anxious to save the child. The abdomen was opened under modem methods,
and in a few minutes the child was lifted out without any more difficulty,
and, indeed, with less difficulty than in doing a Caesarean section. The
placenta, a large one, was adherent to many coils of small and large intestine,
and not at all to the broad ligament. The blood supply of the bowel was
enormously increased. If he had left the placenta alone, after tying and
removing the cord and tying the marsupialized membranes or sac and quickly
closed the abdomen, the woman would probably have been alive to-day. After
the removal of the child, which was the main object, she was in splendid con¬
dition. But he had not learned one of the most difficult things in abdominal
surgery—namely, to know when to stop. He began to detach the placenta.
In a moment the abdomen was filled with blood. It was too late to stop, and
he went on thinking that, as in the case of placenta prsevia, the bleeding would
cease when detachment was complete. But there was no contracting uterus to
close the gaping sinuses, and in spite of packing and efforts to replace the lost
blood, the poor woman made a tragic ending on the operating table. Why
with such a case before our mind’s eye should we deliberately increase the
mortality from 5 to 95 per cent., just for the sake of extracting the placenta?
It has been there for nine months, why not leave it there a few months
longer or altogether ? As a means of packing enormous sinuses which have
no power to close themselves what better plug can we use than the one which v
has done the work so well for all those months ? What will happen to it if
the operation has been done under modern asepsis? We know quite well
from the hundreds of lithopradions to be seen in museums all over the world.
The child and the placenta in time become mummified, because the peritoneum
has a certain digestive or absorptive power, and gradually drinks up every
scrap of moisture and perhaps absorbs some of the organic structures. The
placenta is a part of the child, not of the mother, and as soon as the cord is
tied the child’s heart ceases to send blood into it, and in sympathy the
mother’s heart emits less and less blood into the coils of intestine which were
feeding her offspring. The vascularity of the whole area diminishes daily,
and at last may be so slight that an appeal must be made to the omentum to
send a few minute blood-vessels into it, as in the case of a twisted ovarian
cyst which is absolutely cut off from its blood supply, and which I have
Section of Obstetrics and Gynaecology
187
several times removed without tying a single artery. To my mind there is
only one thing to do, get in, and get out with the baby as quickly as
possible. And there is only one thing not to do, namely, to start a
haemorrhage which we know beforehand there is no means of stopping as
long as the heart can beat.
Mr. Gordon Ley (in reply to Dr. Arthur Giles) : I cannot understand
Dr. Giles's aversion to primary abdominal gestation, to which I can see no
histological objection. In my study of the literature I came on several cases
of which no other explanation was possible. In one, uterus and tubes were
normal, the ovum being embedded between the liver and stomach ; in another,
in front of the left kidney. I do not feel that the leaving of the placenta in
the abdominal cavity, with closure of the sac over it and of the abdomen is an
ideal operation. I found only three cases in the literature in which this had
been done, and in one of these the sac had to be drained per vaginam at a
later date. The risk of leaving a dead structure, possibly infected, in com¬
munication with large blood sinuses, is considerable, and it is better to
marsupialize the sac and pack with gauze.
Section of ©botetrtes an& (Bsnsecoloap.
President—Mr. • J. D. Malcolm, F.R.C.S.Ed.
A Fibrolipoma weighing 13 lb. which Invaded or Originated
in the Right Broad Ligament. 1
By W. S. A. Griffith, M.D.
The patient, aged 57, was admitted to Martha Ward, St.
Bartholomew’s Hospital, under the care of Dr. Griffith, in May, 1916.
Menstruation, generally normal, ceased at the age of 40. Three
children; one miscarriage. Since the climacteric she had suffered
from abdominal pain, which continued at intervals to the day -of
operation.
The tumour, which was very elastic and tender, occupied the right
half of the abdomen from the pelvic brim to near the costal margin,
and to the left of the middle line. The cervix, enveloped in the inverted
vagina, protruded from the vulva. The tumour was exposed through
an incision in the middle line; it was extraperitoneal, the intestines
being displaced by it to the left.. It occupied the right broad ligament,
displacing the uterus to the left, and had the right Fallopian tube
stretched over it. It was enucleated after incision of its peritoneal
covering ; the lower part occupied the right' broad ligament. The
large cavity left was obliterated by catgut sutures, and without
drainage, and the patient made an uninterrupted recovery. The
prolapse was cured two months later by anterior and posterior
colporrhaphy.
Lipomata of the broad ligaments are very rare. Doran, in his well-
known paper on “Retroperitoneal Tumours,” 2 refers to one only, that
of Treves. 3
1 At a meeting of the Section, held June 5, 1919.
7 Brit. Med. Journ ., 1904, ii, p. 1075.
3 Tra?is. Clin. Soc., 1893, xxvi, p. 101.
Section of Obstetrics and Gynaecology
189
Specimen of Subperitoneal Lipoma weighing 16f lb.
By T. G. Stevens, F.R.C.S.
This, the second Specimen of the kind which the writer has met
with in the past eighteen months, was removed from a single woman,
aged 35. She complained only of abdominal enlargement and some
aching in the left side. The periods were not quite regular, the
intervals being four or five weeks, but were not otherwise abnormal.
On examination there was a large abdominal tumour, filling the
whole abdomen, which felt like a cyst and fluctuated freely—even gave
a thrill in parts. There was some dullness in each flank, which
suggested free fluid as well. The diagnosis of an ovarian cyst was
made, and owing to the patient being very thin, and the possible
presence of free fluid, it was thought to be possibly malignant.
She was admitted to St. Mary’s Hospital, and upon opening the
abdomen the true character of the tumour was at once seen. It
presented a smooth surface with movable, red peritoneum over it. The
ascending colon and caecum were found in the left iliac region running
over the tumour and movable on it. The tumour dipped into the pelvis
and reached up to the diaphragm. A vertical incision 6 in. long was
made over the tumour, the peritoneum only being divided. The tumour
was then enucleated, no difficulty being met with until the right renal
region was reached. Here some cutting of fibrous bands had to be
done, and in doing it the kidney was cut into. This proved to be a
fortunate accident as it enabled the kidney, which was completely
enveloped in fat, to be identified. It was shelled out from its capsule,
the ureter was identified and preserved, and the rest of the tumour was
then easily enucleated. The kidney and uretet were dropped back into
the loin after the accidental incision in the kidney had been sewn up.
A stab wound was made in the loin and a drainage tube was parsed
into the large cavity left after enucleating the tumour. The incision
in the peritoneum was sewn up and the ascending colon then resumed
its natural position.
The patient bore the operation very well, except for a few moments
when the tissues around the kidney were being pulled upon, when the
breathing became very shallow. She rallied well after some saline
infusion and made an uninterrupted recovery. The tumour after
190 Ley: Congenital Teratoblastoma of the Vulva
removal filled an ordinary wash-hand basin and weighed 16| lb. It
consisted entirely of fat and fibrous tissue strands and evidently
originated - in the perirenal fat on the right side.
The description of the tumour and the operation in this case, is
practically identical with that of the first case. The tumour in that
case weighed 16 lb., started in the same way around , the right kidney,
displaced the colon in exactly the same way, an<J was removed without
any difficulty at all. This patient also recovered without any bad
symptoms. In neither case was the true nature of the tumour
diagnosed, but in the first case, it was hot supposed to be an ovarian
cyst on account of its peculiar consistence. Neither was it thought to
be ascites—in fact no diagnosis was made before opening the abdomen.
It is probable that these tumours cannot ever be diagnosed with any
certainty before removal. The fat in them is .fluid at the body
temperature and will always simulate fluid either cystic or free.
It is remarkable how easy was the removal in these two cases and
how few blood-vessels were met with which had to be tied: about -six
in the first case and three only in the second.
Case of Congenital Teratoblastoma of the Vulva
(Rhabdomyoma).
By Gordon Ley, F.R.C.S.
M. J., aged 5 weeks. This child was brought to me with the
following history : At birth a large tumour was noticed by the midwife,
replacing the vulva. The child was taken to a medical man and the
condition was pronounced as incompatible with life. The child was"
eventually brought to me When she was 5 weeks old. The tumour had
increased considerably since birth and in part its surface had ulcerated.
On examination there was a large tumour lying beneath the skin of
the mons veneris, labia majora, vestibule, the anterior parts of the labia
minora and the clitoris, displacing these structures forward. Projecting
posteriorly behind the urethral orifice, which was seen to be a slit slightly
to the right of the midline, was a soft, reddish brown, superficially
ulcerated mass, which projected forwards and had a deep attachment
passing posteriorly to the urethral orifice. On lifting up the tumour
there appeared to be a vaginal orifice in the form of a transverse slit
extending the whole width of the posterior margin of the tumour.
Section of Obstetrics and Gynaecology
191
1 came to the conclusion that it was a congenital tumour, probably
teratomatous, growing from the region of the floor of the urethra*
and decided that the child would certainly die as a result of ulceration
of the tumour if left, and might conceivably recover if the tumour was
successfully removed.
On December 20, I excised the tumour with its pedicle, which
included the urethra itself, and brought down the neck of the bladder,
stitching it to the surrounding skin and posteriorly to the greatly
widened vaginal orifice. The child stood the operation extremely
well, but suffered severely from shock about half an hour later and
died suddenly.
Autopsy.
The bladder, or urethral, orifice has a circumference of 0'7 cm., and
admits a large probe. There is no thickening or sign of tumour tissue
in the lower urinary outlet, nor elsewhere in the uro-genital tract.
The vaginal orifice is 1*5 cm. in diameter. There is very slight
hypertrophy of the bladder and very slight dilatation of the renal pelves.
There is anaemia of lungs and all organs. A poorly nourished, small,
female infant.
Pathological Report.
On the surface of the upper part of the specimen are seen the labia
majora, the anterior part of the labia minora, the clitoris and the
vestibule.
Bulging forwards from between these in front, and the anterior
margin of the vaginal orifice behind, is a puff-ball shaped mass, 5*4 cm.,
by 4*7 cm., by 2 cm. high. The posterior aspect of the pedicle of this
mass is covered by a demilune (0*4 cm. at widest) of thin, smooth
mucosa, corresponding to the anterior margin of the vaginal orifice.
The remainder of the surface of the mass is pink and finely granular.
Beneath the clitoris, labia and vestibule is a second mass, which
measures 3*5 cm. by 5*5 cm. by 3'5 cm. deep. The urethra lies between
the two masses and opens at a point 0*5 cm. to the right of the middle
line. It has been removed apparently in its whole length, its lower end
has been partially split open. It measures 2’5 cm. long and has a
diameter of 1*3 cm. The canal is lined by smooth mucosa. Both
masses are of elastic consistency.
On the posterior surface of the specimen the masses are seen to be
continuous. At one spot is an area 1*5 cm. in diameter which shows a
\> V
l>y: Congenital Teratobla&toma of the Vulva,
Anterior view of vulva.
Fio. %
,, v ! |^6j»tenc*j;;5new M .vulva;
Section of Obstetrics and Gynaecology 193
cut surface made by the knife at operation. This area lies below and to
the 'right of the urethra. Its cut surface is elastic and shows whorls
of narrow grey lines in a glistening pink gelatinoid ground. The
remainder of the posterior surface is encapsulated. The posterior
surface has evidently been shelled out at operation with the exception
of a pedicle severed by the knife.
A vertical ' antero-posterior section through the mid-line of the
specimen again shows that the two masses are continuous. The cut
surface of the mass beneath the clitoris shows whorls of narrow white
lines in a sunken matrix of grey translucent gelatinoid tissue. That of
the puff-ball like mass is very much softer, very translucent, yellowish
and gelatinoid, and eludes a slimy fluid.
Sections were taken for microscopical examination : (a) from the
mass beneath the clitoris; ( b ) from j;he pedicle severed at operation ;
(c) from the puff-ball shaped mass.
Microscopical Description.
Section A .—On one surface is seen the stratified squamous epithelium
of the epidermis, beneath which is a vascular cellular dermis. In this
layer can be seen two sebaceous glands and in the deeper layers a few
Paccinian corpuscles. Beneath the dermis lies the tumour; there is,
however, no sharp line of demarcation between the two, numerous islets
' and strands of the tissue of the tumour lying in the deeper part of the
dermis. The tumour consists of a loose fibrillo-cellular matrix forming
its greater part. This consists of small spindle and oat-shaped cells,
with relatively large spindle nuclei, closely applied to a loose nlesh-work
of very delicate fibrils. Lying in this matrix are many narrow strands
or groups of strands of muscle. These muscle bundles consist of cells
of three types:— * ,
(1) Chiefly in the deeper layers of the dermis, but also in the depth
of the growth, are fibres which are of somewhat smaller diameter
than normal voluntary muscle fibre, but are otherwise typical. The
longitudinal and transverse striation is very distinct and the oval nuclei
are peripheral and lie at a considerable distance from one another.
(2) The great majority of the bundles of muscle consist of somewhat
broader fibres in which the nuclei lie in the centre. The nuclei are
round in cross section, and round, oval or oblong in longitudinal section.
They are always more numerous than in normal muscle and frequently
are so numerous that they form a continuous central chain the members
194 Ley: Congenital Teratoblastoma of the Vulva
of which are in contact. The nuclei lie in a core of clear cytoplasm ;
external to this nucleated core is a narrow peripheral zone of cyto¬
plasm which is clearly striated longitudinally containing a few parallel
longitudinal fibrils. These fibrils are very conspicuous in transverse
section. Cross striation of the peripheral zone is seldom visible but
is certainly present in a few examples.
(3) Typical long fibres of involuntary muscle. These are relatively
scanty, the majority lie in and about the walls of large venous spaces.
There are many well-formed arteries and arterioles in the section.
Section B .—Near the centre is an area of dense stroma containing
scattered bundles of unstriped muscle of ordinary appearance. In the
remainder of the tissue the stroma is less dense and the muscle bundles-
are very numerous. Immediately around the denser area in the centre
the bundles in a broad zone are cut transversely or approximately so.
Externally to this they are for the most part cut longitudinally. The
majority of the muscle fibres are typical striated fibres. Among them
however are striated fibres with a central core of homogeneous cytoplasm
containing a column of nuclei. Arteries and arterioles are numerous
and normally developed. Several large veins of cavernous type with
involuntary muscle forming a broad interrupted zone around their
lumina are seen. Further, there are numerous, normally developed:
nerves.
Section C .—The tissue is similar to that described as the matrix in
Section A, but is extremely rarefied, so as to bear a resemblance to
a jelly tissue. No mucus is visible however, so that the rarefaction
appears to be due to albuminous oedema. One surface is necrosed and
infiltrated by neutrophil leucocytes. There are numerous engorged
capillaries, and in the necrosed and subjacent purulent zones they are
surrounded by red blood. There is no muscle in this section.
Characters of the Growth.
The neoplasm contains fibrous interstitial tissue, involuntary and
voluntary muscle and nerves. It contains therefore mesoblastic and
epiblastic derivatives. It is either a teratoblastoma, or possibly a
teratoma in which the full potentiality of totipotent cells has not been
exercised. The tissue of which it is composed, i.e., connective tissues,
muscle and nerve, are tissues normally found in the site of origin.
It is most probable, therefore, that it is a teratoblastoma and not an
incomplete teratoma. The fibrous tissue is s( mewhat embryonic in
PROG. HOY. $0C. MED.
Vctl, XII. No. 9.
See.tnm of Obstetrics and Gynecology.
Section of Obstetrics and Gynaecology
195
type. A great deal of the voluntary muscle is certainly embryonic,
having a homogeneous core containing numerous nuclei, whilst
contractile fibrils are confined to the periphery. 1
Atypical nuclei such as are seen in malignant neoplasms are not
present. The nerves are normal in structure. The tissue is supplied
with normally formed blood-vessels amongst which are veins such as
are found in cavernous tissue. The growth, therefore, appears to be
a teratoblastoma displaying certain embryonic features, but does not
appear to be obviously malignant.
I have to thank Dr. Hubert Turnbull, of the London Hospital
Pathological Institute for his kind assistance in preparing the Patho¬
logical Report.
Lipoma of the Broad Ligament.
By Cuthbert Lockyer, M.D.
During the removal of an ovarian dermoid cyst from a single
woman, aged 31, in January of this year, I noticed that the correspond¬
ing mesosalpinx was distended with fat and that the latter had spread
itself out on the adjacent cyst-wall. The ovarian cyst after removal was
found to be made up of two loculi, one of which contained dermoid grease
and hair, whilst the other was filled with clear straw-coloured fluid.
In order to ascertain the relation of the fatty tissue to the dermoid
cyst I opened up the mesosalpinx and found it possible to run my finger
round an encapsuled fatty lobe and to separate it easily from the cyst-
wall. The Fallopian tube was stretched out over this lobule of fat but
was not adherent to it. The main bulk of the fatty tissue was therefore
formed by a definitely encapsuled oval lobe with its long axis running
parallel to the Fallopian tube. The round ligament was not removed
and its relation to the fatty lobule was not noted. The base of the
mesosalpinx was spread out on the ovarian cyst, and here the fatty
tissue had been compressed between the peritoneum and the cyst-wall.
As a result of this the simple loculus (not the dermoid loculus) was, in
part, covered with fat. Compression of the lipoma had, in fact, caused a
fatty infiltration of the surface-tissues of the ovarian cyst. The coloured
drawing shown herewith (see Plate) illustrates the following points very
clearly:—
1 Vide fig. 293 b (foetus of two months), in Schafer, “ Text-book of Microscopic Anatomy,”
Lond., 1912, p. 193.
196 Lockyer: Lipoma of the Broad Ligament
(1) The discrete fatty lobule in the mesosalpinx is easily separable
from the cystic teratoma (dermoid).
(2) The cystic teratoma is intact, no dermoid grease has escaped.
(3) The fatty lobule is of a deep orange colour, contrasting strongly
with the pale granular dermoid grease.
(4) The simple ovarian loculus, at its attachment to the mesosalpinx,
is covered with fatty tissue which has been squeezed out and flattened
by compression during the growth of the cyst. There was no fatty-
infiltration on the wall of the adjacent dermoid loculus.
The conclusion drawn from these observations is that the fat in the
mesosalpinx represents a true benign neoplasm—a lipoma—and that it
is not merely an excessive subserous deposit of fat such as may be seen
in some cases of malignant disease, still less is it the result of a
transudation of dermoid grease from the adjacent intact cystic teratoma.
Examples of true lipoma of the broad ligament are rare. The
scanty supply of fat in this retroperitoneal situation affords an easy
explanation of this fact. I have found nine records which have a
bearing upon the present publication. Seven of these are descriptions
of true lipomas. The remaining two are records of dermoid cysts with
distension of the mesosalpinx by some form of fatty material.
A short r£sum6 of these cases is as follows :—
(1) “ Symmetrical Lipomata of the Broad Ligaments: ” Emrys-
Boberts [1]. The author examined a specimen consisting of an ovarian
fibroma and a uterus containing multiple fibroids. He discovered a
small lipoma in each broad ligament. The one on the right side lay
“ at the posterior aspect of the fimbriated end of the tube.” It was
the size of a broad bean and in shape was a flattened ovoid. On section
it presented the characters of a fatty tumour. The lipoma on the left
side was about the same size as that on the right. It contained two
minute cysts lined by columnar epithelium, which suggested that they
arose from Kobelt’s tubules.
(2 and 3) “ Ein Fall von Lipoma des Lig. latum : ” Borrmann [2].
This case is also described by Friese [3] in a “ Dissertation ” published
in Berlin, 1907. The t.umour was removed from a woman, aged 59. It
had caused no symptoms. It lay on the right side between the layers
of the broad ligament and measured 7£ cm. by 6£ cm. by 4 cm. It
consisted of two lobes. The round ligament, which was well developed
in its upper part, dwindled away as it reached the summit of the
lipoma. The author mentions an example of broad ligament lipoma
published by Middleschultze [4], in which the tumour was large,
Section of Obstetrics and Gynaecology
197
weighing 15 kg., and measuring 88 cm. by 90 cm. In this case also the
round ligament, after running obliquely across the tumour for a distance
of 18 cm., gradually dwindled away. Borrmann suggests an inter¬
relationship between the “arrest of development” of the round ligament
and the formation of lipoma in these two cases.
(4) “ Subperitoneal Lipomata : ” John Campbell [5]. This author
published two cases. The first was a large adherent retroperitoneal
lipoma of the abdomen; it was probably malignant and it does not
comp into this category. The second case was that of a lipoma of the
right broad ligament and of the iliac foss k. It displaced the uterus to
the left and was easily shelled out. The patient was aged 50, her
nutrition was good, and she had suffered no pain.
(5) “ A Case of Lipoma of the Broad Ligament: ” Frederick
Treves [6]. The .patient was aged 32, tall, pale and very thin.
She was admitted for pain in the back which lasted a fortnight and
had compelled her to lie in bed. She had known of an abdominal
tumour for many years. The tumour occupied the right side of the
abdomen, it was the size of an adult head and reached to the
umbilicus. It had all the characters of an ovarian tumour; there
was no lobulation, it was tense, elastic, semi-solid and movable. It
could not be reached on vaginal examination. The uterus moved
with the tumour. There was no ascites. Malignancy was suggested.
At operation, the right ovary and Fallopian tube were stretched out
over the growth. The latter was fairly well encapsuled and did not
encroach upon the retroperitoneal tissue about the wall of the pelvis.
The weight of the tumour was 72 oz. It measured 26J in. by
21 in. and is preserved in the London Hospital Museum. The patient
made a good recovery from operation.
(6) Parona [7] : “ Caso di lipoma all’ovaia ed ovidotto de destra,”
quoted by Bland-Sutton and by Treves. Treves’ quotation states that
the broad-ligament lipoma was the size of a pear. The Fallopian tube
was embedded in the growth so that only the fimbriated extremity was
visible. “From this tumour, which Parona assumes had developed
from one of the fimbriae, a normal ovary was pendant ” (Treves).
(7) Peyrot [8] : Also quoted by Treves, who says that a distinct
account of a lipoma of the broad ligament is given by Peyrot. It Was
kidney shaped and about the size of a fist. It was quite movable.
Treves remarks (1893) that this was the only case he had found
which was described under the heading of a “ Lipoma of the Broad
Ligament.”
198 Lockyer: Lipoma of the Broad Ligament
(8) “ Dermoid Ovarian Cyst; Infiltration of Broad Ligament with
Fat” (card specimen). By Alban Doran for Sir T. Spencer Wells [9].
“ The tumour (right ovary) consists of two cavities. One contained
much greasy ovarian fluid. . The other is still full of hair, grease and
spicules of bone. A considerable amount of dense granular fat lies between
the layers of the broad ligament. The left ovary is converted into a
cyst 3 in. long, loaded with a greasy material. The fatty deposit in the
broad ligament resembles the accumulation of fat sometimes seen near
the rectum in rectal cancer. It was observed in the case of recurrence
after primary cancer of the Fallopian tube, described by the exhibitor
in the Transactions of the Pathological Society, vol. xl.” Doran more
than once drew attention to the excessive deposit of subserous fat in
malignant pelvic disease.
(9) “Ovarian Dermoid; Infiltration of Bread Ligament with
Fat.” By John Bland-Sutton [10]. “The tumour was removed by the
late Knowsley Thornton and consisted of an ovarian dermoid the size
of a paelon. The peculiarity of the specimen consisted in the circum¬
stance that the mesosalpinx and adjacent parts of the broad ligament
were infiltrated with rich granular fat. On investigation it was
discovered that the cyst-wall had ruptured and “ the tissues of the
tumour, especially the fat, had burrowed along the lines of least
resistance and made their way between the layers of the mesosalpinx
and surrounded the tube.”
I have already given what I consider to be conclusive reasons for
regarding my specimen as a true lipoma, but have here included the
cases of Doran and Bland-Sutton as being like my own so far as
the presence of an ovarian dermoid and a fatty mesosalpinx goes—
but here the similarity ceases.
I have no opinion to express regarding the aetiology of lipoma of
the broad ligament and the speculations of other writers are not very
helpful. Borrmann suggests that local developmental anomalies may
have a causal relationship. Doran hints at “ some teratological
element ” being concerned. Adami [11] notes that retroperitoneal
lipomata are more common in women than in men (in the proportion
of 25—16), and that the right side is a commoner site than the left.
According to this author the most frequent situations for retro¬
peritoneal lipomata are the region of the kidney and the iliac fossa.
Doran [12] draws a sharp distinction, from a surgical point of view,
between prevertebral lipomas and those of the broad ligament and of
the omentum. The former are often very adherent and many of them
Section of Obstetrics and Gynaecology
199
are sarcomatous, they yield a very heavy mortality where operation is
attempted; whereas lipomata of the broad ligament and of the omentum
are benign, non-adherent, therefore easily removed, and the prognosis
is good.
REFERENCES.
[1] Embys-Roberts. Lancet , 1909, ii, p. 186.
[2] Borrmann. “ Ein Fall von Lipoma des Lig. latum,” Virchow's Archiv f. Path. Anat.
und Phys ., 1907, clxxxix, p. 431.
[3] Friese. Dissertation, Berlin, 1907.
[4] Middleschultze. Dissertation, Greifswald, 1884.
[6] John Campbell. “ Subperitoneal Lipomata,” Brit. Med. Joum 1903, ii, p. 1397.
[6] Frederick Treves. “ A Case of Lipoma of the Broad Ligament,” Trans. Clin. Soc .,
1893, xxvi, pp. 101-104.
[7] Parona. Ann. di Ostet. Milano , 1891, xiii, 103-105, plate 1.
[8] Peyrot. Bull. Soc. Anat. t Paris, 1875, p. 178.
[9] Alban Doran for Sir T. Spencer Wells. “ Dermoid Ovarian Cyst,” Trans. Path. Soc.
Land ., 1890, xli, p. 202.
[10] John Bland-Sutton. “Ovarian Dermoid, &c.,” Trans . Obst. Soc. Lond ., 1892, p. 7.
[11] Adami. Montreal Med. Journ ., January-February, 1897.
[12] Doran. Joum. Obst. and Gyncecol. of Brit. Emp. f 1902, ii, p. 244.
Dr. Amand Routh : There are almost as many of these retroperitoneal
lipomata in men as in women so that many of the (etiological explanations
given will not apply.
Severe Retro-peritoneal Bleeding after Dilatation of
the Cervix.
By H. R. Andrews, M.D.
A patient, aged 37, consulted me on February 4 on account of
excessive bleeding at the periods. She had had two children, eleven
years ago and nine years ago respectively, and no miscarriages. She
had had menorrhagia for a year, the bleeding lasting from eight to ten
days, with floodings on the second day. She was distinctly anaemic.
She had complained for a month or two of what she called “ sciatica in
the wrong place ”—i.e., pain chiefly on the outer side of the right thigh
and hip. She had been through a great deal of nervous strain and was
rather worn out. Abdominal examination revealed nothing abnormal.
The cervix was healthy; bimanually the body of the uterus was enlarged
to the size of a six weeks’ pregnancy. I thought that it contained
a submucous fibroid and advised dilatation, exploration of the interior
AU—25a
200
Andrews: Bleeding after Dilatation of Cervix
of the uterus, and enucleation of the fibroid if one was found. Her
sister some years ago had had this operation performed, and later,
abdominal hysterectomy had been necessary. My patient was anxious
if possible to avoid hysterectomy and asked me not to proceed any
further if I found that a submucous fibroid could not be enucleated
from below.
On February 10 I dilated the cervix up to No. 18 Hegar and found
a submucous fibroid situated posteriorly and to the left. I removed
four small fibroids, which were aggregated into a mass the size of
an ordinary grape, and four separate ones about the size of
peas. I could feel at least two small fibroids situated deeply in the
posterior wall, but found it impossible to enucleate them. There was
a small tear in the right side of the cervix at about the level of the
internal os, but nothing that gave me a moment’s uneasiness. That
evening the patient complained of some pain in the right thigh.
After I had seen her she had a good deal of pain which was relieved
by the passage of urine. On the morning of the 11th she was
eomplaining of pain, in the outer part of the right thigh and in
Hunter’s triangle, which, she assured me, had nothing to do with the
operation. After a small gauze plug had been removed from the vagina
there was no bleeding. There was no tenderness in the abdomen. I
was not quite happy about her and rather suspected a hematoma in the
broad ligament, although at that time I did not know that such a thing
had been known to follow a dilatation of the cervix. At 6 p.m. she
looked ill and had a great deal of pain, chiefly in the right groin, none
in the abdomen. There was no swelling to be felt in the iliac fossa ;
there was no external bleeding. The pulse-rate was 86, so I thought
that if there was ahaematoma it must be quite a small one. On the
morning of the 12th she was still looking ill. She had had a very bad
night with much pain. On vaginal examination there was no bleeding
and nothing abnormal could be felt, but there was a very tender swelling
to be felt in the right iliac fossa. The pulse rate was 90. I saw her
again a couple of hours later and decided that I must open the abdomen.
I arranged for this to be done at 2 o’clock, and, as I knew that I might
be in for a very unpleasant operation, I got Sir Hugh Bigby to promise
to assist me. I went into the Home at 12.30 to tell them of the
arrangements that I had made and found that the sister had just tele¬
phoned to me to tell me that the patient had collapsed. I found her
evidently suffering from severe loss of blood, blanched, with a pulse-rate
of 120. I thought it probable that the peritoneum had given way and
Section of Obstetrics and Gynaecology
201
that bleeding had occurred into the abdominal cavity. On opening the
abdomen there was no free blood, but there was a huge retroperitoneal
hsematoma reaching up so as to surround the kidney and bulging forward
almost into the middle line. It is very little exaggeration to say that
the greater part of the right half of the abdominal cavity was obliterated.
The upper part of the right broad ligament was considerably distended;
the lower part not nearly so much. I incised the peritoneum and let
out an enormous quantity of blood, chiefly fluid or very recent clot, and
then proceeded to do a subtotal hysterectomy as rapidly as possible.
The patient’s pulse was so feeble and the tissues were so infiltrated with
blood that it was impossible to identify the uterine artery. I tied a
ligature in the situation where the uterine artery ought to be, at the
level of the internal os. I pulled up this ligature, transfixed the tissues
just external to the cervix at a lower level and tied outside the first
ligature, and then repeated this again, as I was anxious to make certain
of getting control of the uterine artery and its branches without
endangering the ureter. Exposure of the ureter by a dissection
would have been a slow and difficult business, and rapidity in
operating was essential. After clearing out as much blood as possible
from the retroperitoneal space, I inserted a rubber drainage-tube into
this space, closed the rest of the hole in the peritoneum through
which my hand had passed and closed the abdomen, bringing out the
tube through -the middle of the abdominal incision. During the opera¬
tion a pint and a half of saline solution were inserted under the left
breast. She was put back to bed with a pulse of 140. The foot of the
bed was raised about a couple of feet and she was given saline solution
per rectum, three pints in all, in the next eight hours. I saw her every
hour. She was holding her own, with a pulse-rate of 136 until about
9.30 p.m., when the pulse became distinctly more empty and the rate
more rapid. There was no restlessness nor air-hunger, and she was
conscious and sensible, but I felt that she was losing ground. After
consultation we decided on giving her some of her brother’s blood.
There was no time to find out to what group her blood belonged, and
Mr. (now Sir) Cuthbert Wallace said that if we gave her brother’s blood
slowly we could do no harm if we stopped at once should she complain of
pain in the back or abdomen. At 11.30 p.m., with the help of Sir Hugh
Rigby and Dr. Western, we gave her 350 c.c. of her brother’s blood,
10 or 20 c.c. at a time, with sodium citrate. The immediate result was
excellent. The pulse-rate came down to 130, the artery was distinctly
fuller and her colour improved. She was very ill for the next few days,
au —25a
202
Andrews: Bleeding after Dilatation of Cervix
the respiration-rate usually over 30, often as high as 36 to the minute,
pulse-rate 126 to 130. The temperature was 99° to 102° F. On the
15th it went up to 103° F. She did not sleep at all except with
injections of J or J gr. of morphia. There was a short dry cough
which troubled her a good deal. There were no abnormal physical
signs in the lungs except a few crepitations at the bases.
Her brother, her night-nurse, another nurse and three servants in
the nursing home all developed influenza the day after the operation,
and 1 have no doubt that she had influenza herself. The members
of the depleted staff worked with unremitting care, and the ultimate
recovery of the patient was due to their efforts. For the first four days
after the operation I was extremely anxious about her. During the
first thirty-six hours a good deal of bright red, rather watery, fluid
came through the drainage tube, and I could not feel certain that I had
completely stopped the bleeding. The symptoms of collapse six hours
after the operation were probably due to oozing from the walls of the
very extensive cavity. By the 18th, six days after the operation,
the patient was distinctly better and began to look less anaemic.
I removed the tube on the sixth day, and the wound healed perfectly.
Sleeplessness remained a very troublesome symptom and the pulse was
always rapid. For three or four weeks there was a mild degree of
pyrexia.
The uterus showed only a very small tear at about the level of the
internal os. This tear must have involved a branch of the uterine
artery on the outer side of the cervix so that all the bleeding occurred
outside the uterus. There was no perforation of the wall elsewhere.
No blood came down the canal.
This case was my first experience of broad ligament hsematoma
apart from rupture of the uterus in labour, and I sincerely hope that it
will be my last, as I have never had a case which gave me more acute
and long-drawn-out anxiety. The absence of external bleeding, the
absence of abnormal physical signs on vaginal examination, and the
slowness of the pulse at first seemed to me to contra-indicate
exploratory abdominal section, and I put this off until it was almost
too late. The severe and dangerous bleeding occurred after I had
decided to operate. I presume that the peritoneum at the level of the
iliac crest resisted separation and limited the bleeding for a time ;
when separation occurred the bleeding was as free and uncontrolled as
if it had been taking place into the peritoneal cavity. The infusion
of blood in this case was my first experience of this treatment for
secondary anaemia. The results were most striking and successful.
Section of Obstetrics and Gynaecology
203
DISCUSSION.
Dr. F. J. McCann : The case serves to emphasize the dangers which may
be associated with rapid dilatation of the cervical canal. The larger sized
dilators do not dilate the canal, they tear it. This can be easily proved
by introducing the little finger into the cervical canal after the dilator is
withdrawn. Where a wide expansion of the canal is required it is much better
to reflect up the bladder and to incise the cervix and lower part of the uterus
in the middle line. Thus there is one clean cut, which is subsequently
sutured, instead of several tears. Even with the smaller sized dilators where
resistance to their passage is encountered, it is a good plan to pass a long thin
knife into the cervical canal and to cut (from within) the anterior and posterior
cervical wall for a sufficient depth in the middle avascular line. A larger sized
dilator can then be passed with ease. This procedure is comparable to the
operation of internal urethrotomy as practised on the male urethra. Moreover
the operation of dilatation of the cervical canal should be done very slowly in
order to avoid tearing. It is for this reason amongst others that a tent is such
an efficient dilator, although objections may be urged against its use on other
grounds. I believe much more harm results especially from the use of large
dilators than is generally admitted.
Dr. Fairbairn : Surely Dr. McCann has greatly exaggerated the risks
of metal dilators. I will agree that laceration is frequent, in fact almost the
rule, with the larger sized dilators, but what proof has he to offer that a split
of the cervix is any more dangerous than a cut by a knife ? The chief danger
in both is sepsis, and he has yet to show that there is any greater danger in
the one casd than in the other. As to haemorrhage, the case recorded by
Dr. Andrews is very unusual and the explanation not obvious. I should be
glad to hear if any members of this Section have met with cases of severe
bleeding as the result of dilatation ; so far from thinking that more harm results
than is generally admitted, I must have split the cervix in numberless cases
and so far I have not known of any immediate or remote disaster. I would
rather say that a cervical tear has been given a bad name without just reason,
but I shall be quite prepared to acknowledge its terrors if the evidence is forth¬
coming. My own idea is that splitting and tearing cause less bleeding than
cutting and that muscular retraction playB an important part in checking
bleeding.
Dr. Eden : I have seen one case of severe haemorrhage from a laceration
of the cervix produced during dilatation with metal dilators. It occurred at
the Louise Margaret Hospital at Aldershot; the officer in charge of the hospital
had dilated without difficulty for an exploratory curetting, the vagina being
lightly plugged afterwards. When the plugging was taken out a severe
haemorrhage occurred which was controlled by plugging the cervix. When
this plugging was removed the bleeding recurred and this happened twice.
I then saw the case myself, and examining under anaesthesia I found a
204
Holland: The Syphilitic Placenta
laceration at the level of the internal os which opened up the right broad
ligament. The broad ligament cavity and cervix were plugged for 48 hours and
no further haemorrhage occurred. This differed from Dr. Andrews* case in the
haemorrhage being external and the lesion very easily dealt with. A possible
explanation of Dr. Andrews’ case is that a varicose vein in the broad ligament
was ruptured at a point some distance from the cervical wall. If the bleeding
had been from the uterine artery it must have been quite close to the torn
•cervical wall, and the blood would have escaped into the vagina.
Dr. Amand Routh : It is dangerous to use vaseline when dilating, for
though dilatation is easier to secure, it is more difficult to avoid laceration.
For facilitating dilatation I have found that the insertion by the nurse of a
glycerine wool tampon or pessary encourages physiological secretion from the
cervix, with accompanying relaxation of the tissues, as seen in the first stage
of labour.
Dr. Andrews (in reply): If I have to enucleate a submucous fibroid larger
than a walnut I almost always cut through the cervix and lower part of the
body of the uterus so as to get plenty of room. I have not dared to suggest
that there was an abnormal vessel in the broad ligament in this case, although
the suggestion was made by someone else during the operation, as there was a
large thin-walled vein seen in the upper part of the left broad ligament.
The Syphilitic Placenta.
By Eardley Holland, M.D.
During the course of an investigation into the causes of foetal
death, I have had opportunity to examine a large number of placentas.
Included in these is a series of placentas belonging to syphilitic foetuses.
All modern text-books describe certain changes in the placenta in cases
of foetal syphilis. Although I can present nothing new in the way of
histological or other changes, yet I have thought that members of this
Section would be interested to know the results of the examination of a
series of syphilitic placentas. The individual changes are known to all,
yet most of us are without precise information as to how often these
changes are found in the placenta, and to what extent they are patho¬
gnomonic of syphilis. In other words, it is necessary to have some
idea of the diagnostic worth of these changes; for we may sometimes
wish to use the placenta as a means of diagnosing foetal syphilis,
when other means, such as the presence of spirochaetes in the foetal
organs, or foetal chondro-epiphysitis, are not available.
Section of Obstetrics and Gynaecology
205
The changes commonly described in the syphilitic placenta may be
divided into three: (1) Naked-eye appearances, (2) the ratio of the
weight of the placenta to the weight of the fcetus, and (3) the
histological changes.
(I) Naked-bye Appearances.
I defy anyone to proclaim a placenta syphilitic from the most
careful naked-eye examination. In my experience there are no par¬
ticular naked-eye changes in syphilitic placentas, nothing to distinguish
them from many other placentas. I feel it important to emphasize
this because even nowadays there is a good deal of loose talk about the
appearance of the syphilitic placenta. One hears or reads such state¬
ments as: “ The placenta was, from its appearance, obviously syphilitic.”
The appearances which are wrongly supposed to denote syphilis
are voluminous cotyledons, deep sulci, pale placental tissue, grey and
greasy maternal surface, unusual softness and friability. Some of
these appearances may occasionally be seen in syphilitic placentas,
but they are just as commonly found iu other conditions.
(II) Weight-ratio op the Placenta,
In my experience far too much importance has been attached to the
increased weight of the syphilitic placenta. It is true that, if the mean
of a number of cases be taken, the mean ratio for syphilis is less than
the mean ratio for non-syphilitic cases. But such increased weight is
by no means constant nor is it peculiar to syphilis. This is well shown
in the following tables. I should state that all the ratios have been
worked out from cases of foetal death, so that the mean ratios for the
non-syphilitic cases probably do not represent the mean ratio for the
normal placenta and foetus. The placentas were weighed after the
amnion, chorion and umbilical cord had been removed.
Table I shows the mean ratios for fresh and macerated non¬
syphilitic foetuses respectively: (a) The mean for all foetuses, (6) the
means when the foetuses are divided into three weight groups. The
mean for fresh and macerated foetuses is much the same. The weight
grouping shows that the ratio becomes progressively higher as the
weight of the fcetus increases; that is to say, the placenta is relatively
heavy in premature foetuses. This is an important point to remember
when considering the heaviness of the syphilitic placenta, for syphilitic
foetuses are nearly all premature.
206
Holland: The Syphilitic Placenta
Table I.
Frebh Non-syphilitic.
Macerated Non-syphilitic.
Number of Foetuses
Mean ratio ...
94 Number of Foetuses. 64
8 (7*6) Mean ratio . 8 (7*9)
Number of foetuses
Mean ratio
Number of foetuses
Mean ratio
Fresh .
Under
1,800 grm
20
6
Macerated.
18
6
1,800 to Over
3,000 grm. 3,000 grm.
36 ... 38
8 ... 8
33 ... 13
8 ... 10
Table II.— Syphilitic.
Number of foetuses ... ... ... ... ... 34
Mean ratio ... ... ... ... ... ... ... 6 (5-6)
Under 1,800 to
1,800 grm. 3,0W grm.
Number of foetuses ... ... 19 ... ... 15
Mean ratio ... ... 5 (4*6) ... ... ... 7 (6*8)
Table III. —All together.
Number
Mean ratio
Under
1,800 to
Over
for all
1,800 grm.
3,000 grm.
3,000 grm.
Fresh non-syphilitic ... 94
8
6
8
8
Macerated non-syphilitic 64
8
6
8
10
Syphilitic ... ... 34
6
5
7
—
Table IV.— Ratios arranged in Tables showing Frequency-distribution
amongst Fcetuses op Different Weights.
Fresh Non^syphilitic.
Grm.
•2
3
4
i)
7
s
10
li
12
600 to 1,800 ...
2
0
2
8
3
2
2
0
1
0
0
= 20
1,800 to 3,000...
0
0
0
2
5
7
6
11
4
1
0
= 36
Over 3,000
0
0
0
1
4
11
6
9
2
4
1
= 38
2
0
2 11 12 20 14
Macerated Non-syphilitic.
20
7
5
1
= 94
600 to 1,800 ...
0
1
5
2
1
4
1
2
2
0
0
= 18
1,800 to 3,000...
0
1
2
4
2
7
4
8
0
2
3
= 33
Over 3,000
0
0
0
0
0
1
2
4
0
3
3
= 13
0
2
7
6 3 12
Syphilitic.
7
14
2
5
6
= 64
€00 to 1,800 ...
0
7
3
3
3
3
0
0
0
0
0
= 19
1,800 to 3,000...
0
2
1
4
1
1
3
0
2
1
0
= 15
0
9
4
7
4
4
3
0
2
1
0
= 34
Section of Obstetrics and Gynaecology
207
Table V. —Placentas op 26 Spirochete* positive Fcetusbs.
Typical of syphilis in... ... ... ... 16, or 61 per cent.
Suspicious in ... ... ... ... 6, or 23 ,,
Negative in .. ... ... ... ... 4, or 15 ,,
Placentas op 91 Spirochete-negative F<etuses.
54 Macerated Foetuses. i 37 Fresh Fcetuses.
Typical ... ... ... 5 Typical ... ... ... 0
Suspicious ... ... 6 Suspicious ... ... 4
Normal ... ... ... 43 ! Normal... ... ... 33
Summary as regards Agreement op Sections with Diagnosis op Syphilis.
117 Placentas.
Typical, 21 ... undoubted foetal syphilis in 19 (90 per cent.)
Suspicious, 16 ... ,, ,, ,, 6 (38 ,, )
Normal, 80 ... ... ,, ,, ,, 4 —
Table II shows the mean ratios for cases of foetal syphilis: (a)
The means for all foetuses, ( b) the mean when the foetuses are divided
into weight groups.
In Table III are displayed all together the ratios for, fresh and
macerated non-syphilitic, and for syphilitic, foetuses, both for total
foetuses and for foetuses divided into weight groups.
Examination of these tables shows that there is not a very great
difference between the ratios of syphilitic and non-syphilitic foetuses.
The real test of the worth of heaviness of the placenta as a sign of
syphilis is best got by arranging the ratios in tables showing their
frequency-distribution amongst foetuses of different weights. I have
done this in Table IV. Two facts emerge which show that heaviness
of the placenta is not a sign of great worth in diagnosing syphilis : (1)
Amongst the non-syphilitic placentas, a fair number are heavy, their
ratios being equal to or less than the mean ratio for the syphilitic
placentas. (2) Amongst the syphilitic placentas, a fair percentage are
not heavy, their ratios being equal to or greater than the mean ratio for
the non-syphilitic placentas.
I will now consider the exceptionally heavy non-syphilitic placentas,
selecting only those whose weight is far above the average—those with
a ratio of under 3‘6 for foetuses of less than 1,800 grm., with a ratio of
less than 5'6 for foetuses of from 1,800 to 3,000 grm., and with a ratio
of less than 6’6 for foetuses of over 3,000 grm. in weight.
208
Holland: The Syphilitic Placenta
Under 1,800 grm.
(1) Ratio 2'6. Case of eclampsia. Placenta has interstitial
haemorrhages and red infarcts.
(2) Ratio 1'8. Case of general oedema of the foetus.- Many former
dead foetuses. Villi enlarged and avascular, resembling the syphilitic
placenta histologically, but villi lower and more irregular.
(3) Ratio 3'3. Accidental haemorrhage, macerated foetus, placenta
contained an interstitial haemorrhage and red infarcts.
1,800 to 3,000 grm.
(1) Ratio 5'2. Case of placenta praevia.
(2) Ratio 3‘2. Macerated foetus, Wassermann positive, possibly
syphilis.
(3) Ratio 3‘8. Macerated foetus. Case of albuminuria of pregnancy.
Placenta weighed 700 grm., and was the largest in my series, contained
two interstitial haemorrhages.
(4) Ratio 4‘3. Case of accidental haemorrhage. The villi are large
and resemble exactly those of syphilis.
(5) Ratio 5‘5. Clot, probably ante-mortem, in umbilical vein, other¬
wise nothing to account for death.
(6) Ratio 5'5. Case of accidental haemorrhage. Many white
infarcts and some red.
(7) Ratio 5. Possibly syphilis. Wassermann positive, spleen
enlarged, otherwise no signs of syphilis. Villi normal.
(8) Ratio 5'4. Cause of death unknown. The patient had possibly
had syphilis. Villi normal.
Over 3,000 grm.
(1) Ratio 5'5.
irregular.
(2) Ratio 5'9.
(3) Ratio 6‘3.
(4) Ratio 5-8.
General oedema of foetus. Villi large, dense and
Albuminuria of pregnancy.
Case of forceps delivery. Cerebral haemorrhage.
Case of breech labour. Cerebral haemorrhage.
Summary of these Fifteen Cases, which are very extreme.
(1) Two cases of possible syphilis. Maternal Wassermann reaction
positive and foetal spleen enlarged, but no spirochaetes and no chondro-
epiphysitis. Villi normal. One case in which the mother gave a
Section of Obstetrics and Gynaecology 209
history of previous syphilis, but no signs of syphilis in mother or
foetus.
(2) Six cases of toxaemia of pregnancy, comprising two of albu¬
minuria of pregnancy, one of eclampsia, and three of accidental
haemorrhage. In most of these the placenta showed red infarcts,
and some had interstitial haemorrhages.
(3) Two cases of general oedema of the foetus.
(4) One case of placenta praevia.
(5) Two cases of difficult labour, with foetal cerebral haemorrhage,
and one case in which the cause of death was unknown.
Taking now the syphilitic placentas, which are not especially heavy,
we see from the Table that there are six of under 1,800 grm. with a
ratio of 6 or more, and six of over 1,800 grm. with a ratio of 8 or more.
That is, out of thirty-four syphilitic placentas, twenty-two, or 65 per
cent,., were heavier than normal. Heaviness of the syphilitic placenta
is not constant, therefore, and is not of great value as a diagnostic sign.
(Ill) Histology op the Syphilitic Placenta.
Of the thirty-seven foetuses whose tissues contained spirochsetes the
placentas were examined microscopically in twenty-six. The histological
points which have been noted as characteristic of syphilis, but which
were not found in all of these twenty-six placentas, are
(1) A uniform increase in the size of the villi, resulting in their
being more crowded together than normally and implying a corresponding
reduction in the size of the intervillous spaces. This change is due to
an increase in the amount and density of the stroma, the collagen fibres
being more numerous and the cells more abundant and closely packed.
(2) A greatly diminished vascularity of the villi. The blood-vessels
are usually absent: when present they are greatly diminished in number
and size. The walls of the vessels, when present, are not altered : they
still appear as fine endothelial-lined channels in the stroma.
These changes (fig. 2) sometimes affect the whole placenta uniformly,
and sometimes only partially. The villi coming from one or more main
chorionic stems may be affected, whilst others escape, healthy and
changed villi being seen side by side in the same section. It is obviously
absurd to diagnose syphilis from the discovery in a section of a few
isolated large, dense, avascular villi. Furthermore, it is obvious that
little help may be got from one section : either one very large section
or several small ones must be used.
HoUfttuI: The Syphilitic Placenta
So I have not found special chaoses
in the Wood»vessels fof the placenta; It n commonly stated that the-
vessel? of the ;yHli iri syphilis are olrfiterated by an endarteritis, I
have never observed this What vessels -there--.are re veal themselves as
little, circular collections of .endothelial cells, their walls are not increased
in thickness nor have the endothelial cells multiplied.-
The explanation of the avascularity of the villi in syphilis, I believe^
rs that the tefruinal villi have never been properly vascularized by
Normal placenta: {or contact with iig. 3.
the dowogrowth of blood-vessels, and not that the villi have become
devaaeuln-nzedby ;% later .obliteration of the vessels.
I have one other point to mention—the occurrence of a small round-
celled infiltration -of. the stroma of the villi, indicating an inflammatory
change- In a few sections, at long mtervals, 1 found places where:
Settitih of Obstetrice and G-yimcofagy
neighbouring villi h»d coalesced and where the strorua was infiltrated
with small ronnd ceils; These ayjpeatatices were exceptional and, must
.await further observation.
In fire sections T found a ! if tie node composed-.of leucocytes, three
times lying ia,the thick chorionic membrahe and twice, in the decidua.
They all occurred in syphilitic placentas. If fheso were tiny gurniuata,
they would be of m&teibU aid in (liaguosing placcntal syphilis ifigs. it, -ib
8yp>e}iwo jilaceu tu.
According' to the coiuple.tenesswith which these changes were found
•in the twenty-sis .syphilitic placentas I have esatniued, the. placentas
were grouped into three classes(11 Typical, (21. suspicious. (.3) nega*
tive or normal. ‘When the changes are perfectly developed ana
uniformly distributed they are easily recognizable,, Bui vvheHi the
distribution of enlarged villi is patchy, or where the blood'- vesiaslsv^^
Holland: The ByiMlitic Placenta
only moderately diminished, the riiagnosife is extremely difficult and'
it is only safe for those who art in the habit of regularly examining
placental spefiona to give an opinion. For the changes do not consist
in the formation of . foreign tissue eIement8 v or of rearranged structure;
they are simply .'exaggerations' of the normal, and it is sometimes
difficult to .decide between what Is only a- physiological abnormality
and a realty pathological change. The t wo are not separated by a
sharp line,- A series of control sections, is of great assistance.
wmMm
Small node vn vbbrtonic membrane: prtfb&biy a gumma.
in Table V
Results ire shown
results obtained from the examtnation of the placentas of ni:nety-c*ne
spirochif.'te-ueg'at.vve to Taking now the latter. 1 will exambje
the details of the cases flora which the "typical'’ or “ auspicious 11
sections came. The results give, strong support to tho reliability of
Seotmi of Obstetric* and Qynaeeology 213
Tbgre are five typical ” sections amongst the macerated spirocheote-
negative foetuses Three of these prove to be undoubted cases of
%ta! syphilis. All had maternal positive Wassetmarm reactions : two
•of the foetuses showed chondro-opiphysitis. The third foetus showed
m ehood re-epiphysitis. hut. I had the mother-^ under treatment before
pregnancy, during which time the Wasseraiapu reaction became
negative. The two remaining cases showed no evidence whatever of
syphilis; one was a ease of accidental Inemotthage and alburoinam;
i mm
Fig. 'Ai
Small rnwte of leucocytes, an tbe edge of tb$ probably a gumma
in the other the cause of feta! death was imdetermraed, The results
obtained from '‘typiuaiT sections can be thds summanzed. In the
microscopical examination of HT placec-taa, twenty-one gave appear¬
ances typical for syphilis; pf these tsve»ty*on&, nineteen were tmdMibted
eases of syphilis, whilst in two there was mv evidence of syphilis.
The BijpkiiiHc Placenta
From tins small series it can be stated that the diagnosis of. syphilis
from a typical section ■will be correct in $0 jter.eoofc. of cases. Thus,, a
typical section is highly reliable, " ; '
I will as6fe£- cocsidet the ^‘Vsectiohfr^asbopgst the epiro-
chaste-negative fgaiiisehv in one the Wassermftnn reaction wa# positive
in the mpthftt r the feetas wits killed during a breeehdahoor by’ OPjNfead*
ii^nmrrhage • there was no other evidence of syphilis and the case has
Holland
Section, of (tom a caste &{ ot the foetus: the villi tire &n)arged,
ttM demise and tsdermuauss fcontmyt
with 2i>\ V..
not been classed as such- Two were cadeb of general fcetal oedema*
The interesting point conies. put in the remaining seven—all were cases*
of toxtenha of pregnancy—accidental hi:e«n>t‘i'hftge oh aihurniohyhi of
|jre.gnancy, pi* both. The resPlt* ^rihcoming fropa Tshspidihiift ” v
mettona cad be thus «hrn mimed : lb the Jiiivioaeoiagai pxamidatjpn of
Section of Obstetrics and Gynaecology
2i5
117 placentas, sixteen gave appearances “suspicious” of syphilis: of
these sixteen, six are undoubted syphilis. From this small series it
can be stated that the diagnosis will be correct in only 38 per cent.
A merely suspicious section is unreliable.
DISCUSSION.
Dr. Amand Bouth : As relatively far fewer spiroch»tes are found in the
placenta than in the tissues of the foetus this is probably, due, as I have
elsewhere suggested, to the controlling and spirillolytic action of the chorionic
ferments. Are the pathological changes in the placenta mainly intravillous
(foetal) or are they intervillous (maternal), and as the changes closely
resemble those found in the placenta in cases of toxaemia, does Dr. Holland
consider that the syphilitic changes are due to a specific toxaemia ?
Dr. Eardley HOLLAND (in reply to Dr. Amand Bouth) : The changes
were confined to the foetal part of the placenta—i.e., to the connective tissue
of the villi and the blood-vessels : I have not observed any changes in the
decidua, beyond the very occasional presence of aggregations of small round
cells, which might possibly be gummatous in nature. The changes might
possibly be due to a specific toxaemia; I do not know of any evidence
either for or against that view.
Section of ©bstetrice anb <5snaecoIoa\>.
President— Mr. J. D. Malcolm, F.R.C.S.Ed.
Obstructed Labour due to Ventrifixation . 1
By W. Gilliatt, M.S.
R. C., a primigbavida, aged 32, was admitted to Queen Charlotte’s
Hospital under my care on October 24, 1918. The history given was
that two years previously the patient had an operation for prolapse at
the Hornsey Cottage Hospital. Labour began on October 19, five days
before admission, and the membranes ruptured at the onset of labour.
The pains were at first weak and irregular, but had been extremely
violent on the day before admission, giving way to less violent continuous
pain on the day of admission. On the night before admission, and
again the following morning, the patient had profuse uterine haemor¬
rhage, for which her practitioner had to plug the vagina a few hours
before admission.
When seen in hospital the patient’s general condition was not good,
her temperature was 100° F. and her pulse 112. Abdominal examina¬
tion showed a median subumbilical scar about 3^ in. long. The uterus
was very tense and no relaxation occurred, it was asymmetrical, being
more prominent to the right of the umbilicus, and extending into the
right loin. Owing to the tense condition of the uterine wall no foetal
parts could be made out except the head, which was felt with
difficulty in the right loin. The foetal heart could not be heard.
Per vaginam : After removal of an ineffectual plug of offensive gauze,
an attempt was made to render the vagina as sterile as possible with
1 At a meeting of the Section, held July 3, 1919.
Section of Obstetrics and Gynaecology
217
brilliant green and methyl violet solution. The cervix was very high
and could only just be reached, it was displaced backwards and to
the right. The os was the size of a florin, and some part of the
child could just be felt tightly impacted in it.
The condition seemed to me to be an early tonic contraction of
the uterus, due probably to some trouble in connexion with the
operation for prolapse, and at this time we were ignorant of the
nature of the operation. Further, I regarded the patient as already
gravely infected, and a very difficult decision had to be made as to
how best to deliver her. The three following methods presented
themselves :—
(1) Per vaginam : In order to ascertain if this were possible the
patient was examined under anaesthesia. This revealed the impos¬
sibility of this route for delivery owing to the inaccessibility of the
cervix, its size and rigidity. The canal could not be dilated because of
the impaction of what was thought at this time to be the knee or elbow
(it subsequently turned out to be the latter), and no instrument could be
passed into the cervix.
(2) Caesarean section.
(3) Hysterectomy without previously opening the uterus.
Though I was anxious to avoid opening the peritoneal cavity, it was
not possible, and I decided to do Caesarean section in preference to
hysterectomy: first, because it was a shorter and less severe operation
to a patient in poor condition; and, secondly, I thought the risk of
spreading infection was as great if not greater in opening up the pelvic
cellular tissue as in incising and leaving the septic uterus.
The abdomen was opened by a high incision and the uterus was
seen to be distinctly asymmetrical with a pronounced bulge to the
right. The uterus was fixed to the anterior abdominal wall by a thick
tightly stretched band about 2 in. long, which was attached to the
posterior surface of the uterus, 1 in. to 1^ in., behind a line joining the
uterine ends of the Fallopian tubes. There was marked axial rotation
of the uterus through almost a quarter of a circle, so that the right¬
sided bulging mentioned above was at the expense of the posterior wall
of the uterus. The band fixing the uterus was divided and it was then
seen that the child lay almost entirely in the posterior wall of the
uterus, which was stretched very thin; the anterior wall was short
and about 1 in. in thickness. After packing off the peritoneal cavity
and protecting the wound edges, the uterus was incised in the body
axis through the fundus and posterior wall and a stillborn peeling
218 Gilliatt: Obstructed Labour due to Ventrifixation
child delivered. Considerable difficulty was encountered in delivering
the head, which was tightly gripped in a sacculation of the posterior
uterine wall, and the incision had to be continued through the edge
of the sacculation before the head could be freed. The membranes
were friable and unusually adherent, and this rendered their separation
tedious. The uterine incision was closed with interrupted linen thread
sutures, the whole operation occupying forty minutes.
The patient was extremely collapsed after the operation but improved
slowly until the fifth day when she had a cerebral embolism, and she
died on the eighth day after the operation.
The post-mortem was performed by the hospital pathologist, Dr.
Burnet, who reported : “ There is no sign of peritonitis either local or
general. The uterus has involuted fairly well, the fundus reaching 2 in.
above the symphysis pubis and is quite normal in shape. The edges of
the uterine incision are held in accurate apposition by the sutures, but
on dividing them the edges separated, and no attempt at healing has
taken place. The cut edges are quite healthy in appearance. The
interior of the uterus is covered with a thin greenish layer, it is not
offensive and there is no suppuration in the uterine cavity or wall.
There is a mass of soft fungating vegetations on the mitral valve.
Death was due to septic endocarditis.”
The operation for prolapse had been an amputation of the cervix
uteri and ventrifixation.
DISCUSSION.
The President : The fundus of the uterus should not be fixed to the
abdominal wall, if this can possibly be avoided, when the patient is of such age
that conception might occur. I have lately treated a patient for an incisional
hernia, upon whom an operation for retroflexion was performed when she was
24 years of old. She had been married several years, and was sterile, but con¬
ceived soon after the uterus was replaced. She suffered much pain whilst
carrying the child, and at the delivery serious difficulties arose, the doctor
fearing that the child or the mother must die. These incidents occurred in
India eight years ago, and no account of them had been received from a medical
man, but they were consistent with the conditions found. When the abdomen
was opened the top of the fundus close to its left side, immediately in front of
the line between the insertion of the Fallopian tubes, was firmly fixed to the’
abdominal wall, so that it seemed certain that the uterus must have been ex¬
cessively contorted when the pregnancy was fully developed. Nevertheless
the patient and the child survived, this showing how under most unfavourable
circumstances a successful delivery might take place. But the risk to the
Section of Obstetrics and Gynaecology
219
mother and child in such circumstances must be great, and the hopeless
conditions which may arise are well illustrated by Mr. Gilliatt’s case.
Dr. Lapthorn Smith : As ventrifixation is one of my favourite operations,
giving splendid results when properly performed and in suitable cases, I feel it
a duty to defend it, and to explain why a great many disasters similar to the
one just reported occurred among the first few hundred women who were
operated on according to the directions laid down by its brilliant inventor.
When I read that the back of the fundus was to be stitched to the abdominal
wall I thought it was a misprint for I foresaw that if a woman by any chance
became pregnant afterwards the labour could not be terminated naturally. As
the growing uterus could not rise in the abdomen by its fundus, which was
held in anteversion, the cervix being free would swing round and point upwards
towards the liver, and when labour began the child’s head would be pushed
upwards instead of down into the pelvis. So when I operated a few days later
on a case of retroversion with adhesions, I made a small abdominal incision,
put in two fingers of the left hand, and broke up the muslin-like bands, and
was then able to catch the fundus with a vulsellum and draw it up out of the
incision. The anterior surface of the uterus was “ criss-crossed ” with a
large needle, over an area a little larger than a shilling-piece, commencing below
the insertion of the tubes, and extending downwards about li in., and a similar
surface was made raw on the abdominal peritoneum, just below the incision.
Some of these cases were my own and some were sent to me by other doctors,
and I asked the latter to let me know if any of them became pregnant, and
what kind of delivery they had. A few of my own became pregnant, and
after a normal pregnancy, with the exception of a little dragging during the last
month or two, were delivered without any difficulty whatever. Then my friends
began to send me in reports that they had attended a number of their cases
also quite normally, although one had complained a good deal of the dragging
upwards. One case had miscarried, but it was not certain that this was due to
the operation, as she had miscarried once before. But at the meeting of the
American Gynaecological Society a year or two later, a great many very serious
accidents were reported by different Fellows following the operations done by
the first mentioned method all over the United States, which were obviously
due to the back of the fundus being attached to the abdominal wall, or in
other words, in forced anteversion. From that time onwards the mistake was
corrected, and many thousands of operations have been followed by normal
labours. Some years later I had occasion to open the abdomen of some of
these cases of mine for other conditions, such as appendicitis and pus tubes,
and I found that in several of them the uterus was not adherent to the
abdominal wall, but was held in normal position by a fibrous ligament 2 in. or
3 in. long, which permitted some freedom of movement. But from the day on
which I heard of the great number of abnormal and fatal labours I resolved
never to do a ventrifixation in a woman who was in a position to become
pregnant. Ventrifixation is an excellent operation to prevent the uterus
»
au— 256
220 Gilliatt: Obstructed Labour due to Ventrifixation
from falling back into the hollow of the sacrum which is very often left
after the removal of densely adherent pus tubes. I have done nearly 300
ventrifixations and rather more than 300 Alexander’s operations; the latter
should never be done if there are any adhesions. The failures have been
between 2 and 3 per cent, in either cases; when the Alexander’s method
failed I did a ventrifixation. Now as to what is the best thing to do
when such a case comes into our hands, if we see the case early enough, we
should make a small abdominal incision and free the adhesion by cutting
between two ligatures, when it will be comparatively easy to roll the fundus
up to the line which will bring the cervix down. If we first see the case when
labour has begun we should do the same thing, but make a larger incision,
and terminate labour by Cesarean section. On no account should any
attempt be made by the vagina. This cannot be done without great danger
to mother and child.
Dr. Eardley Holland read a paper on “ Cranial Mechanics.”
PROCEEDINGS
SUITED BY
Sib JOHN Y
W. MacALISTER
l'\r>KK IW fliOWTIu.S j)K
• •L \' 1 -^•; v '•
E mf&M A li CO MM IT T E. E
■
volume the twelfth
ftKas'ius f:u8.io
SECTION OF ODONTOLOGY
LON DON
LONG A1 AN S, GREEN k CO
•v
1919
PAT E I? N OST L-1K KO SV
, . ■ • -
■ . ■
Section of <$>0ontoloa\>
OFFICERS FOR THE SESSION 1918-19.
President —
G. G. Campion, L.D.S.E.
Vice-Presiden ts —
(resident)
M. F. Hopson, L.D.S.E.
J. G. Turner, F.R.C.S., L.D.S.E.
W. H. Dolamore, L.R.C.P., M.R.C.S., L.D.S.E.
(non-resident)
Morgan Hughes, M.R.C.S., L.D.S.E.
G. O. Whittaker, L.D.S.E.
G. J. Goldie, L.R.C.P. & S., L.D.S.Ed.
Hon . Secretaries —
F. N. Doubleday, L.R.C.P., M.R.C.S., L.D.S.E.
G. Paton Pollitt, L.D.S.E.. D.D.S.Penn.
J. Howard Mummery, D.Sc.Penn., M.R.C.S., L.D.S.E.
Hon. Curator — J. F. Colyer, F.R.C.S., L.D.S.E.
Other Members of Council —
(resident)
H. Chapman, L.D.S.E., D.D.S.Penn.
E. Sturridgb, L.D.S.E., D.D.S.(New York).
G. C. Birt, L.R.C.P., M.R.C.S., L.D.S.E.
J. E. Spillbr, L.D.S.E.
C. H. Bubb, L.D.S.E.
H. C. Malleson, L.R.C.P., M.R.C.S.. L.D.S.E.
C. S. Morris, L.D.S.E.
S. Holloway Olver, L.D.S.E.
B. Maxwell Stephens, L.D.S.E.
(non-resident)
L. F. Morris, L.D.S.E.
A. de Mierre, L.D.S.E.
Christopher Badcock, L.D.S.E.
H. P. Pickerill, M.D., B.Ch., M.D.S.Birm., L.D.S.E.
A. E. Rowlett, L.D.S.E.
C. H. Oram, L.D.S.E.
A. W. Wellings, M.D.S.Birm., L.D.S.E.
G. Garnett Ellis, L.D.S.E.
R. Umney, L.D.S.E.
Representative on Library Committee —
J. Lewin Payne, L.R.C.P., M.R.C.S.. L.D.S.E.
Representative on Editorial Committee —
B. Maxwell Stephens, L.D.S.E.
SECTION OF ODONTOLOGY.
CON TEN TS.
July 8, 1918.
F. N. Doubleday, L.R.C.P.Lond., M.R.C.S., L.D.S.Eng. cage
On Local Anaesthesia in Dental Operations ... ... ... ... 1
October 28, 1918.
George Northcroft, L.D.S.Eng.
A Short Review of another Year’s Work at a Jaw Injuries Centre ... 7
November 25, 1918.
J. Howard Mummery, D.Sc.(Hon.), M.R.C.S.
On the Nerve End-cells of the Dental Pulp (Abstract) ... .. 11
Peucival Cole, F.R.C.S.Eng., and ( has. H. Bubb, L.D.S.
Bone-grafting in Ununited Fractures of the Mandible, with Special
Reference to the Pedicle Graft (Abstract) ... ... ... 13
December 2, 1918.
H. P. Pickerill, M.D., M.D.S., Major, N.Z.M.C.
Intra-oral Skin-grafting: The Establishment of the Buccal Sulcus ... 17
December 9, 1918.
F. M. Wells, Major, C.A.M.C.
Food Deficiencies as a Factor influencing the Calcification and Fixation
of the Teeth
23
IV
Contents
February 24, 1919.
•T. F. Colyer, F.R.C.S., L.D.S.
Variations in Position of the Teeth in New World Monkeys
... 39
January 27, 1919 -
William Billington, M.S., F.R.C.S., Captain R.A.M.C.(T.), Arthur H. Parrott,
M.D.S., L.D.S., and Harold Round, M.D.S., L.D.S.
Bone-grafting in Gunshot Fractures of the Jaw
March 24, 1919.
W. Kelsey Fry, M.C., M.R.C.S., L.D.S.
Prosthetic Treatment of Old Injuries of the Maxilla? ...
April 28, 1919.
C. Ernest West, F.R.C.S.
Experiences with Transplant Grafts in Ununited Fracture of the Mandible 9;j
May 26, 1919.
F. N. Doublkday, L.Ii.C.P.Lond., M.R.C.S., L.D.S.Eng.
Case of Gunshot Wound of the Mandible with Extensive Loss of Tissue
treated by the Colyer Method ... ... ... ... 101
J. G. Turner, F.R.C.S., and Aubrey H. Drew, D.Sc.
An Experimental Inquiry into the Bacteriology of Pyorrlnea ...
... 104
The Society does not hold itself in any way responsible for the statements made or
the views put forward in the various papers.
John* Bale, Sons & Danif.i sson, Ltd., 83 PI, Great Titoldield Street, London. W.l.
Section of ©Oontoloas.
President—Mr. J. H. Badcock, L.R.C.P.Lond., M.R.C.S., L.D.S.Eng.
On Local Anaesthesia in Dental Operations . 1
By R N. Doubleday, L.R.C.P.Lond., M.R.C.S., L.D.S.Eng.
As the advent of general anaesthesia rendered possible the advances
of modern surgery, so, I am confident, will local anaesthesia in the
future render similar service to the dental surgeon by abolishing pain •
from his field of surgery. Twelve years ago, when my experiments
upon local anaesthesia commenced, we were using cocaine, and
experimenting with /?-eucaine lactate and similar drugs. Doubtless
further experience will lead to the discovery of new and better anaesthetic
agents, but my experience leads me to believe that novocain is at
present the safest and most satisfactory drug. The E tablets, containing
0’02 grm. of novocain and 0 0005 grm. of suprarenin are employed, one to
each cubic centimetre of water, making a 2 per cent, solution of novocain.
By observing the effects of solutions of tap water, normal saline, and
Ringer’s solution^upon myself and upon patients, I have found that on
the tissues there is little difference between tap water and saline solution
as regards the irritation produced. Three cubic centimetres of boiling
water are put into a graduated test tube, three novocain E tablets are
added, the whole is boiled, and poured into a sterile drug holder; this is
then drawn into a sterilized all-metal syringe, the needle is screwed
into the syringe, turned nozzle upward, and tapped, to free from all air.
The solution is then ready for use. If the patient has previously
shown signs of susceptibility to the drug, strychnine sulphate 0 0022 grm.
or atropine sulphate 0 00065 grm. is added to the solution before
boiling it. If the blood-pressure is excessively high, as may occur in
n—6
At a meeting of the Section, held July 8, 1918.
q
Doubleday: On Local Anesthesia in Dental Operations
alcoholics, an inhalation of amyl nitrite is given before the injection
to reduce the blood-pressure, for suprarenin will restore it to the normal
height. The all-metal syringe fitted with a vulcanite washer, can be
boiled. A short hub, with two types of needle, the short one 2 cm.,
and the long one 4 cm. in length, with a bayonet attachment, complete
the equipment. Before inserting a needle into the soft tissues these are
dried and painted with tinct. iodi. (6 per cent.).
The following are the methods of inducing anaesthesia:—
Submucous infiltration for the anaesthetization of the nerve-twigs
going to the pulp and periodontal membrane, being used for filling of
teeth, or for their immediate separation. It is employed for all the
teeth, except the lower molars.
In the case of the maxillary incisors, canines, and pre-molars, the
lip is held away from the jaw to expose the reflection of the mucous
membrane from the gum to the cheek. Into the midpoint of this
reflection the short needle is passed with a sharp thrust- Some
resistance is encountered in the submucous tissue, but as soon as the
cellular tissue of the cheek is entered the passage of the needle is easy.
Half 'the length of the needle is introduced so that its injecting surface
lies above and father posterior to the nerve-twig in its passage through
the maxilla to the apex of the root. The needle lies outside the peri¬
osteum but does not pierce it. Two to 3 c.c. of the solution are then
injected into the part not too slowly, but without forcibly producing
distension of the tissues. This usually takes about thirty seconds;
generally at the end of that time, always within two minutes, the pulp,
dentine, and periodontal membrane will be quite insensitive. In the
case of the mandible the technique is similar but the injecting surface
of the needle should be more directly beneath the apex of the root,
because of the different course pursued by the nerves as they pass to
the teeth.
Submucous anaesthesia of the maxillary molar teeth is obtained by
utilizing the bayonet attachment, with the short needle, the injecting
surface of the needle being directed forwards and inwards; the mouth
should be nearly closed, the needle is passed into the reflection of the
mucous membrane opposite the maxillary third molar and directed
upwards and inwards until the posterior superior dental foramina are
reached. Their position depends upon the development of the maxillary
antrum ; sometimes the injecting surface of the needle is opposite the
foramina when the hub of the needle is at the occlusal margin of the
third molar, and sometimes when the hub is at the cervical margin;
Section of Odontology
3
the needle is moved slowly up and down, bathing the whole of this
surface with 2 to 3 c.c. of the solution. Care is taken to have the
needle too high rather than too low ; gravity will tend to make the fluid
descend along the bony, muscular, and fascial planes.
Alveolar anaesthesia is, I believe, generally employed by dental
practitioners in extraction of one or two teeth, and answers well except
in the case of the lower molars. The injecting surface of the needle is
passed beneath the gum, but not beneath the periosteum of the alveolar
process of the tooth to be extracted ; about 7 minims of the solution are
inserted upon the vestibular and oral surfaces of the tooth. Anaesthesia
is practically instantaneous.
lntra-alveolar anaesthesia is advocated by Mr. Parrott, of the Dental
School of Birmingham, for obtaining anaesthesia in the molar region
of the mandible. A few drops of the solution having been inserted
beneath the gum upon the buccal surface of the root, a small opening is
drilled through the outer alveolar plate into the cancellous tissue of the
mandible ; through this opening the needle is inserted, and a few
minims of the solution are injected. Very satisfactory anaesthesia is
obtained. Personally I do not care to take the risk of introducing sepsis
into the cancellous tissues of the mandible. Regional anaesthesia, which
we constantly employed in Berlin in 1909 10, at first inspired me with
apprehension, but as I found that Mr. Rowlett and Major Kazanjian
constantly used it with safety and success, their example has led me
again to adopt regional anaesthesia. Sometime, possibly, I may employ
Mr. Parrott’s method, since it has proved successful in a base hospital
in France.
Regional Anaesthesia in the Maxilla .—For this a bayonet attachment
is added to the syringe; a long needle is employed if complete blocking
of the infra-orbital nerve is required. The needle is inserted as nearly
as possible in line with the buccal roots of the third molar, the patient
having the teeth almost closed ; the direction of the needle is upwards
and inwards, towards the midline; its injecting surface is directed
forwards towards the posteiior surface of the maxilla. About 2 c.c. of
the solution are introduced.
Regional Anaesthesia in the Mandible. —Two useful methods may be
utilized for this purpose: (a) A short hub and long needle are employed.
The patient has his mouth open 4 cm. The needle is passed over the
premolar teeth of the opposite side, into the inner third of the anterior
pillar of the fauces on the side to be anaesthetized. The needle will lie
just below the occlusal surface of the upper third molar, having its
4 Doubleday: On Local Anaesthesia in Dental Operations
injecting surface directed towards the bone. It is then passed back
into a triangular space, having its base uppermost formed by the
external pterygoid muscle, its inner wall formed by the internal lateral
ligament and the internal pterygoid muscle, and its apex by the attach¬
ment of these to the mandible. By passing the needle in for half its
depth the injecting surface will lie above and posterior to the lingula,
covering the commencement of the inferior dental (alveolar) canal;
2 c.c. of the solution is then introduced. (b) The bayonet attach¬
ment and short needle are employed. The technique of injection is
similar to the above but the short needle is used. Its advantage lies
in the fact that it can be utilized when the patient cannot, or will not,
open the mouth widely.
In comparing these methods, one must remember the three
standards to which local anaesthesia should conform: (1) Simplicity
of technique; (2) rapid and certain onset of anaesthesia; (3) absence
of after-effects. Submucous anaesthesia is the simplest, and for filling
teeth is unrivalled. For the extraction of teeth the alveolar anaesthesia
is the most simple ; while regional anaesthesia is invaluable for all
operations upon the mandibular molars and for multiple extractions.
Some typical instances of the uses of local anaesthesia are as
follows :—
On July 5, 1918, Mrs. J. Devitalization and removal of the pulp of the
maxillary left central incisors was necessary. A submucous anaesthesia was
administered at 10.20, and the pulp exposed and removed without pain at
10.25.
On July 4 Dr. X. was given a mandibular regional anaesthesia for the
extraction of a broken-down second molar at 10.30. At 11 the tooth was
removed without pain, though he was a very nervous and sceptical patient.
On May 3, Mrs. D. Extraction of a crowned second mandibular, which
had an acute abscess upon its root, was necessary. She was five months
pregnant, and particularly desired to avoid a general anaesthetic. A mandi¬
bular regional anaesthesia was given at 2.10, the tooth removed, and pus
evacuated without pain at 3 p.m.
On April 9 Miss I., a hospital sister, with acute local periodontitis of the
mandibular second molar ; the tooth was too tender to bite on or to touch. A
mandibular regional was given at 11.30. She went back to the wards and
gave out her dinners, returning at 12.30, when an amalgam filling in the
tooth was removed without pain, the root canals opened up, and the tooth
eventually saved.
Section of Odontology
5
On July 8 a hospital surgeon presented himself for the removal of a small
cyst in the region of an upper first molar. At 10.10 a submucous injection
was given, also an injection to catch the posterior palatine nerve as it emerges
from the posterior palatine foramen. At 10.20 the operation was commenced
and completed without pain, although it lasted forty-five seconds, and involved
a good deal of chiselling away of compact bone.
A Toxic Case .—On July 5, Miss H. presented herself for the devitalization
of the maxillary left canine and the preparation of cavities in both maxillary
premolars of the same side. A maxillary regional anesthesia was adminis¬
tered at 9.30. At 9.55 the patient showed some blueness of her lips and
slight sweating, and within half a minute fainted. She was at once given
strychnine sulph. 0 0022 grm. in 1 c.c. of water, and within another half
minute her pulse had recovered. She apologized for her stupidity, which she
attributed to the rubber dam interfering with her respiration. I think,
however, that her symptoms were really due to absorption of novocain.
Although I have used the drug in my private and hospital practice
four or five times daily for several years, I have never seen a worse
case than this, and believe that if only freshly made solutions were
injected with absolutely sterile instruments, toxaemia would very
seldom occur. Blueness of the lips and sweating over the upper lip
are the early signs of novocain poisoning, and should be at once
combated by the administration of strychnine as above.
I desire to acknowledge my indebtedness to Mr. Hancock,
Anatomical Curator, for the admirable dissections which he has
made, and lent for the purpose of the demonstration.
[The methods of inducing local anaesthesia were then demonstrated,
by means of skulls and dissections, upon the epidiascope.]
DISCUSSION.
Mr. C. S. Morris : I have nothing new to add to the discussion. I came
here rather to learn, particularly about regional anaesthesia. I have never done
regional injection, but have done intra-alveolar and submucous injection
frequently, the former probably some thousands of times. I prefer the sub¬
mucous method wherever it is possible. It is not so rapid npr so certain in
my experience, but it is less disturbing to the patient. Absorption is slower,
and therefore general effects are not so noticeable. b Intra-alveolar injection is
very rapid indeed in its effect: as soon as the needle is withdrawn one can
commence to operate with certainty. With regard to strengths of the drugs
employed I prefer a 1 per cent, solution of novocain for the intra-alveolar and
2 per cent, for the submucous method. The stronger the solution the greater
6 Doubleday: On Local Anaesthesia in Dental Operations
the toxic effect, and the more the after-pain ; this is probably due to a
temporary partial paralysis of the nerve-endings in control of the arterial
walls producing a passing state of artificial inflammation. Some patients,
however, seem to have practically no pain, though they always notice
a sensation of heat. The denser the bone in intra-alveolar anaesthesia the
greater the after-pain. It has been observed that patients are less easily subject
to toxic effects after meals—that it is just as necessary to give a local anaes¬
thetic on a full stomach as it is a general anaesthetic on an empty one. The
only thing I should like to add is that early morning after breakfast is not a
good time, or certainly not* as good as after luncheon or after tea.
* . *
Mr. G. PATON Pollitt : Has Mr. Doubleday found it advantageous to
alter the strength of'the novocain solution used? and has he found the
novocain vary to any extent since the war m its properties? Personally,
I find it desirable to use three E tablets in 2 c.c. saline in order to get a rapid
and complete anaesthesia. I have not seen any bad effects when using this
strength.
Mr. F. N. DOUBLEDAY (in reply): I am glad that Mr. Morris has called
attention to the importance of giving a local anaesthetic after a full meal. It
certainly lessens the toxic effects considerably. I found that novocain went off
considerably in quality soon after the beginning of the war, but it has very
much improved since.
Section of ©Dontoloas.
President—Mr. G. G. Campion, L.D.S.Eng.
A Short Review of another Year’s Work at a Jaw Injuries
Centre . 1
By George Northcroft, L.D.S.Eng.
Another year of war has passed since our last President expressed
the opinion that reports of the work done at the various Jaw Centres
would prove useful and stimulating, forming data on which both the
administrator and clinician might base their organization and treatment
respectively.
It is, therefore, proposed to analyse the further figures obtainable
from another year’s'work at the Jaw Injuries Department at No. 1
General Hospital with the hope that any conclusion arrived at may
prove useful to the now large body of men interested in this subject.
The total number of cases registered, as seen from July, 1916, to
October, 1918, amounts to 554, exclusive of the ordinary dental cases
seen by the commissioned officers attached to the department. Of these
seven have died, fifty-eight have been transferred, 398 been discharged,
and ninety-one are still under treatment.
Our ratio of mandible to maxilla cases and of mandible to mandible
and maxilla cases differs somewhat from our earlier figures. It may be
remembered that Lindemann gives the figures as 5 : 1 : 1. Our former
figures were 5 to 1 and 8J to 1 respectively. Our present figures show
a proportion of 4$ to 1 and 9J to 1, which means we have seen more
fractures of the maxilla and fewer of both mandible and maxilla.
At a meeting of the Section, held October ‘28, 1918.
8 Northcroft: A Years Work at a Jaw Injuries Centre
Only one out of the seven deaths that occurred was in any way
directly connected with the work of our department. This man died of
septic pneumonia, and he had a general anaesthetic and several septic
roots removed in order to clear up the very foul condition of his mouth.
It is an open question whether he would not have succumbed in
any case.
In many of the fifty-eight cases transferred treatment had already
been commenced. It seems a pity that some scheme cannot be devised
to lessen this lack of continuity in treatment which exists in military
service.
Of the 398 men now discharged forty suffered from fractured teeth
and alveolar process only, thirty-two have been treated for old standing
trismus and other jaw conditions, and it is difficult to gather whether
some of these cases had had a breach of continuity or not. In twenty-
one cases there was no jaw injury.
Seventeen out of the remaining 305 were discharged without
obtaining bony union. The seventeen cases were supplied with
mechanical appliances, greatly ameliorating the patients’ unfortunate
condition, and enabling them to exist on a modified diet. Twenty
bone-grafts have been inserted. It is too early as yet to speak of
the results of all the bone-grafts, but they promise well, and 50 per
cent, have already been discharged with firm and efficient bony union.
It is interesting to note that Mr. Percival Cole’s and our own
earlier figures proved that 10 per cent, of the cases failed to obtain
union without the resort to bone-grafting. Our new figures show an
increase to 12 per cent., this being probably due to the severity of
several of the cases we have been called upon to treat.
It must be understood that in some of the ununited cases the jaw
was in such a bad condition as to render the successful insertion of
a bone-graft so doubtful that even the daring of our surgeons had to be
tempered with caution. Other cases were complicated by the general
physical condition of the patient, and in others, unfortunately, the
patient refused operation, which was certainly a pity considering what
good results our surgeons obtained as a general rule. One man, having
lost the use of his tongue, it mattered little in his case whether the
remaining fragments of the jaw were united by fibrous tissue or bone
as no bolus of food could be manipulated.
The time factor is a very difficult one to estimate ; an average of
four weeks may be deducted from the total weeks in hospital in order
to arrive at a general idea of the length of time these cases take.
Section of Odontology
9
Many cases are not discharged from the Jaw Injuries Department until
after plastics have been completed, in case any alterations have to be
made to their dentures. This greatly increases the average time a
man with a fractured jaw remains in hospital. On the whole, one
obtains the impression that the ordinary gunshot wound takes some¬
what longer to heal than a civil fracture and averages from eight to
twelve weeks : patience on the part of the patient and operator is
rewarded, however, by excellent results after much longer periods.
I am inclined to think that if a period of twelve weeks is much
exceeded, with few exceptions, it is wise to contemplate the invaluable
co-operation of a sympathetic surgeon.
One point that has struck me as important in going over our
records is the necessity for unifying the form of discharge. I cannot
help thinking that a printed form should be issued to all Jaw Centres
to be filled in with such details as to make it available as a “ specialist’s
report ” for the subsequent use of the Pensions Ministry.
N —(Sa
Section of ©OontolOG^.
President—Mr. G. G. Campion, L.D.S.Eng.
On the Nerve End-cells of the Dental Pulp . 1
By J. Howard Mummery, D.Sc.(Hon.), M.R.C.S.
[To be published in the Philosophical Transactions .]
(ABSTRACT.)
(Mr. Mummery gave a lantern demonstration on this subject,
accompanied by the following remarks.)
In former communications I have described the distribution of the
nerves of the dental pulp to the dentine, and I hope I have demonstrated*
to you satisfactorily that nerve-fibres actually enter the tubes of the
dentine in company with the dentinal fibril, and are distributed within,
the hard tissue of the dentine.
I had thought, and the same conclusion was arrived at in the more
recent researches "of the late Professor Dependorf, that these fibres
passed from the plexus beneath the odontoblasts to the dentine without
any further important re-arrangement within the pulp, a large number
being distributed to the odontoblast cells around which they formed a
plexus or enveloping network.
At the end of last year modified methods of investigation showed
me that the whole question of the distribution of these nerve-fibres had
not been completely worked out and some new and surprising facts
were brought to light which I will shortly explain to you. This last
investigation was embodied in a paper read before the Eoyal Society
in May last.
The neurofibrils which arise from the axis cylinders of the
medullated nerves of the pulp, pass into a plexus beneath the odonto¬
blasts, but at the lower margin of the odontoblast layer, the fibres of
ja—10
1 At a meeting of the Section, held November 25,1918.
12 Mummery: On the Nerve End-cells of the Dental Pulp
this plexus are connected with a definite layer of nerve-cells. These
cells are more or less stellate in form, with a clear nucleus. They are
arranged in groups, situated at fairly even distances from one another.
The cells have two sets of processes, which, as in the cells of the
central nervous system, must be termed “ axons ” and “ dendrons.”
The branched processes or “ dendrons,” which arise chiefly from the
lower part of the cell, communicate by synapsis with the fibres of
the deep plexus, and they also give off fine divisions which surround
the odontoblasts, while from the distal end of the cell a long unbranched
process or " axon ” is given off which passes direct to the dentine and
enters the tubule in company with the dentinal fibril.
This whole investigation has occupied a great many years and it is
only by gradually advancing steps that one has been able to arrive
at the true explanation of this much debated problem, but I think it
will appear that we have now reached a more definite solution of it,
at least so far as the histological part of the problem is concerned.
The chief point which remains to be cleared up is, what portion of
this nerve distribution consists of trophic fibres and what of purely
sensory fibres ? We know the dentine and the pulp are sensitive, and
that, as Langley has shown, there are present in association with
medullated fibres some non-medullated fibres forming the autonomic
system, “including not only what has hitherto been known as the
sympathetic system, but also other nerve-fibres—distributed to the
visceral and vascular systems ”—and to secretory glands.
This mode of distribution of the nerves of the tooth is altogether
unexpected and remarkable, for we appear to have a distinct “nerve
end-organ ” from which the dentine is supplied with sensory fibres and
a sensory “ nerve end-organ ” or “ sensory neuron ” is not known in
any other part of the body. Sensory nerves are described either as
ending in ramifications of the axis cylinder and its ultimate fibres which
terminate between the epitheliunl cells of the sensory surface, or in
special organs, as the tactile corpuscles and Pacinian bodies which are
composed of the connective tissue sheath of the nerve-fibre. In the
nerve-cells of the pulp we have however apparently a peripheral sensory
end-organ from which the final distribution takes place. It appears to
be, as an eminent authority says: “ the interpolation of a neuron at the
peripheral end of a sensory neuron, an unheard of thing until now.”
However anomalous such a mode of distribution may appear to be,
I think there can be no escape from the evidence that such an organ is
present in the teeth of man.
Section of Odontology
13
Bone-grafting in Ununited Fractures of the Mandible, with
Special Reference to the Pedicle Graft . 1
By Percival Cole, F.R.C.S.Eng., and Chas. H. Bubb, L.D.S.
(ABSTRACT.)
[Full text in the British Medical Journal , January 18, 1919, p. 67.]
The evolution of the bone-graft as applied to ununited fractures of
the mandible is a matter of considerable interest. Since the outbreak
of war orthodox opinion has undergone a radical change. The extent
of this change can be gauged by the perusal of the Proceedings of this
Section.
As to the number of ununited fractures existent information is
very scant, but certain figures are available. Northcroft had 10 per¬
cent. non-unions in his series, Forty had 16 per cent., and we,
counting all types of cases, had 11 per cent. It may fairly be estimated
that non-union occurs in approximately 10 per cent, of all mandibular
fractures. If this be so, the number of ununited fractures must be
considerable, for over 1,300 cases have been treated at the King George
Hospital alone. That non-union can only be remedied by operative
measures is an admitted fact. It is on that account that we have
brought for your inspection every available case, irrespective of
their condition or the date of operation. These cases number twenty-
three, and include nineteen pedicle grafts and four free transplants.
In addition, cases have been shown which are regarded as suitable
for one or the other of these grafting operations.
The proportionately large number of pedicle grafts will be noted.
We have employed this method in thirty-four cases. Free transplants
have been employed in twelve cases only. The latter method is only
adopted when a pedicle graft cannot be utilized. The pedicle graft
operation has been described in previous communications. We propose
briefly to summarize the conditions our experience shows to be neces¬
sary to permit of the performance of a pedicle graft operation.
ja— 10a
1 At a meeting of the Section, held November ‘26, 1918.
14 Cole and Bubb: Bone-grafting in XJnunited Fractures
(1) Site of Fracture .—The loss of tissue must implicate the hori¬
zontal portion pf the bone—that is, the lesion must be situated at or in
front of the angle.
(2) Size of the Gap .—This should usually Dot exceed 4 cm. In
favourable circumstances it is possible to cut a thick, well-nourished
graft of 6 cm. in length, and a gap of 5 cm. (before trimming) may thus
be dealt with, if end-to-end union is resorted to.
(3) Condition of the Soft Parts .—It is necessary that the tissues of
the submaxillary triangle should'be free from scar tissue on the side
from which the graft is to be cut. It is extraordinary how frequently
this area escapes even when the soft tissues of the face are extensively
damaged.
As stated, thirty-four cases have been dealt with by this method. In
twenty-three the result is known, and of these twenty-one, or over
90 per cent., have been completely successful. In the two remaining
cases the patients are thoroughly satisfied, but we could only regard then-
condition as considerably improved : they are counted as failures in the
appended table of results. The pedicle graft operation permits of the
utilization of a portion of living bone, possessed of its own blood supply
passing to it from a natural musculo-fascial pedicle. Free transplants
are only employed when conditions do not permit the ’'use of a pedicle
graft.
Of our own twelve cases, the result is known in ten, and of these,
seven have been completely successful: this gives a percentage success
of 70. Splints are removed in from three to six_ months. Progress is
slow, and firm consolidation cannot be expected in less than from six
months to a year. The position as regards all cases of non-union dealt
with by us may be tabulated thus:—
Nature of operation
Number of cases
Result known
Failure
Success
Plating
2
2
2
0
Wiring
20
20
i
19
Pedicle graft
34
23
2
21
Free transplant
12
10
3
7
Operation abandoned
3
3
3
0
Totals
71
58
11
47
(19 per cent.) (81 per cent.)
No selection whatever has been exercised: we have operated on
every case submitted to us. It will be noted that the balance is heavily
weighted against ourselves. Thus three cases are counted as failures, in
Section of Odontology
15
which the physical conditions found.by exploration rendered in our
judgment any further steps impracticable. Again, “ no improvement "
column has been included, though in most cases improvement has been
considerable. In no case has the patient's condition, general or local,
been adversely affected by operation. Finally, there has been no
mortality and ijo complication of a nature to cause alarm.
DISCUSSION.
Captain FRANK J. Tainter, M.C., U.S. Army : Transplanting bone is now
an established surgical procedure. The success, however, varies in proportion
to the ultra-aseptic technique adopted, and the condition of the parts—
which are not always what is desired—following the severe injury which
necessitates this major procedure. As a matter of fact, we know that tissues
harbour infectious products for great lengths of time; these may never become
pyogenic until after they have been disturbed by surgical trauma, or by the
introduction of foreign bodies, as, for instance, free bone-grafts. There is
perhaps no other part of the body which lends itself so badly to the implanta¬
tion of dead bone-grafts as do the lower jaws. This, of course, is due to
the wound previously being bathed, day and night, with all forms of bacteria.
It is quite obvious that where we have a choice, if we can fill in the defect
with a bone-graft, supplied and nourished by its own blood supply—in short,
a live bone-graft—this borders on the ideal, and should always be used.
I have done the pedicle graft operation myself in eleven cases, and have been
struck by the great vascularity of the pedicle. The pedicles, without exception,
have all consisted of one or both anterior bellies of the digastric with platysma
and cervical fascia. In one case of my series I was amazed to find a very large
amount of bleeding from an artery in the bone after it was detached from the
lower border of the mandible ; I have been attached to Mr. Cole’s clinic quite
long enough to note the ultimate results in his cases. Operation had to be
abandoned in several cases because there remained so little of the ramus, which
was drawn up out of reach. Mr. Cole, in his modesty, has classed these cases
as failures when, in fact, they should not have been. The results have been so
brilliant that I feel I have something good to take back with me to the States
for our unfortunate boys who must be repatriated in the beftt possible con¬
dition in which we can place them. Mr. Cole has spoken to the profession
the last word on this subject of jaw restitution for bony defects.
Major H. P. PlCKERlLL, N.Z.M.C. : Mr. Cole's patients show good func¬
tional results which may improve in time. Bone-grafting is not necessary in
all cases of ununited fracture, as numerous patients have grown their own
grafts under physiological stimulus of function in healthy tissues. Indis¬
criminate extraction of teeth is bad, but equally so are curetting and numerous
16 Cole and Bubb : Bone-grafting in Ununited Fractures
sequestrectomies. The vitality of the mandibular bone is such that the majority
of fragments can be saved provided dead spaces be eliminated and frequent
irrigation carried out. I doubt the practical utility of the pedicle, and almost
always use a tibial free graft, the size and shape of which is consistent with
the size, shape and mechanics of the mandible, and secures better permanent
results, especially as regards eating.
Section of ©Oontoloap.
President—Mr. G. G. Campion, L.D.S.Eng.
Intra-oral Skin-grafting: The Establishment of the
Buccal Sulcus . 1
By H. P. PiCKERiLt, M.D., M.D.S., Major, N.Z.M.C.
(Officer in Command , New Zealand Section, Queen's Hospital, Sidcup.)
It is necessary that there should be adequate buccal and labial
sulci in order that both the jaws, lips, tongue and cheeks should
perform thejr natural and proper functions of both mastication and
speech.
It is also necessary that adequate sulci should exist in order
that functional artificial dentures may be worn. The obliteration of
buccal sulci means unstable dentures, since it is largely upon the grip
of dentures upon the external surfaces -of the alveolar processes that
the stability of artificial dentures depends.
It is also recognized that the persistence of a hypertrophied frenum
labii is a frequent cause of separation of the two upper central incisors.
In the same way I think the dense adhesions one so frequently sees
between lips or cheeks and jaws obliterating the sulci are frequently
causal factors in preventing or delaying firm osseous union from taking
place.
Obliteration.
The buccal and labial sulci may become obliterated either actually
or relatively from general causes, the chief of which are :—
(a) Excessive atrophy of the alveolar processes. As is well known
this occurs as a result of the prolonged infection and suppuration of
At a meeting of the Section, held December 9, 1918.
Pickerill: Intra-oral Skin-grafting
18
chronic dental arthritis ; 1 it also occurs from prolonged disuse of the
alveolar processes ; lack of the stimulus of function transmitted either
through natural or artificial teeth leads to a corresponding atrophy of
the process, and thus to a flattening out or relative obliteration of
the sulci.
(b) In civilian dental practice it is well known that local oblitera¬
tions of the sulci in the form of hypertrophied buccal and labial
frena cause much trouble in the stabilizing of artificial dentures.
(c) Ulcerations, due to alveolar abscesses, ulcerative or gangrenous
stomatitis also occasionally obliterate the buccal sulci, owing to
adhesions forming between the cheek and jaw in the process of
healing. Under this heading may also be included the effects of
severe burns and corrosive fluids.
(d) Gunshot wounds .of the jaws as seen during the present war are
almost invariably followed by adhesions more or less great between the
lips and cheeks and the jaws, obliterating the buccal sulci, rendering
plastic restorations of the lips in particular frequently abortive, and the
wearing of any artificial prosthesis either impossible or extremely
inefficient and uncomfortable.
Treatment.
Until recently the methods of treatment of this condition have
been, in my opinion, more or less unsatisfactory. The methods which
I have employed have been the following :—
(1) Preventive. —In a certain number of cases the early use of
“ shields ” of vulcanite or metal may prevent adhesions forming, but in
severe cases will not prevent subsequent contractions from taking
place.
(2) » Stretching. —For this some arrangement of rubber-covered
springs resting on the adhesions or the obliterated sulci is necessary,
or padded vulcanite shields may be inserted, and the size of the pads
periodically increased. This method, however, is slow, tedious and
ineffective except in trivial cases. Moreover, stretched scar tissue
always tends in time to contract again (unless constant pressure is
kept up).
( 3 ) Simple Division of the Adhesion and so the Immediate Estab¬
lishment of a Buccal or Labial Sulcus. —This appears quite simple, and
at the time may appear to give an excellent result, but one is left with
1 I prefer this term to “ pyorrhoea v as being more correct anatomically and surgically.
Section of Odontology
19 .
a raw ulcerating surface, which will inevitably contract, and thus
recurrence is absolutely certain.
(4) Flap Method. —In order to obviate some of the above objections,
about eighteen months ago I devised a method of raising a flap of
mucous membrane from the cheek, and having made a sulcus by
incision and curetted the alveolar bone, planting the flap down on the
raw bone area and holding it there with a prosthetic appliancte, the raw
area in the cheek being closed as far as possible with sutures. This
method gave' greatly improved results, but was not entirely satisfactory
on account of some contraction occurring in the cheek.
(5) Epithelial Inlays. —This method as practised by Essex and others
on the Continent, and at this hospital by Major Gillies, consisted in
endeavouring to establish a buccal sulcus by approaching the obliteration
from the exterior of the lip or cheek, and thus doing an aseptic skin-
graft operation. This was a considerable advance, and was the first
attempt to obtain a definitely skin-lined sulcus as far as I am aware.
The disadvantages of this method are: (a) The extreme difficulty of
establishing the skin-graft evenly in close proximity to the buccal
mucous.membrane when working from the outside. Thus when the
operation is successful, it is more of a pocket than a sulcus which is
formed. ( h) The frequency with which such inlay operations suppurate,
and thus produce additional scarring on the face, necessitating further
operation at a later date to remove the scars.
With the above experiences it was but a short step to the next stage
— intra-oral skin-grafting. I argued thus: (a) the establishment of a
sulcus by direct incision undoubtedly gives the best-shaped sulcus; (b)
my buccal flap operation would be quite satisfactory if contraction in the
cheek could be prevented, and if sufficient tissue were always available;
(c) skin-grafts frequently “ take ” even when bathed in pus for many
days; (d) the superficial cells of the epidermis, which compose a Thiersch
graft, must have a very high resistance to surface organisms, and are
able to live in spite of their presence, or organisms would penetrate a
skin surface, and severe ulcerations from trivial injuries of the skin
surface would be common; (e) I have observed in other skin-grafting
operations that pressure, even and continuous—the obliteration of dead
spaces—seemed to be the most essential factor for success.
I therefore determined in February, 1918, to try the skill-grafting of
a re-established buccal sulcus directly into the mouth and under pressure.
I was extremely gratified by immediate success,,and have continued to
use the method ever since, and no single case has failed. Some have
20
Pickerill: Intra-oral Skin-grafting
been better than others, bat the fault where there has been one, has
been mine, due to insufficient or insufficiently continuous pressure.
Given accurate technique, the establishment of the sulcus and the skin-
grafting of its surface will be certain in every case. The method of
procedure is as follows:—
(a) When Adjacent Teeth are Present .—In this case I prefer to
have an appliance similar to a dental splint, constructed previously,
carrying an arm attached by screws to the “ splint.” To the arm is
attached a perforated shield, which will approximately fit in the sulcus
when established. An incision is made dividing the “ adhesions,”
b
c
cl
Fig. 1.
A, alveolar process; B, lip or cheek; C, obliterated sulcus ; D, adhesions
divided'; E, composition impression covered with skin graft in situ ; F, sulcus
established, covered with epithelium on both surfaces.
keeping the knife close to the bone. Bleeding is arrested. The shield
is covered with modelling composition and an “ impression ” obtained
of the raw area of the sulcus. This is removed. A Thiersch skin
graft is cut from the arm (or leg) and placed raw surface upwards
upon the impression of the sulcus: it is smoothed down flat and
passed up into place and the arm secured by the screw provided. Thus
the skin-graft is pressed evenly into all the unevennesses of the sulcus,
and maintained there with constant pressure.
(6) When no Teeth are Present .—In this case the procedure is the
same in all particulars except that I ligature the “ impression ” into
Section of Odontology
21
place and maintain it there with circumferential silk-worm gut ligatures
in the lower jaw or by passing sutures through the palatal muco-peri-
osteum and cheek or lip in the upper jaw.
There is another class of case in which I have found this method
useful. Private H. was admitted to this hospital with an old united
fracture of the jaw, but with elevation of the posterior fragment, so that
the upper molars (three) impinged upon the muco-periosteum of the
mandible (edentulous posteriorly), thus rendering the fitting of a lower
Diagram of appliance to hold composition in place when teeth are available.
C
Diagram of method of retaining composition when no teeth are available.
A, aw ; B, lip ; C, composition reinforced with sheet pewter; D, circumferential
ligatures; E, tied externally over pad soaked in tincture of benzoin.
denture impossible. I am aware that some would advise the extraction
of the upper molars, but not being an advocate of the unnecessary
sacrifice of teeth, I proceeded as follows with very satisfactory results.
The elevated alveolar process of the mandible of the left' side was
resected. This of course produced a “ relative ” obliteration of the
buccal sulcus, which would probably have become progressively worse.
22
Pickerill: Intra-oral Skin-grafting
So at the same operation I deepened the buccal sulcus by incision, and
implanted a skin graft on the raw areas. The composition was held
by an appliance attached to the incisor teeth. The graft took excel¬
lently, and the patient now has perfect function with a partial lower
denture.
Remarks.
General or local ansesthesia may be used as indicated in each
particular case.
The composition I leave in position for ten days, and then remove
and replace at once by a prosthetic appliance—i.e., permanent or
temporary denture or vulcanite shield.
The method has yielded such uniformly good results to all who
have used it, that I think its use should be made widely known to all
those dental surgeons who are engaged in treatment of gunshot
fractures of the jaw. I think, moreover, that in civilian practice this
procedure will be of not inconsiderable use and advantage in a great
number of cases.
Section of ©fcontologj).
President—Mr. G. G. Campion, L.D.S.Eng.
Food Deficiencies as a Factor influencing the Calcification
and Fixation of the Teeth . 1
By F. M. Wells, Major, C.A.M.C.
I cannot lay claim to any special knowledge of these accessory food
factors or so-called “vitamines.” In fact I have only a very superficial
and inadequate acquaintance with the various and varying theories that
have been held on this subject.
The problem of so-called “ vitamines ” has of late years received an
increased amount of attention; and an abundance of facts which seem
calculated to enlarge our conception of the dietetic value of foods is
forthcoming from very different sources. The investigations made
have shown that satisfactory growth of nutrition cannot be maintained
upon a diet containing protein, fat, carbohydrate, salts and water, but
that, in addition, certain other essential constituents are necessary,
about which as yet, very little is known. These are known as accessory
food factors or “ vitamines ” : they are present in a very small amount
in most natural foods, and though their chemical nature is unknown,
healthy life is impossible in their absence.
The diseases that are known to be produced by defect of these
accessory factors are beri-beri and scurvy, others which are believed
to be caused by defect of accessory factors but of which the proof is
incomplete, are rickets, sprue and pellagra.
Before proceeding with the experimental part of the work done by
Dr. Zilva and myself, I will give a short review of the work on scurvy
and rickets and a few of the many theories that have been advanced as
to the cause of the rapid increase of tooth decay.
a—8
At a meeting of the Section, held December 9, 1918.
24
Wells: Food Deficiencies
The aetiology of beri-beri is well understood to-day, but as this
disease is not endemic in this country and rarely occurs in infants, and
as far as I know causes no dental disease, it is not to our interest
to discuss it here to-night.
Thrush or “ sprue ” is interesting to dentists, but as yet I know of
no scientific work done on this disease.
Scurvy is not a new disease, as some people are led to believe.
A description of scurvy is to be found in the narrative of the campaign
of the Christian Army in Egypt under Louis IX, about the year 1260.
The historian, of that crusade was not only eye-witness of the disease in
others but was himself attacked by it. He speaks of the debility and
tendency to swoon, black spots on the legs, bleeding from the nose,
and the livid and spongy condition of the gums, &c. The barbers
used to go around trimming the gums of the sufferers. Scurvy has
unquestionably existed in the north of Europe from the most remote
antiquity. That we have no mention of it in the early history of the
northern nations must be imputed to the ignorance of the people,
especially as regards medicine.
Well-marked, so-called florid, scurvy among infants was not an
uncommon occurrence about the period 1875-1900, when artificial
feeding was popular and patent foods were enthusiastically adopted.
At the present day it is probable that mild incipient scurvy is more
common than is usually believed. This condition is solely due to the
rapid increase of artificial feeding of infants. Obscure though the
exact aetiology of infantile scurvy may be, it is probable from clinical
facts that this affection arises from causes distinct from those that
produce rickets. Almost all that is known of the pathology of scurvy
amongst infants is due to the investigations of Sir Thomas Barlow
and Professor Still, of the Great Ormond Street Children’s Hospital,
London.
In adult scurvy we have conclusive proof that the prolonged
deprivation of fresh vegetables, or their equivalent, is certain to bring
about a scorbutic condition. We are also sufficiently familiar with the
fact that proprietary infant foods do not contain the accessory factors
that are necessary to prevent scurvy. It has been demonstrated
experimentally that those accessory factors which prevent scurvy are
contained in human milk and in the milk of the cow, but not in large
quantities, and they are destroyed by the process of heating to a degree
dependent on the time and temperature of heating. It is clear then,
and fair to say, that the further we get from a natural food which is
Section of Odontology
26
consumed in the raw condition, like the mother’s milk, the more
frequent will be the risk of the disease. Dried milk contains less of the
antiscorbutic factor than raw milk.
The age at which we should be on .the qui vive for the initial
symptoms of scurvy, is about the eighth month of infantile life.
It is exceptional for the symptoms.to appear earlier. This point is
of considerable importance in diagnosis. Professor Still’s clinical
picture of the fully-developed disease is striking enough; an infant
which has been fed upon one of the patent foods, with or without milk,
or on milk which has been condensed, sterilized, or otherwise altered,
has been ailing for some weeks, has taken food badly and probably lost
weight. Moreover, the mother says it cries whenever it is touched,
and, as she puts it, “ has lost the use of its limbs.” The infant is pale,
it lies quiet perhaps until it is approached, when it cries out in obvious
dread of being touched; the legs lie motionless, usually with the thighs
slightly abducted and averted and the knee slightly flexed ; the arms
are less often affected. Thqre may be some swelling of part of one or
other of the limbs, obliterating the natural curves. Any handling
of the affected limbs causes a piteous cry, evidently of acute pain.
If teeth are present the gums around them are swollen and purple,
occasionally projecting like a mass of granulations almost completely
hiding the teeth, and bleeding readily when touched. The urine
is perhaps smoky, if not red with blood. Such in outline is the
characteristic picture of infantile scurvy.
Rickets is believed to be a disorder of nutrition, and as such affects
the whole system. The bone changes.are only part of a general disease.
The child may suffer severely and yet show so slight a degree of rachitic
change in the bones that if only the osseous system were considered the
disease might almost pass unnoticed. The temperature is normal, even
during the most active stage of the disease. A rise in temperature is
almost always due to some complication. There is little to be said
in favour of an infective origin. Rickets amongst children in the
British Isles has grown to a very alarming state. From 50 per cent,
to 80 per cent, in London clinics show signs of rickets to a more or less
marked degree. It is found in the Dominions to a less extent, hut it is
quite common.
Symptoms .—Delayed dentition is one of the most constant symptoms.
It was found in thirty-two out of forty-two consecutive cases of
rickets between nine months and three years old. Frequently no
teeth have appeared at the end of the first year. Rarely their
26
Wells: Food Deficiencies
appearance is delayed beyond the peripd of eighteen months. If
dentition has begun before the onset of rickets, it is often arrested
for several months. ’ There is a striking tendency to very early caries;
even before the tooth is fully cut the enamel at the cutting edge is
often completely destroyed. Amongst other symptoms and signs are
sweating of the head during sleep; large protuberant abdomen;
reluctance or inability to stand, which makes the child late in learning
to walk; the softness of the bones and ligaments, which makes the
bones bend and the joints yield, with resulting bandy-leg, knock-knee,
or other deformity, stooping curve of the spine; large size of the head,
which is square shaped, with all the tendency to convulsive disorders
and to catarrh of the respiratory and alimentary tract, adenoids, chest
affections, indigestion, &c. The most prominent symptoms, no doubt,
are those that affect the bones, but in rickets there is a general
disturbance of metabolism and its effects are not limited to any one
tissue of the organism. Until a cure is effected the disease prevents
satisfactory nutrition of the bones and teeth, stunts aind deforms the
bones of the face and jaws, &c.; and the damaging results are in
evidence throughout the whole of the patient’s life, even after recovery
from the disease itself. This great affliction, which appears to become
more common every day, if not altogether prevented, can easily be
remedied, if the baby is started from the outset on a proper diet, which
is the mother’s milk and which every baby needs. If the conditions
are such that the baby is prevented from getting its proper diet and
has to be artificially fed, too much care cannot be exercised in watching
its progress for the first eighteen months, especially in regard to the
weight of the infant. The early stages of scurvy and rickets are
almost impossible to diagnose and a baby that has to be fed on an
artificial diet should never be allowed the use of a teat or “ dummy ”
as the diseased condition of the bones, caused by imperfection in
nutrition, with constant suction of a “ dummy,” will rapidly produce
badly developed jaws and nose, followed by adenoids, nasal ob¬
struction, irregular articulation of the teeth, mouth breathing, and
the whole train of evils to which this condition gives rise. It is
important that a baby’s weight should be kept normal. Rickety babies
usually appear to be fat. If the disease is to be checked before serious
harm is done to the child, the early signs must be recognized as soon
possible. The first symptoms appear in pain from teething. (Painful
teething in children is just as much a disease as any other baby
ailment.) The second symptom is late dentition. (Every baby should
Section of Odontology
27
have at least two teeth between the sixth and seventh month.) If the
child shows these signs rickets should be suspected. It is amazing that
these evils are known to exist, and it has been pointed out that they are
due solely to improper diet, and yet medical men will allow mothers,
who are quite capable of suckling their infants, to feed them on
artificial foods and so deprive the infant of its heritage. Perhaps the
fault lies in not having absolute scientific evidence to show that a
faulty diet is the direct cause of improper fixation and calcification
of the hard tissue.
Now we will take up some of the most important theories that have
been advanced during the past fifty years, as to what is the cause of the
rapid increase of tooth decay. Miller’s “ chemico-parasitic theory,”
which accounts for the phenomena of caries of the teeth, does not
explain the rapid progress made in the increase of dental caries accom¬
panying civilization in the past hundred years. In view of the fact that
the incidence of dental caries has been greatly on the increase especially
in the past fifty years, it would seem obvious that our present mode of
treatment of dental caries has been radically wrong, that the judgment
of time and experience have alike condemned it, and that such measures
as are now in vogue have proved futile to arrest the progress of what
has become the most prevalent disease of civilized communities.
Heredity .—I have no intention, for I have not the necessary
knowledge, to express an opinion on heredity. The only information
that is at our disposal in regard to this theory is statistics of family
history, which appear to throw very little light on the subject.
Chemical analysis of our teeth has yielded us so far little or no
information, and biochemistry is, as yet, still in its infancy.
To what extent do “ vitamines ” affect the enamel ? We do not,
at present, know how far differences in their action may modify the rest
of the tooth, but the connexion which appears to exist between the
enamel and the odontoblastic cells is direct; if this is not so I should
call it an “ inborn error of metabolism.” I know that I shall be
severely criticized by my friend Mr. Mummery, and very generally by
all of the leading dental anatomists, who state, as I understand it, that
when the enamel is once formed it is formed for good, but strong reasons
have convinced me that this belief is not based on such sure grounds as
is generally supposed.
I made a trip to Scotland last month with a view to studying the
diet conditions in the Highlands and Lowlands. I have always been
led to believe that the Highland Scotch had better bones than are to be
28
Wells: Food Deficiencies
found in any part of the British Isles, and I thoroughly believe they
have. This is largely accounted for by their simple diet of natural
foods. Up to a few years ago the Highlanders’ meals were very simple.
Their breakfast, consisted of brose at 6 a.m. Brose is made by pouring
boiling water over oatmeal, stirring all the time, and adding a little
salt. It was eaten with milk, syrup or treacle, with some butter.
The next meal was between 11 and 12 o’clock, which consisted of
potatoes and salt herring. No bread was eaten, but for the second
course a bowl of milk and a piece of oatcake were taken. This was a
universal dinner all through the North of Scotland. The next meal was
at about 6 p.m. Again brose, but as a variation it was made with
boiling milk, instead of boiling water. Between the mid-day meal and
supper a glass of milk was taken, and in later years tea came in.
The only variation from this diet was on Sundays. Breakfast was
usually later and dinner, which consisted of boiled cabbage and turnips,
was served after church. For supper on Sunday there were boiled
potatoes and fresh fish, and sometimes pork, but the pork was very
sparingly used, as one pig had to last a family for the whole of the
winter. Beef was rarely eaten.
Rickets is unknown to Dr. Bremner, of the Department of Public
Health for the County of Sutherland. He told me there has not been
a case in his district. He also stated that the proportion of artificially-
fed inf&nts was practically nil. A mother looked upon it as a disgrace •
if she was unable to feed her child, and it is only recently there has
been a small amount of hand feeding in the coast towns where the
women are compelled to hawk their fish and render other duties,
which make it impossible for them to breast-feed their children, but
away from the coast there is practically no artificial feeding.
A remarkable thing among the old type of fishermen to-day is that
there is hardly any decay in the teeth of men of 70 to 80 years of
age, but the young generation has quite a considerable number of
decayed teeth.
The following is a little incident which I would like to relate. I
happened to call on a very intelligent old lady, aged 81, and after a
short conversation with her relating to the subject of my trip, she
immediately told me that the curse of the Highland Scotch to-day
is tea. All the crofters or poor farmers keep the teapot going' from
morning until night, and are sipping tea all day long. I remarked that
she had a very good set of teeth, and she told me that she had lost one
tooth through an accident, and that she had never had a toothbrush in
Section of Odontology
29
the house. I might state here that a toothbrush was hardly ever known
among the last generation of the Highland Scotch. However, I will
refer to the toothbrush and its uses later on.
Dr. Bremner gave me a large amount of valuable information in
regard to his examination of the men for the Army and Navy from his
district. He found that all the men over 20 years of age and up to
45 had exceptionally good teeth; as they advanced in years their
teeth showed wear but no decay, but there was a vast difference in the
teeth of the men under 20 years of age. I asked him what he thought
it was due to, and he said he thought it was due to nothing else except
to the rapid change in the diet. He also stated that there is an increase
in tuberculosis, due to the same cause. The crofters are taking to
artificial foods and discarding Ihe natural foods. The oatmeal and
potatoes are being exchanged with the grocers for white bread, jam,
syrup, and tea. These are all less valuable foods as regards content of
accessory factors. I was told by one Public Health Officer in the
Highlands of Scotland that there are a great-many families at the
present time who make two meals a day off bread and jam or treacle,
that their mid-day meal consists of potatoes and fish, and that this
class have become inveterate tea drinkers.
What a different condition presents itself in the Lowlands. I found
in the Clyde district a different type of Scotchman altogether. The
great reason for this is, to my mind, the diet of more refined foods.
The people are better housed, and sanitary conditions are better than
in the North. Pickets and scurvy in the infant are as bad in this
district as in any part of the British Isles, and* they have left their
mark on the older generation. Nearly every person is wearing false
teeth, or presents a row of decayed teeth when the mouth is opened.
The Use of the Toothbrush and Antiseptics in the Mouth.
Has oral prophylaxis been a success as a preventive against tooth
decay ? Our great army of dentists and teachers all over the civilized
world are recommending the diligent use of the toothbrush. One
dentist that I know conceived the idea that he could prevent his
patients’ teeth from decaying altogether by oral prophylactic measures.
His method was to get his patients to come to his office as often as he
thought desirable, once a week or once in two weeks, &c., and thoroughly
cleanse all the interproximal spaces. This kind of practice did not
last long, as the cavities were multiplying so rapidly that he had
30
Wells: Food Deficiencies
either to send hjs patients to another dentist or return to his general
practice. He decided on taking no chance of losing his patients, so he
went back to his general practice.
No, I do not believe the toothbrush ever prevents tooth decay. If the
enamel will not resist the action of the fluids of the mouth, the tooth¬
brush will not prevent the onset of decay on the surface of the teeth or
in the interproximal spaces. It has been found that mouths that are
immune to decay very often harbour a greater number of fermentative
bacteria than do the mouths of patients where decay is rampant. The
plain fact is, that the toothbrush is a dangerous germ-ridden instru¬
ment, which it is impossible to sterilize. It cannot be boiled, and we
have no disinfectant which would render it aseptic and not leave it unfit
for further use.
On my way back from Jena to Canada in 1904, I called on my old
friend Mr. Gilmour in Liverpool, and I was telling him about some
experiments that I had made during the summer with different tooth¬
pastes and washes that are in general use. I showed him my results
and told him how short a period the antiseptic properties of these
washes would last, and of the increased growth of bacteria over the
normal within a few hours’ time, due tt> the destructive effect of the
tooth-pastes and washes on the delicate mucous membrane of the
mouth, causing an impaired condition of the natural resistance and
thereby intensifying the growth of bacteria. In no case did the anti¬
septic action last over fifteen minutes. He then told me that he had
been watching the results of different patients of his upon whom he
could rely as being very careful to cleanse the mouth out regularly,
and that frequently they had an increased amount of work to be done
over the previous year. On turning up his records I found some of his
patients to whom he was referring were using the same pastes and
washes with which I had experimented.
For our own comfort we are bound to keep the toothbrush in use,
but it is not going to prevent tooth decay. Tartar has never decayed
teeth ; on the other hand, in numbers of cases it has, I believe, saved
them from decay. If you gather records of conditions of the teeth
extending dver a large area, you will always find the least decay where
the toothbrush is not in use, and this has been my universal experience.
We have, therefore, to look to some other source to find the true
cause of tooth decay, and I think it can usually be traced to the
improper diet of the child in infancy.
Antiseptic Washes .—The conception which prevails generally
Section of Odontology
31
among medical and dental practitioners in regard to the use of anti¬
septic washes in the throat and mouth is singularly confusing and
confused. It is credited by them with consistent and often contra¬
dictory attributes, so great is the lack of clearness and precision in
scientific work on this subject, when it approaches this topic, which
has so weighty a bearing on our daily work. I began to despair of
ever being able to get an antiseptic wash that we should be able to use
on such a delicate structure as the mucous membrane of the mouth and
throat; but through the work of Dr. Browning (of the Bland-Sutton
Institute) on flavine, we have now a wash that will act as a good
antiseptic, without causing irritation, and its retentive powers are
such that it keeps down the bacterial flora for hours, instead of a few
minutes.
Experimental.
The following account is quoted from the paper by Zilva and Wells,
now in course of publication by the Royal Society. The report is based
on histological work carried out on the teeth and jaws obtained from
considerably over 100 animals.
Method of Investigation .—For the purpose of this inquiry the lower
incisor and molar teeth of the guinea-pig were chosen. As in all
rodents, these teeth grow from persistent pulp and are never shed.
The teeth while still in situ in the lower jaw were decalcified and
sections made in an antero-posterior direction, parallel to the long axis.
In advanced cases of scurvy the teeth were apparently sound, but
useless, inasmuch as they had been loosened by the gradual absorption
of the cement membrane of the alveolar sockets, which had left that
portion below the neck ‘exposed. As a result there must have occurred
that peculiar periostitic pain, or something analogous, which follows in
the case of human patients who are suffering from shrunken alveoli.
These teeth presented, in addition, all the appearance of the changes
of senility. A great number of longitudinal and transverse sections
suitable for microscopic examination were obtained. The revelations
offered by these sections are of a particularly interesting nature. Note
the fine line of the dentine and odontoblastic cells in figs. 1 and 2 of
normal teeth as compared with figs. 3 and 4, which show sections of
teeth from animals suffering from scurvy.
Figs. 1 and 2 are of a normal tooth and give one the opportunity of
studying the histology and histo-pathology of the dental pulp in its
normal relationship to dentine. The enamel is not quite as heavy as in
32
Wells: Food Deficiencies
the natural tooth on account of the decalcifying process which has
reduced it to about half its thickness, but it gives one an excellent
example of the typical appearance of the blood-vessels in relationship
to the dentine, the fine cellular tissue and odontoblastic cells when in a
normal condition.
Figs. 3 and 4. It is obvious that the term “ fibrosis,” or fibroid
degeneration, is the only one which can with certainty be applied to
this particular form under notice. There is no doubt that it is a
specimen of degeneration and it is equally easy to eliminate those
other degenerative varieties, such as the mucous, calcareous or fatty,
which animal tissues may undergo.
The present instance affords an opportunity of examining certain
structural metamorphoses in the pulp, which are believed not to be
dependent on any inflammatory condition, but simply attendant on and
produced by altered metabolism or constitutional changes, due to the
diets.
Minute descriptions have been published of pulp nodules, calcareous
pulps, and elaborate work on ulcers and tumours connected therewith,
but this affection seems to have been unknown or overlooked by the
pathologists both in Europe and America. In no case does one find
the condition, as depicted in fig. 3, brought about by a dietetic
experiment. It is evident in this picture that in complete pulpous
fibrosis no cellular elements of any description occurred. It is clear at
once, and it is an important fact, that no trace of cellular organization,
no trace of cell nuclei, no trace of interstitial cement substances can be
found anywhere. Nerves, cells, blood-vessels and odontoblasts have
all shared the process of fibrification and are no longer recognizable.
The fine cellular connective tissue, which is but a loose mass of network
in the normal state, has either become grossly hypertrophied or quite
obliterated and its place taken by a new structure, firm and fibrous,
devoid of cells, nuclei, or any regular arrangement of constituted parts.
Figs. 3 and 4 show an advanced state of scurvy. The irregular
osteoid condition of the dentine is well marked and the different
refractive appearance of the dentine is probably due to the haemorrhagic
condition of the dentinal fibrils. In a scurvy tooth the condition
persists right up to the apex of the root; the trouble at first appears to
start in the odontoblastic cells at the top of the pulp, working towards
the apex, followed by distended blood-vessels and haemorrhage, then .
complete fibroid degeneration follows.
With the object of obtaining some insight into the condition of the
•Ktf
Section of Qddnioloqy
Fig. i
.
Lt*n#»tudu:mi fcBmon through Iferoial £unisa-pig tooth. Tbp pulp is in situ,
IVepiued hy fhu:ak:ifiert.fciou. .St 6.1 ned with. Ehrlich V :».e*d
-id times. ROdentin*; K.B.iR U^od-vcssels ; 0.0., odoutnbUsU ;
K.F., ruaiiicj
Sa£i* r*s preceding figure. Magnified 200 tijautiv 0 t *
tissue; B. f bloods
34
Wells: Food Deficiencies
teeth of pregnant guinea-pigs, I placed eight pigs, which were in a
more or less advanced state of pregnancy, on a scorbutic diet, to study
the biological relation existing between the mother and offspring.
Two of the guinea-pigs that were used for this experiment were in the
early stages of pregnancy, the remaining six being in an advanced state.
The diet given, in each case, consisted of autoclaved milk, oats and bran.
The pigs which were in the early stages of pregnancy died on the
eleventh and thirteenth day respectively, and death from intestinal
infection was suspected. Microscopical sections were made of the
embryos of both pigs, but on account of the haemorrhagic condition
and the very early stage of pregnancy, nothing could be discovered.
The six pigs that were in an advanced state of pregnancy all dropped
their young at various stages of the experiments, from eleven to fifteen
days. Microscopical sections were made of the teeth of the mother and
offspring and in every case an advanced state of scurvy could be seen.
This work has yet to be carried out more extensively, and hence it
is a little premature to make a positive statement, but the indications
lead me to believe that during pregnancy guinea-pigs are more
susceptible to scurvy than when in a normal condition.
For the past four months I have been working on rickets, but my
great difficulty has been to obtain material for histological work.
Advanced cases of rickets are not so common now as they wer.e from
1890-95, when artificial feeding of infants was at its height, and when
less was known of the contents of artificial foods. To-day if a child
enters a hospital and rickets is diagnosed, a cure is brought about in
a very short time, consequently material to be had from infants for
histological work is very rare indeed. Mr. Sidney Spokes kindly gave
me some old specimens and from these I made a great many sections,
which lead me to believe there is a great change taking place in the
enamel organ. These sections are not sufficiently clear for me to
exhibit here, as the material, from the jaw of a child 8 to 9 months old,
is very old and the sections I have made are very poor, but the results
are sufficient to show that the enamel cells are greatly deranged.
Mr. Spokes has lent me his sections which he made from the same
specimen when he first obtained it a few years ago and which is
exhibit No. 9. This work is to be further developed and I expect
within a very short time to have a considerable amount of material to
work with. The teeth were all decalcified in a solution containing
40 per cent, formaldehyde, 30 per cent, formic acid, and 20 per cent,
distilled water. This is rather a slow process, but I found it gave
Section $ Qdontolofjy
Fio. 3.
A ■saetimi of tooth o£ a ^Oft»ea-pig k»pl yn & acovfel^-ic
aU>ut fifteen: (lays. !>,, destine; E , nuaine !\ V'., pulp tissue pro|KX t Xbowfog
ilcgenetate cundUiau Magnified fO tmie.f ; to. pfeodding figure.
?, I 06 -times. tXe.pwwi fcivl stato^l ttf
O.O. r iiegoiieratC' bcJoKtubists ;. V., pulp U>wu<s proper
V
36
Wells: Food Deficiencies
better results than the more rapid method. The rapid method which
I used was to decalcify with phloroglucin and nitric acid. This process
will give very quick results but is not so efficient as the slower method..
After the decalcification was complete, sections were cut by freezing in
gum and then staining with Ehrlich’s acid hsematoxylin and eosin was
carried out.
Throughout the whole of the experimental work the earliest
alteration to be noticed takes place first in the odontoblastic cells,
in the upper part of the pulp, the decalcification gradually working
down to the apex; it is followed by dilatation of the blood-vessels and
haemorrhage.
Conclusions.
That scurvy does affect the pulp of teeth is indisputable. It is not
a theory but an absolute fact, a doctrine in the true sense.
Becords that have been made of patients’ mouths during the
eruption of the second dentition, in regard to the decay of the teeth,
must be very unreliable. How many in this room could give a proper
record of their diet even for three days, if asked to do so ? I venture to
say there are very few who could state everything they had eaten for
three days, or twelve meals, including tea.
The dentists who are working in infants’ and children’s hospitals are
the most fortunately placed to get reliable information for records that
would be of great assistance in studying the development of the first
dentition from a dietetic point of view. But this work, like all other
medical research, has to be carried out on animal life, if scientific *
results are to be obtained, and work that is carried on with animals
that are always kept in cages and carefully watched and given a certain
diet, is bound to give a definite result, if the experiment is repeated
often enough. We have used considerably over 100 animals in work on
this experiment.
I am obliged to confess that twelve years ago when I published my
first article on the effect of artificial light on infants in regard to the
calcification of the teeth, I certainly thought that it played a much
more important part than the diet. It was while I was arranging my
work to carry on research still further with the artificial light that
I was attracted by the work that was being done on scurvy in the
Lister Institute. After having examined the teeth of several animals
that had been fed on a scorbutic diet, I found the pulp of the teeth
was affected, even before any clinical symptom appeared in any
other part of the system.
Section of Odontology
37
To Dr. P. P. Laidlaw, of Guy’s Hospital, I wish to express my
gratitude for much useful advice and help in the histological work,
and to Mr. F. Martin Duncan for the pains and skill taken with the
photom icrographs.
DISCUSSION.
Major H. P. PlCKERlLL : There are several points in Major Wells’s paper
open to criticism. First, Major Wells has not recorded the conditions of the
experiments performed—he showed* effects without stating causes or supposed
causes. In all experiments on animals it is vital to keep the conditions as free
from artificiality as possible. Secondly, there are no means of knowing that
the sections shown are all from the 6ame level in corresponding teeth, neither
were controls sufficiently shown or insisted upon. In rodents’ teeth where
pulp degenerations occur normally these are extremely important points.
Thirdly, degeneration of the pulp has no bearing whatever upon the problem
of immunity to caries: the whole fight takes place at the surface of the enamel
and Major Wells, apparently, has not examined the enamel surfaces. Fourthly,
I suggest that the whole problem of scurvy is really one of oral toxaemia due to
feeding upon salivary depressants. And lastly, I should like to know whether
Major Wells has carried out certain control experiments which I suggested to
him and his colleagues at the Lister Institute some months ago, because
without such controls the value of the work done must be much decreased.
Mr. SIDNEY Spokes : The interesting work of Major Wells goes to show
that in addition to the general symptoms of scurvy and rickets due to a
“ scorbutic ” diet he has found that the pulps of the teeth are affected
similarly to the other tissues. An article in the present number of the British
Medical Journal 1 dealing with rickets occurring in puppies reminds me of a
litter I dealt with many years ago when breeding bull-dogs. One was sent to
a country butcher and had the advantage of running free and probably also
a liberal diet. The others were restricted to a garden and the streets of a
town, and although carefully fed with meal, milk, &c., became affected with
the marasmic condition alluded to in the article mentioned, and died. The
country bull-dog was then brought back in excellent condition but ultimately
shared the same fate. The microscope section alluded to by Major Wells is
one prepared by the Weil process over twenty years ago from the maxilla
of a child eight or nine months old described as rickety. The tip of the
temporary incisor is erupting through the gum and the developing permanent
incisor is in situ in its crypt beneath. I thought that the forming enamel in
the latter might show some signs of the hypoplasia which gives rise to the
ridges found on such permanent teeth, and in the specimen there are indications
of “spaces” in the forming enamel picked out by the infiltration of the
Paton, D. Noel (and others), Brit. Med. Journ December 7, 1918, p. 625.
38
Wells: Food Deficiencies
perchloride of mercury used in preparing the material. The question of
dietetics and of environment in the causation of rickets seems to be still
unsettled, but Major Wells’s paper is a valuable contribution to the discussion,
and his unorthodox remarks on “ dental decay ” and other points provide
material for criticism.
Major F. M. Wells (in reply) : First, all the experimental animals were
maintained on a scorbutic diet, which consisted of bran, oats and water, or
bran, oats and autoclaved milk. Scurvy is so well understood to-day that it
can be produced in animals which are kept in cages, by omitting all anti¬
scorbutics from the diet and the animals can be brought back to normal
condition again at will, by administering the accessory food factor that is
required. Secondly, the specimens shown were taken from a selection of
over ten thousand sections cut,.three thousand of which were mounted and
examined, and the sections shown of each condition were typical of the results
obtained of the pulp throughout. Thirdly, I believe that the pulp has a direct
bearing upon the immunity to caries, as I stated in my paper, and it has all
to do with the surface of the enamel in regard to the resistance of oral
fermentation. Fourthly, the theory relating to scurvy put forward by Major
Pickerill is an altogether new one. Lastly, Major Pickerill asked Dr. Zilva,
who was carrying out the dietetic work of my experiments, if he would also
undertake some experiments with salivary excitants. This was not done, as
salivary excitants had no connexion whatever with the work we were doing
and I do not believe that they have anything to do with the prevention of
decay. This is one of the oldest theories and was promulgated by my father
fifty years ago.
Section of ©Oontoloap.
President—Mr. G. G. Campion, L.D.S.Eng.
Variations in Position of the Teeth in New World Monkeys . 1
By J. F. Colyer, F.R.C.S., L.D.S.
In a paper published in the Dental Record (January, 1914), atten¬
tion was drawn to several specimens illustrating variations in position
of the teeth in monkeys. Since the appearance of that paper a
systematic examination has been made of monkeys in the British
Museum, in the Royal College of Surgeons, and in a private collection.
The British Museum furnished by far the largest number of specimens,
and these with but few exceptions are from animals in the wild state.
In all, just over 1,500 specimens have been examined, and the facts
gathered are, I think, of sufficient interest to warrant their publication.
It is, however, impossible to do justice to the subject in one paper, and
I propose to-night to limit my remarks to the monkeys of the New
World, which are divided by zoologists into two families : (1) Cebidse;
(2) Hapalidse. In all 629 adult specimens were examined, those
specimens being classed as adult in which the dentition had reached
the stage where the third molars and canines were partly erupted.
With these few preliminary remarks we may pass to a detailed
account of the variations seen in the different genera.
Family Cebid.e.
Genus Cebus (the Sapajous or Capuchin Monkeys).
Specimens examined 146.
The typical arch in Cebus is shown in fig. 1. In the maxilla the
teeth are placed slightly oblique to the line of the arch, and are arranged
1 At a meeting of the Section, held February 24, 1019.
MY —7
Fia. t
Typical Urcb iij CebtfS.
(c) Irregular arrangement of prenitflafs. lb Ctbm the maridibolslc
Orat pretfiofftr is frequently a little ofe'jipje to the line uf the sref?. the
distal aspect of the/tooth pointing inwards y io two specimens the
obliquity was sathcientiy marked to constitute a definite irregularity.
In four specimens there was apir regular arrangement of the pt-e-
rnnlarA ; in one case; a, male Cebm hypokucu. s, fig. ■% both the maxillary
and «iftrtdibr*!ar preiuolars weire crowded. In anothet specitneo, a Ctf/tix
II there Wa^
preraolar. In this specimen the esc me had erupted slightly forward
1 CebftA ajric.ni&im (Tf.M. 70=1] ,10.-1 )* ; Cfibu* jaidpUiv. |fei iumvH 0.11.«*.2).
? unclassified (B/.M. b‘h); CMas htjpoizMa* (K r C & Odonio. Snneaj.
* tt.M: 4*-i,28.32;
* B.M., abbreviation iut British Museum*
Section of Odontology 41
nod. external to-the norma! position. There web no evidence that the
inalposftioa, of th.e premolat was 4ue to persistence of a fragment of
a deciduous motor. In two cases the mandibular premolars were
crowded
Island W' T oi Patiala.
specimen* sJwvy* of tWpJteiDolairv.
Fig. 3 t
■Q&to0. a. tli&r>v fafjt
(cf) In C«im$ the third motors occlude either edge to edge or the
maxiUary teeth lie a little internal to the mandibular teeth; The
latter condition may be exaggerated, and in four cases one or both of
Fig. ■'fyffwlnom &&7.9.1)
^ _ ^ . k ^ , ¥ ....... In this sp&cxUim fcbe nuudlJ^ty
right s/.eocui ujifl.iijiid woUir* urr- p)«vced internal to the lino of the arch.
sg, 5;—CV^s w >nti“l,^Tfic'd.(H.M. 3 (i.4.19). Au this *prj£s.hieti all the molars
second molars. Iri one specimen 1 the maxillary tight second molar was
distinctly rotated, this irfegulaj ity being associated with slight crowding
hi. the incisors,
(fh In three specimens a. carious w echelon ” amittgement of the
molars was present, the teeth being placed with the *iut«!or-exterbal
angle slightly mwanis shown m fig. !j.
Ctincs (B.yt,
42 C’olyer; Position of Teeth in Now World Monkeys
the: maxillaryteeth occluded well inside the mandibular teeth. In six
specimens the second and third molars on one or both sides Were
placed internal to the arch (6g. 4)/ three examples being met with in
Cebus apella. In one specimen, fig. 5, all the molars were placed
slightly internal to the. line of the proraolars.
{<?) In Cebu?, there would seem to be a tendency for the molars to
be rotated. In the norniah as previhuify stated, the cheek teeth are
placed slightly oblique to the hue of the; 0c&... 'This oblique position
may be sufficiently increased to constitute a definite irregularity, as
shown' in fig 4. .'Here the third molars are rotated so that the anterior
external angles are brought in contact with the distal aspects of the
Section of Odontology 43
(• 7 } In the toandible the third tncO&t -s placed with the roots sloping
backwards : this backward slope may be mcteAsed sufficiently to result
irt a forward tilting of the tooth. This irregularity was rioted in two
cases ; 3 m: cue, shownin fig. 7, both third molars were tilted ami rotated
inwards.
(h) Iri four eases there was slight inferior protrusion, the iriscidi-
bular incisors occluding in front of the maxillary teeth.
From the above it will be apparent that thOre is a wide range in the
variations* in position of the teeth in Cebu;;, the number of specimens
Fig. fi.—t.Yiw* unciftiisified (bM. 1.5.24,2) to shew “echelon ,l arrangement of
tha maxillary tight,
Fig. 7,- G' tuf; xatuhor.-pltalw fB.M. 49h)i The hiatiSilailar third molars are
tilted and rotated Inward*.'
snowing variation Demg tnim^ix, the majority being m connexion
with the molar series,
In addition to variations in position, five cases of absence of teeth
’,'.>•10 seen, and in twelve cases the mandibular first' pretoolar was
abriomially large, facts which seem to suggest that the genus Cebus is
in ft “ changeful mood.”
Cebu* hypctlevcus (B.M. 4.7; C«bn$ (li.M. 4‘?hj.
Colydr: Position of Tenth in New World Monkeys
Geatt $ Lagothrix tfch* Woolly Hockeys)
Bpiei/Hens e^amiti/’jJ 2 '.).
S’hW iyo0iy monkeys, first described by von Hmoboidt, “ take their
»4ine from the thick- coat tit woolly fur which is found beneath the
bortger hairs.*'
(1) In this genus five specimens exhibited an irregular arrangement
fit the preinolara, In one, a fagptiiri? itmnboUltii, llg. 8, there was, a
Ijitiolhrix (fi.M. The . ■maxillary left $uni pretnols-r
misplaced.
definite outward displacement, of the maxillary left third premolar. In
another epucimarii fig. 9, the maxinary left third piemoiar wits rotated
so that, the external aspect looked backwhrdsi on the opposite aide iif
the arch a space was present between the maxillary first molar ami
third prumokr In 4 third speoimen a LagoHitu- infimainti, fig, 10,
there was a definite agyifimfetry oi the facial IxmesV Chr the right side
(t) the maxillftry canine .rested in ocolfision over the mandibular first
and second preoiplara; fii) fchh.re wte crowding of the preoiolars ; (inf
the thud molarwaa misplaced wfifcb the pCcUmmg surface looking well
baekwacdse There was a definite croesi-bite of the incisors, the mandi¬
bular right incisors passing in £coht of the .maxillary teeth. The
Section of Odontology 45
general appearance of the! bones sogge&ted an arrest iu growth of the
right maxilla. Of the t%yo remaining specimens showing, irregularity of
the premolars, in one; 5 the maxillary' first pr-eniolars were slightly
ihlero&I to the arch, and in the Other 2 the n*nndibftlte first premohaii's
werepTaeed almost transverse tu the arch. definite spaces horng pre^mt,
Vi) ho. one specimen^ Ihem was an ahoomia) baijf ward, slope of the
roots of the maxillary third oioiars:
0, — Lagolfifiz wtidftar&ed.y • from MarcopiitaL (B.M: d/ti.5.15). The
maxima,ry u4v prcmolar is misplaced.
Fig.- Xil~2,(VjQ$lu : i*: itofuwata? iron; Upper Ccayoli (B.M. G6.3.2S.7), Bbowing
uyiximidticuil of the tn&xnlla?.
in front of the upper teeth, a .fact which suggests th
there is a definite tewkmoy towards inferior protrusion.
The totahritiBi.be/of spedfinhsa^ varying was efeveii
Lagctlhrise- Mnihboldtu 43 / 1 , 0 . 21 . 12 )
Logoi hr lr ti^olfts&ified 11/7.19,1).
Lagomfr infumm
46 Colyer: Position of Teeth in New World Monkeys
Genus Brachyteles (the Woolly Spider Monkeys).
Specimens examined 13.
This genus, which is confined to South-east Brazil, forms a kind of
connecting link between the Lagothrix and the A teles.
(1) The chief interest in this genus lies in the frequency of inferior
protrusion. Of the thirteen specimens nine were marked as coming
from the Bugenhero River, Esperito Santo. In this group there were
seven examples of protrusion of the mandibular incisors; in one the
condition was doubtful owing to the post-mortem loss of the incisors,
and in one the incisor bite was edge to edge. Of the four specimens
not marked as coming from the Eugenhero River, only one showed
inferior protrusion.
(2) In one specimen the diastema in the maxilla was absent.
(3) In two specimens there was slight crowding of the mandibular
premolars, and in one slight irregularity in the position of the maxillary
right first molar and third premolar.
(4) In a Brachyteles hemidactylus' an additional premolar in the
right maxilla had caused the maxillary canine to assume a forward
position and the mandibular canine to be misplaced.
The number of specimens varying was eight. •
Genus A teles (the Spider Monkey).
Specimens examined 30.
The Ateles or spider monkeys show a remarkable degree of variation.
(а) In two cases the presence of extra teeth had led to irregularity
of the canines. •
(б) In a male Ateles vellerosus 2 there was marked irregularity of
the maxillary premolars (fig. 11). On the left side the third premolar
was almost external to the bite, while the canine seemed to be placed
more posteriorly than normal. In the mandible a slight space existed
on both sides between the first and second premolars.
(c) A rare condition was noted in an Ateles melanochir , 8 The
mandible was distinctly asymmetrical; on the left side the cheek teeth
were in normal occlusion; on the right side the mandibular teeth
occluded external to their normal position.
1 B.M. 45.4.2.7. * B.M. 89.12.7.2. * B.M. 808a.
Section of Odontology ' ■ • 47
((f) Amongst other irregularities noted were crowding pf the
incisors; a slight space, between the maxillary left first and second
molars ; tilting of the mandibular third molar.
The total munher of specimens showing variations in position of the
teeth was eleven ; in two of these extra teeth were present. In three
further specimens additional teeth were noted, making a. total of fourteen
out of thirty specimens showing dental variations. The tendency to
vary would appear to be greater in certain species, for example :
■ In -Urn* specimens >A Altht m^Tfictiir ... ... 5 rsiriVd
In -four spe^meiis of Atd*s MiltrzHUs •••.„■; 3 v
: . .. %i\f$ *• of iiitjer . V ' ,fy; . £ ,>,
Fit;. 14.
A teles vellcivstt* (B. M. 89. 1*2 .7/2 1 . The maxillary promoters are misplaced.
(th& Uowlifcg
Specimeth* I'mtnined \Q6.
la Mycctes the. incisors are small compared with the stee of the skull!
and are set in a curve, there is usually a well marked diastema; the
piemolars and molars are arranged in a straight line, the two sides:
gradually diverging as they approach the back of the mouth. A typical
■»rcfc\ is shown io. fig. 12«v ;
Tin’ variations seen were as. follows ■—-
(ai Slight crowding of the premolars 5 ih three oases both maxillary
and macidrbQjiJr premalars were in vol ved—hi four cases only .I the
Colyer : Position, of Teeth in World Monkeys
Ft.., 12,
Typical ;uvh bj Mycttes.
v -; V 4V*• &v;.v/«<>
. ; •ttiiiV i;}:> - • .
ZlyccUt uriclatrsifjod Bh-mhig irregularity hi position of the
... , , ■■ ■
Rectum of Odontology 49-
. .. -'■■■■ . '
lOasillatcy preiuolars;. An example ik show?) in fig, 13. Three out
pf the seven eases were iu -Mijcetes- senmitus:
(b) In .six specimens a cunoita arrangement was ..present,.. the
preinnhirs and molars being itr ragged in straight lines with tire tine
of the preiuoliit’s lyieg. mteioai to that of the molars as seen in fig. U
(b| In a Mitrifi-.s iiigrr,* fig. 15, the maxillary left first preruolar
was placed intemjfi to the seconds ’’itae 5$i*iiBe was not-
present but the condition of th«i hone suggested that this tooth had
boon lost from injury, the centre? incisor was mglforiopd, and it is
therefore .possible that the ircegular position of the- prbnml&T' in this
specimen was due fo trauma.
ru.. u
Mticcics nigvr < ll.M. iiO.O.O.Jt). hi this BjMjcicrteti the preuioiivrs ore <>l,v.vd
internal to the line of the molttw
ftf) An abnormal spacing ot the teeth was present in six specimens.
•In one case there was a marked space between the. mamillary central
incisors; in three cases spaces were present between the central and
lateral incisors in both the nnixilht arid the mandible; in one case spaces
existed between the umndibnlar second and third pmncJars. in one case
■dfifihite spaces were present between the maxillary third preniojars and
first molars, the mandibular third premolars in this specimen being
transverse to the arch.
1 II, U. 51.8.12.3.
50 Oolyer ; Position of Teeth in Neu >'. World*.
(t) Rotation of the mandibular third molars. In fiye. ease?, the
antero-intemal angle Was rotated inwards; ia ope the ahterp-
external angle was rotated outwards; It is of interest to note that
five out of the eix specimens belonged to the species Mycetes
pi.ilUa.ta.
if) Protrusion of the mandibular teeth was present in forty-five
oases. -The Various species show a different degree of variation in this
direction, for example :—
Nmbhnr Number slifrtvmiy
Sptcie* ao»mi?nn,i ittfHnor protj uaian
ifycdes pdlliaia . 2|> ... ... 12
Myce-le* Macconnelli . v ... I , t , 3
Myeetex ursiyui .... ... ... Ik ... ... l
($) The diastema in the maxilla was absent in two eases;
The total variations noted were forty-four.
.dfliztfc* ,ntfjer 51.8.12,8). Showing irregular po^Hiofi of the fxs. ill 'dry'.
left first pmuol&r.
tfenus Chi'!jf<ot.hrif (the Squirrel Monkeys).
SSpedimns 58b ■ ‘'y-r.
In this genus only three variations were present, as follows ;—
{a.) Irregular position of both, maxillary and mandibular premolars.
Section of Odontology 51
(b) Irregular position of mandibular premoiars; the maxilla being
too defective to obtain reliable data.
(o') Irregular position of tbs maxillaiy right canine in a Vhnjsotfrris
stiurmt' from the Coast Kegioa, Denierara. fig. 16.
Ch/tjsnlbke tciuri’U* ( i.'.it. 8.3.7.11)
Genus CaUithrix (the Titi Monkeys)
Specimen. 1 , cin/iunai ( 0 .
In this .genus the. iftcisorK are mt in a well marked etirvc : the.
canines are not so well developed as in many of the morikey* afid are
separatedi from the lateral inciscu^ by a small diastema, which is often
entirely absent. T:{)tt jirenmlaxs and, first molars run backwards
outwards, the second arid third molars turning slightly inward:;. The
arch approximates in character that seen jc man.' The following
variations were noted
(a) Irregularity in position of the meifbis. When the teeth are
in occlusion the maxillary incisors are often a little in. advance of the
mandibular .teeth, but thehe is a tendency -t0 the niaXiHary' lateral
incisors to bo placed slightly internal to the arch, and in some cased to.
be overlapped by the distal edge of. the mandibular teeth, or to lie in
the space between the nrandihuTltti: hjteral incisors ahd canihesi This
' - . *•-;
i '£.21.8.3.7.14.
5‘2 Colyer PouHvm of Teeth in New World Menhirs
inward position of the maxillary lateral mgisors may be so marked as
pie of crowding of the mandi-
to. constitute an irregularity. An exam
buter. incisors was noted in CallUhrhi■ gigo.l 1 and in two specimens space#
existed L'etween the inandibuiar incisorB.
(h) Irregularity in position of the promoters..In one case the
mandibular left canine and premol&rs were misplaced, the maxillary
right promoters were internal to the line of the molars and the lateral
incisors were slightly internal to the arch.
(a) Inferior protrusion Was preaent in only one specimen (Qallithrix
cnUgatuA?
'. ; Ifhe nutoher of specimens showing variations was ten.
Gerais Nj/clipWiccua - (the Nocturnal Owl-faceS Monkeys)
Sp/n.'mints' examined ' 35’. ■
Variations were noticed ifi. two specimens, as follows
Pig. 17 (ij. Fl«. n (ii>.
ti’jcniritheevs niietassilted. (8;Jf. Fl.-l.'-iii.SOu .Sltwin* irre§&!fttity'in ppsiUan,
of the uiasaUacj incison-i.
(a) Slight overlapping of the maxillary- central incisure with the
mandibular left incisor in advance of the corresponding tooth in the
maxilla.*
z(p) Slight crowding of the maxillary promoters,*
1M& fkhjlA, ■ : : y ■
B-M. si.% 5;7
rtychi.'HhrvUV tUloififwified (BAp
yyctivilhvctu t-i f‘tr(IAlUH jiir.M. 'i : S, 1 XI)
Section of Odontology
Genus Bracbyams (the.Qukari Monkeys).
*' fa • ► * ' •’*'*.'• * 7 -
In the eleven specimens exnmmed, the arrangement of the teeth
was normal.
Genus Pithccia ithis Saki Monkeys).
In Pithecia the maxillary incisors are set in a. sharp curve ; there is
a wide diastema, with the canines placed at the corner of the arch. The
line of the cheek teeth commences slightly internal to the canine and
follows a direction slightly inwards and then outwards. Insufficient
space in the region of the preniolacs results in the second and third
premolars being pushed inwards to the arch, a condition’ noted iu font
specimens.
The only other irregularity noted was \n. JPtthecitt cioropo/.?*.' in
which the maxillary Irrst premolaM were transverse to the .^rch instead
of oblique* as in the normal.
Family Hapamtlk
, ' ' t‘ \ ' I, * * . ' > -w A ‘ . ' .. . .
Genus Midas (the liong-tusked Marmosets or Tamarins)
Spec-imw* cwahml H4.<
\n this genus five specimens showed variations in position of the
teeth; ij» four of these theirregularity was only slight bat in one a
Pig. is.
Mida* (B.M 0.7 .7.2)
‘ B.31. 3.3.7 6.
54 Colyer: Position of Teeth in New World Monkeys
remarkable condition was present. This skull' was marked as coming
from the Perene River and is shown in fig. 18.
The mandibular right canine strikes the labial aspect of the
maxillary lateral incisor; the mandibular incisors are pushed over to
the left side; the maxillary right canine in occlusion lies over the
mandibular first and second premolars; the teeth in the right half
of the mandible, with the exception of the second molars, are in
abnormal occlusion.
Genus Hapale.
Specimens examined 43.
Three specimens showed variation; in one the incisors were crowded,
in a second the mandibular premolars were irregular, and in a third a
space existed between the maxillary central and lateral incisors on both
sides, the mandibular lateral incisors having grown up into the spaces.
The following table gives the number of variations in the position of
the teeth in the various genera :—
Variations in the Position op Teeth in New World Monkeys.
Family Cebid®.
Number
examined.
Variations other
than inferior
Number showing
inferior
Total
number
protrusion
protrusion
varying
Cebus ...
146
...• • 34
3
36
Lagothrix
29
6
8
11
Brachy teles
13
5
8
8
Ateles ...
30
11
0
11
Mycetes
106
28
25
44
Chrysothrix
52
3
0
3
Callithrix
40
9
1
10
Nyctipithectis ...
35
2
0
2
Brachyurus
11
0
0
0
Pithecia
40
5
0
5
—
—
—
—
502
103
45
130
i
Midas ...
84
Family Hapalidae.
5
0
5
Hapcile
43
3
0
3
—
—
—
—
127
8
0
8
The points to be noted are:—-
(1) The degree of variation in the Cebidse compared with the
Hapalidae.
(2) The degree of variation in the various genera of Cebidse.
Section of ©fcontolOQp.
President—Mr. G. G. Campion, L.D.S.Eng.
Bone-grafting in Gunshot Fractures of the Jaw . 1
By William Billington, M.S., F.R.C.S., Captain R.A.M.C.(T.),
Arthur H. Parrott, M.D.S., L.D.S.
AND
Harold Round, M.D.S., L.D.S.
For rather more than two years we have had charge of the “ Jaw
Department ” at the First Southern General Hospital, Birmingham, to
which all cases of injuries to the jaws requiring special treatment are
sent from the whole Southern Command. A very large percentage of
these cases suffer from compound fracture of the mandible. Successful
treatment involves (1) osseous union, (2) functional occlusion, and (3)
avoidance of disfigurement.
In the majority of cases these results have been obtained by means
of mechanical technique associated with due regard to the establishment
of aseptic conditions. A certain number of cases, however, present
difficulties which cannot be overcome by this technique alone: such
treatment, whilst serving to secure alignment, may fail to produce
osseous union, owing to one or more of the following causes:—
(1) Extensive loss of bone as the direct result of the injury,
resulting in the formation between the fragments of fibrous tissue only.
(2) Persistent sepsis accompanied by necrosis and loss of bone
tissue, due to the injury being compound either to the interior or the
exterior of the oral cavity, with or without the presence of foreign
bodies or sequestra.
(3) Intervention of soft tissues between fragments.
1 At a meeting of the Section, held January 27, 1919.
ju —13
56 Billington, Parrott and Round: Bone-grafting
(4) Separation of fragments in the endeavour to restore alignment,
particularly in cases where spaces of £ in. or less are present.
(5) Over-riding or malposition of osseous fragments.
(6) Persistent mobility of fragments due to muscular action, in
some cases uncontrollable by mechanical means—such as short posterior
edentulous fragments.
For convenience of consideration, these ununited fractures may be
classified according to position, thus :—
(1) Anterior area, between the canines.
(2) Lateral area,between the canine and the last molar (inclusive).
(3) Posterior area, behind the last molar.
(1) Anterior Fractures. —Delayed union in this region may now be
considered rare, but it does occur. Where the loss of tissue is not
considerable the case is handed over for surgical treatment. In some
cases removal of intervening fibrous tissue and freshening of the ends
of the fragments, with subsequent approximation and fixation with
dental splints, may suffice. But, in cases in which it is doubtful
whether a good result can be obtained by such means or only by
approximation of fragments with loss, of alignment and resulting
deformity, we have come to regard bone-grafting, with restoration of
alignment, as a preferable procedure.
(2) Lateral Fractures. —In this class of injury displacement of frag¬
ments occurs more frequently and to a greater -extent than in anterior
fractures, this being due primarily to unbalanced muscular action. For
this reason ununited lateral fractures are more common than anterior.
Once a bone-graft has been decided upon as necessary, every effort is
made to restore the fragments to alignment as near the normal as
possible, both for ultimate restoration of function and for aesthetic
reasons. The dental arch usually provides a sure guide to this, and
interdental splints of various types are the direct means of obtaining
restoration of position. When this is satisfactorily accomplished,
retention is maintained for at least a month after all soft parts are
fully healed, and evidence of sepsis has disappeared. Then we usqally
consider the case ready for operation; the splints are removed and
the same, or new splints, are applied after the grafting operation,
and when the wound is healed.
(3) Posterior Fractures. —In this region we are confronted with
one of the most difficult problems which jaw injuries present to
dental technique, that is the edentulous posterior fragment. This
edentulous fragment which is severely displaced generally upwards,
Section of Odontology
67
forwards and inwards, is irreducible by the application of any internal
mechanical appliance, owing to the intolerance of the soft tissues to
pressure. This intolerance, due largely to muscular movement,, is
further aggravated by the presence of sharp edges or spurs of bone
projecting at the parts where pressure is required to depress the
fragment. The difficulty of satisfactorily reducing and retaining such
displaced fragments has been made apparent to us in our earlier
efforts when using a variety of mechanical devices (soft rubber pads
with springs, hinges, levers, &c.). The result of this line of treatment
has led us to abandon such attempts at fixation as being liable to
cause serious and prolonged discomfort to the patient with little or
no practical gain in the prospect of obtaining osseous union. Our
present view is that it is better to leave these fragments uncontrolled
until the time for surgical interference has arrived; the displacement is
then largely reduced by release of muscular or fibrous attachments, to
which it may be due. Projections of bone liable to cause discomfort
beneath any covering splint subsequently applied are removed at the
same time. This method of procedure has shown that posterior
fragments surgically treated in this manner will retain their restored
alignment in contact with the graft inserted long enough to enable
the graft to heal in. This permits of the adaptation and fixation of
the most suitable splints for retaining the restored alignment.
Dental Technique.
The advantages of allowing free access to the mouth during
operation, both for the surgeon and the anaesthetist, and for efficient
treatment in the event of any post-anaesthetic complication arising
being kept in view, the principles of dental technique adopted in all
three classes of fractures—anterior, lateral, and posterior—are the same
and may be given as follows :—
(1) Removal of all sources of sepsis.
(2) Reduction of misplaced fragments to normal position as far as
mechanically practicable, without detriment to condition of soft tissues.
(3) Removal of all appliances before the grafting operation is done,
no appliances being adapted until the operative wound is closed and the
graft is healed in sufficiently to avoid all risk of sepsis or disturbance, a
period varying from two to four weeks or even longer, according to the
amount of displacement corrected (surgically) at the time of operation,
condition of the patient, &c. Naturally, the greater the reduction, the
58
Billington, Parrott and Bound: Bone-grafting
greater will be the intolerance of the tissues to pressure- from dental
splints. We consider that in some earlier cases the nutrition of the
graft and its bed may have been interfered with by the pressure from
splints applied too early.
(4) Re-adaptation of Splints .—New models are taken and splints
made for the retention of all parts in the alignment gained by the
operation. Where any slight alteration of the occlusion attained before
operation has resulted from the insertion of the graft or the reduction
of a fragment, such deviation has been found readily reducible by a
suitable method of splinting without interfering with the retention of
the bone graft in a position favourable to union. That this can be done
is due to the fact that the graft is firmly held in situ by the deep layer
of soft tissues and the ends of the graft and the fragments being so
bevelled and overlapped as to allow a certain amount of movement
without loss of contact, as described later. The correction and retention
of the fragments are attained by the use of cast silver cap splints,
adapted and cemented to standing teeth, supplemented by vulcanite
extensions with soft rubber lining covering edentulous parts in the
neighbourhood of the graft. Where interdental splints are used, the
position of the closed bite is resorted to and the splints are fixed to
each other by means of articulating tubes and bolts, hooks and wires,
&c. If a satisfactory articulation can be assured, it has been found
quite sufficient to splint the mandible only. As such treatment
restores function, it is naturally a comfort, and an aid to the
patient’s recovery. A metal chin cap splint of standard type covered
with lint or chamois leather is applied in all cases as soon as the wound
has healed.
We are of the opinion that no effort should be spared in the way of
bringing the physical and mental condition of the patients to the
highest possible standard of efficiency, before and after the operation
of bone-grafting, by means of healthy surroundings, good feeding and
plenty of outdoor exercise. Massage and ionization have proved
useful adjuncts in the treatment of soft tissues, both before and after
operation. In a few cases, even twelve months after the union of a
bone-graft, we have found evidence of a rarefying osteitis around the
apices of teeth; these were obviously considered at the time of the
operation to be so far removed from the seat of the graft as to cause
no anxiety. Such a fact raises the doubt as to whether the extraction
of one tooth on each side of the gap leaves sufficient margin for
safety.
Section of Odontology
59
Surgical Technique.
It is essential that firm osseous union should be obtained even at
the expense of deformity, otherwise the power of mastication is
gravely impaired. When, however, the gap is wide, the deformity
resulting from allowing the fragments to approximate is so great
and renders the fitting of suitable dentures so difficult that it can only
be the extreme resort. A satisfactory functional and cosmetic result
can then alone be obtained by successfully bridging the gap by means
of a bone-graft.
Other classes of cases in which surgical assistance is necessary to
secure osseous union are those (1) in which there is overriding or mal¬
position of osseous fragments; (2) when mobility of the fragments from
muscular action cannot be prevented by mechanical means—for
example, short posterior edentulous fragments. Operation in these
cases consists in carefully dissecting away the scar tissue from between
and around the ends of the fragments, rectifying the deformity by
the division of contracted muscular attachments and fibrous bands, and
immobilizing the fragments by means of a plate and screws. If, as is
often the case, a gap remains between the fragments when pared and
brought into correct alignment, a small graft is introduced; the
technique is similar to that described for bone-grafting.
Bone-grafting in fractures of the jaw resulting from war injuries
has presented many difficulties. At first success was so rarely
obtained, that the attempt was given up and discouraged by highly
competent surgeons as not being worth while. The, alternative of
obtaining union by allowing the fragments to approximate led to so
much disfigurement, and the resulting configuration of the alveolar
margin when the gap was a wide one rendered the adaptation of satis¬
factory dentures so difficult, that we felt compelled to persevere;
especially was this so, because in spite of sacrificing normal alignment,
osseous union could not be obtained in a definite percentage of cases.
To discharge such cases with non-union was a confession of failure
that could only be made with extreme reluctance.
The technique we now employ has been reached only after much
experiment, many devices having had to be abandoned. Without
enumerating the various stages through which we have passed, we
think that a short account of the preparation for and the performance
of the operation now in use will be helpful. Whereas success was the
60
Bjllington, Parrott and Bound : Bone-grafting
exception two years ago, it is now the rule, and it rarely happens
that the graft fails to consolidate.
Preliminary Preparation .—This is prolonged, and it may be many
months after the original wound was received, before the operation of
bone-grafting can be undertaken. The fracture is always complicated
by sepsis, usually severe, and often by extensive injury to the sur¬
rounding soft tissues. As soon as possible an X-ray examination
should be made, after which the patient should be anaesthetized and the
wound explored. Foreign bodies, teeth situated in and adjacent to the
fracture, and loose fragments of bone should be removed. Larger
fragments of bone with reasonably good attachments tojsoft tissues may
be left in the hope that they will live. At the same time it is often
possible to carry out some preparatory plastic work, the fragments of
bone being replaced in as normal a position as possible and soft tissues
being drawn together. Within the mouth care must be taken to
provide efficient drainage and access to raw surfaces. Finally, before
attempting to bone-graft, it is very important that dribbling of saliva
from the mouth should be prevented by plastic operations. This drib¬
bling is very common where there is a defect in the lower lip, and
saliva soaking into the dressings greatly increases the risk of sepsis in
the operation wound. After all wounds inside and outside the mouth
have healed, an interval of from four to six weeks should elapse before
the bone-grafting operation is performed. During this period the patient
is usually sent to a convalescent hospital. Immediately before the
operation all dental fixation splints are removed from the mouth. It is
found that the retention of these militates against the success of the
operation. They cause risk from post-ansesthetic vomiting, greatly
adding to the discomfort of the patient, and, where pressure is exerted
by them in or near the operation area, they increase the risk of sepsis.
For these reasons no attempt is made to fix the fragments of the jaw
during the operation or for at least a fortnight after. Everything
which interferes with prompt “ healing in ” of the graft must be
discarded.
Operation.
A skilled anaesthetist is essential, and we owe much to the skill with
which Captain McCardie has maintained successful anaesthesia under
very difficult conditions.
A curved incision is made in the neck beginning 1' in. behind the
extremity of the posterior fragment and ending 1 in. in front of the end
Section of Odontology
61
of the anterior fragment. The incision commences and finishes about
i in. above the line of the lower border of the jaw and in the neck Tuns
about 1 in. below that line. It is only by carrying the incision well
below the jaw and raising a flap that soft tissue sufficient to envelop
the graft satisfactorily can be obtained. Often at the, site of the
fracture there is nothing but dense scar tissue extending through to the
mouth. In splitting this great care must be taken to avoid opening
into the mouth, an accident which, necessitates postponement of the
operation. The unsatisfactory bed provided by this scar tissue con¬
stitutes one of the difficulties of bone-grafting.
The incision is deepened by cutting upwards and inwards until
the lower border of each fragment is reached: the soft tissues covering
their outer surfaces are then raised for an inch away from the gap and
turned up in the flap. The ends of the fragments and the fibrous tissue
occupying the space between them are now carefully cut away; finally,
each fragment is bevelled by cutting away a flake of bone from its outer
surface with bone forceps. In this way raw bone is exposed on either
side of the gap and on the outer aspect of the fragments for about 1 in.
from its extremity. All bleeding is then carefully arrested and the bone-
graft prepared.
After experimenting with bone from the ribs, the tibia, and from
the mandible itself, the iliac crest was finally selected as the site from
which to take the graft. The bone is tough and can be cut with bone
forceps without splitting. Further, a graft can easily be obtained of
any length or breadth and the slight natural curve of the crest is
approximately that of the mandible. The graft should be taken
62 Billington, Parrott and Round: Bone-grafting
preferably from the same side as that of the operation wound; this
allows the patient to lie comfortably on the opposite side.
An incision is made over the crest, commencing at the anterior
superior spine and extending as far back as required. The muscles are
then separated on either side of the crest and pressed back by retractors.
The bone is cut by an ordinary Horsley's hand saw. The graft should
be 2 in. longer than the gap to be filled. If a more curved piece of bone
is required, for example, to fill a space near the chin, the graft is made
to include the bone between the superior and inferior spines. In this
way a graft 4 in. long has been obtained to fill a gap extending from the
angle of the mandible on one side to considerably beyond the chin
on the other; the nattiral curve was so accurate that no subsequent
modelling was - needed.
After removal of the bone the muscles detached from it are sewn
together with catgut and the wounds closed. No inconvenience what¬
ever seems to result. The ends of the graft are now bevelled with
bone forceps, the bevelled areas lying on the prepared outer surfaces of
the jaw fragments. In this way the graft overlaps the gap at each end
for an inch. Two advantages result from this : (1) A broad line of bony
contact between the graft and the fragments is provided with increased
prospect of speedy firm osseous union, and (2) there is practically no
risk of separation in the event of the gap being increased by subsequent
manipulations during the application of dental splints, as a certain
amount of sliding tan take place without contact being lost.
Pig. 2. Pig. 8.
No attempt is made to fix graft or fragments by plates and screws,
by wiring, or even by dovetailing the graft into the fragments. All
these measures have been tried and discarded. The presence of foreign
Section of Odontology
63
bodies greatly militates against successful healing, a sinus down to the
plate or wire almost invariably forming. Attempts also to make the
graft act as a splint by dovetailing it between the fragments have not
led to satisfactory results.
Our practice now is to keep the graft in place by sewing the soft
tissues closely over the graft and the ends of the fragments by hardened
catgut. This has the additional advantage of closely surrounding the
graft with living vascular tissue and abolishing dead spaces in which
blood-clot and serum can collect. This improves the nutrition of the
graft and diminishes the risk of sepsis.
Finally, the skin is approximated with a few interrupted stitches.
No drainage is employed beyond that of leaving spaces between the
skin sutures to allow of the escape of serum. A simple dressing and
bandage is applied and the patient sent back to bed.
No attempt is made to reintroduce dental fixation splints until the
wound is firmly healed and the compound fracture has been converted
into a simple one. This usually occurs in two weeks, after which the
case is treated as one of simple fracture of the jaw. Firm osseous union
occurs in from two to four months, but it is inadvisable to fit the final
dentures until at least four months have elapsed, and it is perhaps wiser
to allow an interval of six months.
During the nine months, October, 1917, to July, 1918, 25 bone-
grafts were done; in 11 of these cases the graft was taken from the
tibia, and in 14 from the ilium. In this series the results obtained were
as follows: In 17 cases good bony union was established. In 6 cases
union had taken place at one end only (all these have had the ununited
ends freshened and splints refixed, and in one or two cases small pedicle
grafts were done) ; in 1 case the graft healed in well but there was no
union at either end ; in 1 case the graft came away altogether.
From October, 1918, to December, 1918, 9 bone grafts were done,
8 of which were taken from the ilium and 1 from the tibia. In this
second series the results obtained so far (beginning of January, 1919)
are as follows: In 1 case union is practically established ; in 6 cases the
graft healed in well, and shows satisfactory progress ; in 2 cases there
was a little discharge from the wound for a short time.
In order to illustrate these results we have selected 6 cases from
these two series for publication.
64 Billington, Parrott and Round: Bone-grafting
Case I .—Private A., aged 22, wounded by shrapnel on January 14, 1917 ;
admitted on February 2, 1917. Extensive damage to left horizontal ramus,
with comminution and lose of bone. Suppuration severe. Wound cleaned up
and splints applied to correct severe displacement. On June 20, 1917, a final
sequestrum was removed under general anaesthesia and cap splints again fixed,
the patient being sent home on leave. In March, 1918, fibrous union, only,
was found, with much muscular movement of posterior fragment (edentulous),
and on May 27 a bone-grafting operation was performed, a graft 2 in. long
being taken from the tibia. The graft healed in and the splints were again
fixed on July 13, 1918 (metal cap splints with vulcanite extension). On
December 30,1918, splints were removed, osseous union being well established.
Dentures were supplied and the patient was discharged on January 31, 1919
(see figs. 4-6).
Case II .—Private B., aged 34, wotinded by shrapnel on September 27,1917 ;
admitted on October 11, 1917. Deep septic wound (2i in. in diameter) of left
cheek, fracture (comminuted) of left horizontal ramus, open to oral cavity.
Teeth loose ; speech deficient. General condition good. The loose teeth were
removed with sequestra and the wound cleaned up well. On October 27,1917,
cap splints were fitted, restoring alignment, with lever extension on to the left
posterior fragment. On November 15, 1917, further sequestra were removed
from the left posterior fragment. Extension was made in vulcanite splint and
the patient sent on leave. On April 4, 1918, as fibrous union only was esta¬
blished, bone-graft was decided upon. A tibial graft 3 in. long was inserted on
July 15, 1918. Splints with vulcanite extension were fitted on July 30, 1918,
a graft having healed in. On October 10, 1918, firm union was demonstrated,
both by X-ray and clinically. Dentures were inserted on October 29, 1918,
and the patient subsequently discharged ; masticating power good on the right,
and fair on the grafted side. Scar much improved and disfigurement slight
{see figs. 7, 8).
Case III. —Lance-Corporal E., aged 26, wounded by shrapnel on October 11,
1917 ; admitted on December 14, 1917. There was an extensive lacerated
wound of the whole of the chin and both sides of the neck and almost entire
loss of bone in the region between the two lower first molars. This patient
had received treatment in France and when admitted there was a temporary
splint in position capping the two last molars on each side, and preventing
convergence of right and left fragments. Some time elapsed before the parts
were in a condition for bone-grafting to be attempted and finally only one
tooth, the last molar on the left side, was allowed to remain. A bone-graft
was attempted on July 29, 1918, but a small opening was made into the mouth
and the attempt abandoned. A second attempt was made on December 2,1918,
when a graft taken from the ilium and measuring 5 in. in length was inserted
into the gap. This graft was allowed to heal in well; the bed for the graft
was a very poor one owing to excessive scarring, and splints were not fitted in
position until January 5, 1919. These splints consisted of metal Caps covering
Section of Odontology
65
the upper teefch and the one molar on the left fragment—with soft rubber lined
vulcanite extensions, the whole being fixed by means of articulating tubes and
bolts. The present condition is excellent and consolidation is apparently
taking place {see figs. 9, 10).
Case IF.—Lance-Corporal R., aged 31, wounded by shrapnel on June 23,
1917. Admitted on August 9, 1917. There was an extensive lacerated wound
of the whole of chin, neck and lower lip, and almost entire loss of bone in
region between 6~| and ! 6 . This patient had received treatment in France
» * j
and when Admitted was wearing a loose vulcanite splint capping the remaining
teeth in the mandible. A bone-graft 3^ In. in length taken from the ilium was
inserted on April 26, 1918. This healed in well and splints (metal caps with
vulcanite extensions, articulating tubes and bolts) were fixed on June 5, 1918.
Good progress was made and the splints were removed on January 13, 1919,
when good bony union was found to be established. Dentures were fitted and
the patient discharged (see figs. 11, 12).
Case V .—Corporal J., aged 29. Wounded,by shrapnel on October 5,1916;
was first admitted to First Birmingham War Hospital on October 20, 1916.
There was an extensive lacerated wound over the symphysis, right body of
mandible and right side of neck. There was entire loss of bone for about f in.
in the region of 5 3 |, the mandible was practically edentulous, only the*
incisors remaining. In the first place an attempt was made to approximate
the fragments by wiring—necrosis supervened and the result was a failure.
Later an attempt was made to bridge the space, now about 1{ in. in width, by
removing a piece of bone from the right angle and planting it in the gap.
This also failed, the graft coming away into the mouth. The patient was
transferred to the First Southern General Hospital on December 3, 1917.
The remaining teeth in the mandible were extracted and the parts allowed to
clear up well. On April 22, 1918, a bone-graft measuring 3 in. in length and
taken from the ilium was inserted. The graft healed in well and splints were
fixed oil May 7, 1918. Metal cap splints with vulcanite extension in the
upper, were fixed by means of articulating tubes and bolts to a soft rubber-
lined vulcanite splint in the lower, and the mandible being edentulous, a metal
chin splint, struck to a model of the chin and covered with chamois leather,
was worn. Good progress was made and the splints were removed on
September 30, 1918, when good bony union was found to be established.
Dentures were fitted and the patient discharged (see figs. 13, 14).
Case VI .—Private W., aged 30, wounded by shrapnel on July 31, 1917 ;
admitted on October 1, 1917. This patient had been treated at another
hospital for two months, and when admitted the wound over the left body of
mandible had practically healed and splints were in position. The old splints
were removed and there was found to be a gap of about l£ in. in region j 7
to angle. Some teeth were extracted and the parts allowed to clear up, position
68 Billington, PaiTOti; and Bound : Bone-grafting
being axamfc&ined with new Split* t& A bone-graft was inserted cm April 8, 1910*
the graft: measuring 2i in. in ieagth, being taken from the tibia. This. healed
in well and splints—metal caps^ with vulcanite extensions—were fixed on
April *20. i9iB The splints were removed on September 23./1918 : firm union
had taken place at the anterior end, but there was some slight movement at
the posterior. Splints were reinserted for a time ami they were again removed
on November 4. 191$, when firm bony union was established .at'both ends.
Dentures were inserted and the patient discharged Ubq rigs. 15, 16).
Wtrdesire to record our appreciation of the very valuable assistance
the operations that we baveJi6oe*rve.d from Captain Learmonth and
Bister Dorothy Jones, of the First Southern General • Hospital; also to
Captain Sirann&ek,.Dental OX. Jaw Centre, and to Captain Patterson
and Lieutenant Beott, ‘Dental Surgeons, for their valuable help m the
Dental Dopartmehi
Billing-ton, Parrott and Round: Bone-grafting
Section of Odontology
Fia. 10 (Case III, p. 64}
B'&ti&n of Odaototdgy
Fw. iS !Cast: 7 , p. 65).
Fm. H (Case V, p. 60)
Biltington, Parrott and Bound: Bone-grafting
Section of ©t>ontolo0\>.
President—Mr. G. G. Campion, L.D.S.Eng.
Prosthetic Treatment of Old Injuries of the Maxillae.'
By W. Kelsey Fry, M.C., M.R.C.S., L.D.S.
(Late Officer-in-Charge, Denial Department, Queen's Hospital , Sidcup).
For the past two and half years I have had the opportunity of
dealing with a large number of cases of old injuries of the maxillae, and
although at first our lines of treatment were very indefinite, we have
now reached a stage when it is possible to divide the cases into more or
less definite classes. This work is very closely associated with plastic
surgery, and many cases which previously required prosthetic treat¬
ment are now adequately dealt with by the plastic surgeon. It is very
seldom that I have had to construct a prosthetic appliance for the
restoration of the soft parts, and these cases are chiefly of men who
for various reasons are unable to undergo operations, and to such
isolated cases as the loss of eyelids, &c. ’ In no instance have I had
occasion to restore a large loss of the soft palate, and I fear that the
majority of these cases end fatally in the early stages.
In this communication I only propose to discuss intra-oral prosthetic
appliances.
Before describing these appliances in detail, I propose to dwell for
a short time on the difficulties met with in taking impressions for the
construction of the appliances and the means to overcome them. All
impressions as far as possible are taken With plaster of Paris, in many
cases with the aid of cotton wool and black gutta-percha. The plaster
of Paris for these cases is of special importance owing to the fact that
1 At a meeting of the Section, held March 24,1919.
74 Fry: Prosthetic Treatment of Old Injuries of Maxillse
almost invariably they present false attachment of the soft parts to the
maxillse. The chief difficulties met with are :—
(a) The Frequent Constriction of the Opening to the Mouth .—
In such cases it is often impossible to insert an impression tray of
. sufficient size, and it is necessary to make two special half trays, as
shown in fig. 1. It is then possible either to take a whole impression
at once or to take the two half impressions separately and construct the
necessary base plate for them, and later to take an impression with the
two base plates in position.
- rr -f(r<■ ?«< «uc a
D
Fig. 1.
Special impression tray made in two parts.
(b) A Narrow Sulcus. —Many cases present themselves with tight
scarring of the soft parts of the face which maintains them in the
closest apposition to the maxillse; it thus becomes difficult to obtain
the necessary impression of the sulcus. This is overcome by inserting
in the sulcus cotton wool soaked in plaster of Paris immediately before
the main impression is taken.
(c) Openings in the Palate into the Nasal Cavities. —When it is
required to take an impression only of the palatal opening, cotton wool
soaked in plaster of Paris is again used; but when it is desired, as often
happens, to take a - deep impression of the cavity, the use of black gutta¬
percha, as first suggested to me by Sir Francis Farmer, proves of great
value.
These difficulties are well illustrated in the case of Captain T.
This patient came under my care for the construction of a denture.
There was marked constriction of the opening of the mouth, together
with very narrow sulci, and also a perforation of the palate, but a
palatal arch of normal width. The fact that the patient had a very
sensitive soft palate, and was unable to control the flow of saliva, was
Section of Odontology
75
another difficulty. It was necessary to obtain impressions of the oral
surface of the palate, a deep impression of the opening, together with a
portion of the nasal surface of the palate. The method employed was
as follows: A small piece of black gutta-percha was • inserted in the
opening of the palate, and by continuous pressure was made to take an
impression of part of the nasal surface of the palate and of the opening.
The gutta-percha was removed before it had become hard and was
shaped by the aid of a hot knife in such a manner that it was easily
removed and inserted. It was then partly softened again and re-inserted
to obtain an accurate impression, being left in situ for about two hours.
The gutta-percha was then vaselined, and cotton wool soaked in plaster
of Paris inserted in the dental sulci in the right and left molar regions,
and a third piece placed in the deep part of the perforation where it had
been necessary to remove a portion of the gutta-percha. The left half-
Fig. 2 .
Impression of maxillae showing perforation.
impression tray was then filled with plaster and inserted, quickly
followed by the corresponding right half, which had been previously
vaselined to prevent the adhesion of the plaster. The plaster having
set, the right half-tray was easily removed, the impression of the right
maxilla was then taken out, together with the cotton wool from the
Sulcus and the perforation, by fracturing it along the line of the left
impression tray. This latter, together with the impression, was then
easily removed, and finally the black gutta-percha was taken out, the
whole was fitted together, making one impression, and cast, as shown
in fig. 2.
In the construction of intra-oral appliances, the great aim had been
to restore as far as possible the contour of the face and the function of
mastication. The appliances are made as simple as possible, are easily
removable, easily kept clean, and in case of damage easily reparable.
76 Fry: Prosthetic Treatment of Old Injuries of
Fixed bridge work has not been used except in rave instances, In
describing in detail the. construction ol these appliances, it is advisable
to classify theta according to the nature of injury received as follows
flj Diaplaceit'ent of hard tissue without loss: pZ) toss of teeth only;
(3) Loss of hone.
' (J) ; .SeTh'Piar ; efi88s have .-presented. themselves in 'which thebe has been
a displacement hackthe.maxtfiafe witbeut loss of timie, due in
most cases to- flying accidents. Qn examie&Mori it has generally been
found that at} attempt had been made in th» early stages at treatment
to reduce the displacement, and the ruaxdhe have become firmly fixed
in their new position with a resulting loss of articulation and the falling
back of the upper part pf the face {set figs. B and 4jy They appliance
Model showing loss of articulation dud;,t«
vised to correct the deformity, as first suggested by Major Bisb worthy
N.Z.D.C., is one by which it is
forward by using the forehead and mandible .da point" d'nppui and
obtaining the necessary forward pressure by means pf: screws {**<-■ fig. $,
p. 7H) This apparatus has proved very efficient, and is visually not
veuidrcd to be worn for more than one week For the first two or three
days the patient experiences pain in the region of the glenoid cavities
and slight headache. It is very essential in using this Apparatus that
when- the have been brought to their correct position, they
should be immediately immobilized by fixing them to the mandible
by • means of a double Gunning splint This splint i> then worn for
Section of Odontology
a further two or three weeks., after which thiJ patient i&..gt?$n. upper
and lower splints with guiding ftanget-.
(2) Loss of Teeth only .—These cases resolve 'themselves generally
into the necessity of constructing a more or less simple denture,
NevcrttielesB, there is one type of case, which has caused eohS'demlde
difficulty—viz,, when there is a lews of all the teeth on one maxilla with
all the teeth remaining on the other toiWullfSr-^
appliance used is shown lit fig. >3 (p, 79}. As will he Keen, the main support
for the denture is by means of stimip bands.. I am greatly indebted to
Fl<i. i.
Photograph ^bowing deformity flue to Tli*phicenK2» l
Sir Fr&ncis Farmer for having broughtt td my notice the use of these
claepe for this patfesui&r type of case, and if is. very essential that these
clasps should be made of specially drawn out platinized gold wire.
(3) Lota of i>'coiiif,™-These cases are sub-divided into the following :
i a) Loss of alveolar border of max iWa: 'if) loss of palatal portion;
(c) loss of prentaxilla; (d) loss of preoi&xBlo, with part of alveolar and
palatal portions of maxilla; (<r) total loss of premaxilla, alveolus and
palate.
pup
Hy?m
■; tf''.' i!
• ^ it f i
wmsam
’78 Fry: Pro&fotfr $r$#£wmf; of Old Injurm of McixiU&
ia* I Ho not- propose to dwell on this class except to point dirt that
most instances are complicated -fey extensive false attachments of the
soft part of the iMxilfse, which prevent the construction of a functional
denture, It ie then usually necof^sary to perform an epithelial inlay
operation for the restoration of the 'dental ardcjis before the denture
U; constructed. To aid the Hurgnoa in this operation the splint shown
in fig. 7 (ji SO) is used for the purpose; of raaiptstmiug the ” stent ; ’ in
position while the•.epithelium becomes attached id the required position*
Mujot Kiab worth's: K|^atiU8 to ..correct of TiiaxiUdc?
It must bo rouierribered fhai once the siifeus has beep restored and the
“ stent ” removed, the iiuni denture must be inserted immediately, other¬
wise there is a danger that the sulcus may retract.
(fiy h<m of f'i.rlatal Portion,—- -The$| cases have proved of exceptional
interest from the fact that, in many inetanees, one would have .been
unable- to construct a functional denture had it not been for the hold
obtained for the denture by making use of the perforation, In the early
Section of Odontology
79
cases under treatment soft rubber was attached to the denture and
made to hold into the perforation, anxl thus to support, the denture by
.lateral pressure, but it was generally* found that such pressure resulted
in ulceration and absorption, and the denture rendered non-functional
in a very short time. The method now adopted is to Utilise definitely
the nasal surface of the palate for the means of support of the denture,
the denture being made to consist of turn portions, nasal and oral, wbfohi
are locked together by a simple mechanical device. Thus the means of
support tor the denture is by lodgment upon the nasal surface of the
palate instead of by continuous lateral pressure upon the sides of the
perforation. For the purposes of describing the appliances used it is
advisable to classify cases of loss of the. palate as follows (i) When the
Mamas
Plw 6.
P^DUtre m base of torn of. a) Hoe th op nm side,
-
perforation is hot required for the support of the denture ; (ii.) When, it
is only partially •required,' the. main support being obtained by other
means; .(Hi) When it is required for the main support of the denture.
(?) When the perforation is not. required for the support of the
denture) the denture is merely made to lit over the opening, and thus
prevent food, &c., passing'.through the perforation*.
(ii) Many case? are mot. iu which *Jtinre.q$.a foss of all the teeth on ope
side together with a perforation, ft is obvious that if a simple denture
is constructed for this eftse, it is, very liable to lie unstable from the
■weight being one-sided. To fiver com t; this a partial support is obtained
from the perforation. . A- denture is made in the usual manner except
80 Fry: Prosthetic Treatment of Old Injuries of Maxillae
that where it passes over the perforation a small loop is attached on the
nasal surface of the denture. Black gutta-percha is made to fit and
extend into the perforation and to be attached to the plate by means of
the metal loop. A large number of cases have been treated by this
method with good results, the black gutta-percha being far more
serviceable than soft rubber, and having the great advantage of being
able to be renewed whenever necessary. Quite recently a patient was
returned to hospital for further plastic operations who had been wearing
one of these plates for one and a half years, and on examination, the
black gutta-percha was found to be in a very satisfactory state.
(iii) Cases where the perforation is required for the main support of
the denture are well exemplified by the case of Captain T., referred
to above. A piece of black vulcanite was made the shape and size of
the .previously-described piece of black gutta-percha, which the patient
Fig. 7.—Splint used in epithelial inlay operation.
Fig. 8.—Vulcanite plug fitting on .nasal surface.
was able to insert and take out of the perforation, the addition of a
small metal knob on the palatal surface of the vulcanite rendering this
more easy. There was also fixed in the vulcanite over the perforation a
metal tube carrying within it in the upper part a smaller threaded tube,
as shown in fig. 8. The denture was then made to fit over the plug
with a vulcanite prolongation upwards into that part of the perforation
which was not occupied by the plug. The means of attachment of the
denture to the plug was by a simple mechanical device which enabled
a screw to be attached to the denture and to pass into the tube in the
plug, and to be screwed up by means of a matrix spanner bringing
the denture and the plug into close apposition (see fig. 9). Thus the
chief means of support to the denture is the plug resting on the nasal
Section of Odontology
81
surface of the palate through the perforation, and it is impossible to
remove the denture except by releasing the screw. As will be seen
by figs. 9 and 10 this screw is so constructed that it is undetachable
from the denture and cannot be lost or swallowed. The complete
denture is shown in fig. 11. This prosthetic appliance also illustrates
Pic. 9.
Metal parts of plate, showing screw attachment and Lennox spanner.
another very important mechanical device. As will be seen from the
diagram the patient had only the upper left molar remaining. Had
a clasp been fitted in the usual manner—i.e., fitting round the mesial,
palatal and distal surfaces of the tooth, it would have had the tendency
82 Fry ; Prosthetic Treatment of Old Injuries of-Maxilla:
to lift the plate away from the -right side, but by the construction of
two separate bands ffirthe oho, tooth, one fitting Jteiund the. mesial and
part of the paiatal and bdccal eut-faces, and the other round the distal
and part of the palatal and buccal surfaces, this detrimental effect was
Fxij; ip.
Njisal pottkm attatC:lidd W poffciiori hofofe teeth .were added.
■ ' \ •• - y •?',
Fia. U«
kuaptete den tare
Spoc&il clasp.
avoided; and the full benefit, of the rfmp obtained fig, 32).. This
type of clasp will be‘found of very great value: in ordinary dentures
with only one or two teeth • standing/
Section of Odontology
83
(c) Loss of Pre-maxilla .—Patients with loss of the pre-maxilla
present themselves in one of two conditions: (i) When the patient has
been under special treatment from the early stages, it is often found
that the soft parts have been held out by a prosthetic appliance in their
normal position, thereby keeping patent the opening between the oral
and nasal cavities, (ii) The more general way—viz., when the nasal
cavity has become closed off from the oral cavity with a resultant
falling in of the upper lip and of the lower portion of the nose, with
the consequent difficulty of fitting a functional denture owing to ihe
abnormal adhesions of the soft parts to the maxi Use. It has often been
noticed that in these cases operations have been performed in the early
stages of treatment for the definite closing up of the opening, this re¬
sulting in a marked deformity. When the opening has been closed the
method of treatment now adopted is to separate the soft parts from the
maxillae by means of an epithelial inlay operation, and to restore the
opening, the object being to correct the contour of the face, and to
enable a functional denture to be fitted. The case of Private P.
illustrates this method of treatment. As will be seen from fig. 13, he
b4 Fry: Prosthetic Treatment of Old Injuries of Maxillm
presented a distinct, falling in of the upper lip and of the lower portion
of the nose, and tin intra-ova! examination it was found that he had
only one molar left on each maxilla, and there was marked forced
attachment of the soft parts. Had a-.aituj>ie denture been made to be
held in position by clasps taimd theae teeth ft hfletf of tpty/
id.tic functional value, and the strain put upon the teeth would have
been such that they would not have rendered him service for very long,
and their loss would have been disastrous from the point of view of
afterwards fifetmg him with a satisfactory denture: Aft operation was
performed to separate the soft parts from the m&xillie, and the pros¬
thetic •appliance shown in fig. li inserted. The appliance consists of a
Fig. 14,
Prosthetic appliance worn by Private P.
simple denture with a prolongation upwards- made to replace the pre-
max ilia lost. The premaxillary portion is best made- of black gutta¬
percha and attached to the denture as previously described, the reason
being fcluit it possesses jUHfc the necessary spring to enable the apparatus
to be easily removed and inserted. This blackgutta-percha may
rajuire renewing at the end os a year, and when it is impossible to
keen the patient under observation it is necessary, after the patient has
.become used to wearing the gutfca-pfircha, to have it replaced by hard
rubber with a small portion of soft rubber on the anterior surface of the
upper extremity, where it rests against the soft tissues. As will be
seen from fig- idy the main support of the deutere ia by nieans of the
86 Fry: Prosthetic Treatment of Old Injuries of Maxillae
prolongation into the nasal cavities, and the strain is thus taken off
from the two remaining molars. In the case under notice the result
was very satisfactory, the contour being restored and a very functional
denture obtained.
(d) Loss of Premaxilla with part of Alveolus and Palatal Portion
of Maxillae .—Cases of this type naturally present the same deformities
and loss of masticating power as the above type, but to a greater degree,
and the patients are very sensitive about such deformities and seek means
Fig. 16.
Sketches from X-rayB showing condition before and after epithelial inlay.
Before operation : showing soft tissue After operation : showing “ stent ” held
adherent to hard parts. in position by means of splint.
for their rectification. This being the case it becomes necessary to bring
forward the soft tissues to their normal contour, and this naturally
results in a large communication between the oral and nasal cavities.
This loss of bone is replaced either by means of plastic surgery or
by a prosthetic appliance. The latter method has been adopted because
Section of Orfonioloou
jjpP the doheuity resulting from.-fitting a fuiietionij'l .denture over .s<*db. ; .&.
large surgical.'replacement. Nevertheless, Major'H. D. Gillies, B.A
ha? sererai f%ases np& iSn&t ; trerttm$Qbio whiob surgical replacement!?,
being adopted. In cptiSi'Heviii^ the : cpbati^e'ti6ft ; .of the appliance for
the-t:- patients. one point differing from the above- clatnjes is of great
ir4}k»r^^C^v^^a^^fe^y.r that owing to. the imali tyirmuit of the, normal
palate rftWAibhig' hi tffelfe eases, the main upward pressure of the Unit tore
(rt| Model before treatment
MWt&i
(% Model; a her;; tiv&lmxw t
88 Fry: Prosthetic Treatment of Old Injuries of Maxilla*.
during mastication is. taken by- that portion of thro .appliance which is
made to replace the bony loss. In the* early cases under treatment this
'ivka "not fxitiy realized, with the result that every time the patient put
pressure on the denture dm'iug mastication there was. an unpleasant
lifting of the soft tissues (upper lip andynose). 7 . JSiif- thhi. ; -hilatft *.
been overcome by al ways finding some jcejrwnibing ittfcr&n&s&i bony tissue
to take the pressure, and if necessary to extend the prosthetic •appliance
backwards or laterally to obtain such support. yThh foltowt'O^'' cashwell,
illustrates shch an appliance : Mr. W. This patient was admitted with
the very marked facial disfigurement shown in fig, 15 (p. 85), and with only
a small part of the palate and two teeth remaining. The treatment
adopted was to separate the soft tissues imtn the hard bv means ol‘ m
f-'n-,. ih.
Oojo^te denCiire,
epithelial inlay operation (see fig's, lb, 17, pp. ;•>(>, 87) and to construct
the necessary appliance which both held the 'soft tissues forward and
acted as.a fiiactiyoal denture To facilitate easy fitting sod removal,
the appliance, as ghovvn in fig, IhV.was made in three parte.: ,(i) a simple
deutare fitting over the remaining* part, of the'palate arid the prosthetic
replacement of the lost palate : (jil a hollow box held ip frost of the
remaining part of ftib maxilhe constructed to represent the bone lost;
and (tii) a prolcuigatjou backwards. with th§' pb|ect of olitaihiug the
necessary bony Support to the upward press ore exerted by the denture.
As will be keen fr* <i vj figs. 19 and *20, the apparatus .s simple and easily
kept clean. Part (iifi is first inserted, followed by part (ii), which will
be seen to fit over part (iii). and.-is held in close contact with it by tbe
»,-•>* ’■•'‘-a
Section of (Jdftftipltfgy
pressure oi the soft t>i$spescovering it. The deuture is then . jda-eed
jn position, In most- huxws: it te- necessary to. affix the denture to
part (tij. by means of% V'sctew .hilt in the case andet notice the sciiew
yva* discarded after a week's use, as it was found that the denture
remained in utu fpjite satisfactorily without- it owing the structure of
the parts.
h ■ si
wm
if
4v :B,
§0 Fry: Profit tic. .'Treatment; • of Old lujur if•» of .Mari’he
(*)• Tefal of Pinna i. Pnotin and Po(oh., .Extensive Icm*.of
this nature is very m&*y. and nplv x $$p case has com® raider mv notice,
and with this [iatififu the nasal spin* of tlu- premaxilia was tenmiomg.
which preserved the contour of the fact;, Nevertheless, there was a
complete loss qf all; the ihtraHif&l portions of the maxiUtn (We hg *21):
The ease referred to H that of .Lieutenant' W-, arid hi a iojuries were
the. reKhl.t'of an aeroplane accident The early treatment of this case
has both descnbed in the. of' the Rdjjftl Society of Medicine,
hut*, xh (Section of laryngology), pp, 90-04. The support for the
i Joadit)orj ,ou k&i&fe&Qii
denture was obtained by enlarging the ^khady present into
the antra, this bppratiou being • performed by. Major G. Seccom.be. Hett,
It.A.M.C, (see fig, 22} -The prosthetic appliance finally fitted differs
completely from the apparatus described m the previous, arfihlej as it
was found that, the fatter was quite hupvaeticahle. The apparatus now
being worn was made as follows r The neeestian impresaioh of the antra
md surrounding tissues was obtained by the plastei and black gutta-
percha method, and two bellow hoses were pi&dw which tVigethcr ret-
WrtfiK
#2 Fry : Prosthetic Treatment, of Old Injuries of Mazilhz
masfcwatiod, ajid y-i'jft obviating the unavoidably conspicuous .apparatus,
suggested.! by Major Kaxarjjian, entailed by using the forehead and
:supra, orbital ridges? to resist this pressure.
tlOJ
were
The construction ot the ho)low boxes presented difficulty for somf;
M'ftttV *if nifi 'rftilat IKa ^ /if p!.W &r*
. X a
accuracy of .fit that was required ; these methods did not prove suc¬
cessful. Eventually .the followingmethod was adopted : The wax mould
with the mefc&j fittings having been ptepared, t^ihpejrsiy' vyir$s were
attsched to the metal parts to hold them in position in the plaster. A
jueoe of aluroimum about i in. thick and nearly in. io diameter was
... . . ■.
K V.'-
flllTW
VA; 7M$ ;
teSptfe -:'*A
■
i* V *0 t f ij [
mmmm
" . . " '• y/PtU ‘24.
swfitido; *h.wi*i/ 5 - je-ffisthetic appnn»V.is m jJ.asitio»-
- *• ' - K'C' 'T.; T s-“ *=t-vri
thnti tMeaded with a ^ ini thread. The necessary undercuts having
ifl the vulcanite; wall of the box, it was then
embedded in the wax mould m a suitable position. A screw of aiu-
minium .was then made to fit the thread, extending outwards from
the wax so a*, to hold-the ahiminimn in position whilst in the pfastet.
The wax- .ditmifl. '•■wiis-..:thieoi:#a8kfed in th e nshal manner, the smoothest
aurfaco being kepit, upixy uiost The wax haying been, washed puty a
solution of rubber m chloroform was painted: round the edges of; .the
'mould', care being taken to cover up the metal parts. One layer. q {
rubber was alien inserted in the mould, and to facilitate the compression
of this rubber agamxfc. the wails of the mould, a wet cloth was placed
Seoimt of Qdontotlagii 93
over the rubber and compression made by filikig the centre, of the
mould with wet aaliestos. The two halves, of the flask were then
screwed up, and extra pressure obtained. The flask was then opened
repeatedly until just .sufficient rubber was present, ail overflow being
removed, >nd numerous small' gateways made. At the last ti toe of
opehiug the flask, the wet asbestos and cloth were; removed, and just
F ro . :2e
Complete prosthetic appliams?.
‘ •. l\. k. -■ r »•' ; ;’.V- \ \ . • /
sufficient silver sand insetted to replace the ashestos. The box was
then slowly vulcanized, arid when it was taken out of the vulcanizer, the
kliuotuiuiu screw Was .removed, and the silver sand shaken out.
vulcanite, screw was. then made to replace* the alnmijimxn screw and
filed flash with. the .surface of the box; Very little ffitthcc work was
necessary, m polishing plates, were used as far as possible.
94 Fry: Prosthetic Treatment of Old Injuries of Maxillae
It has been my wish to convey to you the general principles under¬
lying the treatment of these cases rather than to describe in detail the
construction of unique dentures, and to illustrate the great value of
prosthetic appliances, and the wide field now open for their use in the
treatment of diseases and injuries of the maxillae.
It is quite obvious that it is only by the dental surgeon working in
co-operation with the operative surgeon that the best results can be
obtained, and I have been fortunate in this respect in having as my
colleague Major H. D. Gillies, R.A.M.C., who has performed all the
operations referred to in this paper (except where otherwise mentioned),
and who has worked in the closest co-operation with me in our endea¬
vours to restore as far as possible the powers of mastication to their
normal condition.
Section of ©Oontoloa\>.
President—Mr. G. G. Campion, L.D.S.Eng.
Experiences with Transplant Grafts in Ununited Fracture of
the Mandible . 1
By C. Ernest West,F.R.C.S.
The group of cases which forms the basis of the present paper
numbers eighteen, the whole of the jaw cases under my own hands at
the First London General Hospital which were treated by the method
of transplant grafting. In addition a small group of four cases was
treated by the pedicle method, while I have operated on a further small
group of long bones by the transplant method. All the jaw cases were
primarily under the care of the dental surgeons visiting the hospital,
and I am indebted to the great kindness of these gentlemen, Mr.
Northcroft, Mr. Badcock, and Mr. Pearce for the opportunity of
treating the cases, and thus for the privilege of being here to-night.
The total number of grafting operations on these eighteen patients
was nineteen, one patient having a wide gap on either side with a
completely floating symphyseal region. The period during which the
operations took place was just under a year, April, 1918, to March,
1919. All were cases of confirmed non-union, most of them of a
severe type with an interval between the fragments of over i in., and
in some cases of as much as 1£ in. In one case the whole of the
symphyseal region was missing.
In all cases the facial wounds had been soundly healed for consider¬
able periods, at least two months, before a plastic operation of any sort
was undertaken. Plastic operations on soft parts were then carried
out as might be needed as a preliminary to any operation on the bone.
1 At a meeting of the Section, held April 28, 1919.
ATJ —26
96
West: Experiences with Transplant Grafts
When possible, heavy scars near the site of a projected bone-graft
operation were removed, and the locality of the scar moved by plastic
operation. The operation was conducted in each case under rectal
etherization, the composition of the injection being almost without
exception 2 oz. of olive oil, 5 oz. of ether, and 2 dr. of paraldehyde.
Operative Technique .—The skin is sterilized with 2 per cent,
iodine in spirit. The incision used is of the usual type, convex down¬
wards, and planned so as to provide an ample covering for the graft in
all directions. The platysma is taken up with the flap raised, until the
lower border of both fragments can easily be felt. The ends of the bone
are then directly cut down along their lower margins, and the bone
bared with a raspatory on outer and inner surfaces and lower margin
as is considered necessary, and for a minimum of | in. from either end.
Usually no attempt is made to clear the scar tissue from between the
ends of the bones on account of the risk of entering the buccal
cavity, which frequently dips downwards between the ends owing
to the traction of scar. The surfaces to which apposition of the graft
is to be made are now determined. Both fragments often show much
atrophy, while the whole depth of the alveolar portion of the anterior
fragment has often been lost. Thus the posterior fragment may be ex¬
cessively thinned while the anterior is very shallow irom above down¬
wards. Under such conditions the use of an iliac crest graft is particu¬
larly suitable, as it enables contact to be secured with the stout lower
margin of the anterior fragment and with the broad outer surface of
the angle. The selected surfaces are now roughed with a burr until the
cortex of the bone is removed and vascular cancellous tissue is ex¬
posed. The surfaces of contact should both as far as possible be
cancellous bone. The bone is now drilled at each end to receive the
silver wire sutures, two holes in each fragment, suitably placed clear
of the proposed contacts. Haemostasis, if not already complete, is
now made rigorous, and the wound is temporarily closed and protected
with a towel.
In the cases under consideration the graft has been taken from the
rib in two cases, from the iliac crest in eight cases, and from the tibia
in nine cases. The rib is removed by the usual method of resection,
and the graft subsequently trimmed to shape and the inner surface of
the ends shaved down with the circular saw. The iliac crest graft is
obtained from the anterior part of the crest. The outer lip of the crest
and the outer surface to a depth of about £ in. are cleared of muscle
attachments. The circular saw is then taken down the middle of the
Section of Odontology
97
crest and along the onter surface at right angles with this, and the
separated portion is removed. The graft thus obtained possesses two
raw surfaces at right angles with each other, and may thus be applied
at one end to the lower border and at the other to the outer surface of
the fragments without twisting. It is also possessed of a considerable
amount of elasticity, so that it can be adapted to the natural curve of
the jaw. The tibial grafts are cut after reflection of the skin and of
a suitable flap of periosteum. The graft is then outlined by means of
the parallel circular saw, the cuts deepened into the medulla by a
single circular saw, and the ends freed. After being loosened by a
few taps with a chisel the graft is now removed.
From whatever source derived, the essentials of a good transplant
graft appear to be: (1) Sufficient substance to allow of satisfactory
fixation. (2) Sufficient rigidity to give real immobilization. (3) A fair
amount of cancellous bone which can be got into contact with the rawed
surface of the fracture ends. No doubt periosteum in the histological
sense is always present on all grafts, but in the tibial graft the presence
of a periosteal sheet does not appear to have any influence on the
survival of the graft or the firmness of the resulting jaw. Summing
up the points of the three sources, it appears to me that the rib has
the advantage of easy removal, it is easily adapted, has plenty of can¬
cellous bone, and is of good depth. On the other hand the patient
suffers considerably at the site of removal, and there is in my experience
an unfortunate possibility of thoracic complications. The iliac crest
furnishes a graft with all the good qualities of the rib except its vertical
depth, with the one disadvantage that the patient always suffers a good
deal of pain for several days owing to the separation of the abdominal
muscles from their iliac attachments.
With the aid of a motor and parallel twin saw the tibial graft,
presents no difficulty in separation, but without this device it is a
laborious and troublesome task. The graft itself can be made of- any
reasonable width, and is very rigid and strong. There is one good can¬
cellous surface. The greatest advantage of the tibial graft is the almost
entire absence of pain after its removal and the uniformly exoellent
course taken by the wound of the tibia in healing. The channel in
the bone appears to fill up rapidly, and there is no difficulty in the
patient’s walking in three weeks or so. The only earlier obstacle has
been an apprehensive feeling of weakness by the patient. On the
other hand the rigidity of the graft makes it impossible to pull the
graft to a curve, and this is sometimes a very great disadvantage.
98
West: Experiences with Transplant Grafts
I have fixed the graft in place in every case with silver wire,
passed through the holes prepared in the ends of the fragments and
surrounding the graft. Whenever possible two wires have been used
at each end. They are carefully tightened up by twisting with pliers
until really tight, the ends are cut off and then turned in. In one
particular case a small intermediate separate fragment was secured to
the bridge formed by the graft by an independent wire. The wound is
then sutured and drained for twenty-four hours at its most dependent
part with a glove finger drain.
The essentials for satisfactory results seem to be largely obvious. I
would state them as operative asepsis, use of extreme caution in
avoiding too close an approach to the buccal cavity, actual contact of
cancellous surfaces, and good fixation. At the end of the operation the
jaw should give the feeling of absolute rigidity.
To me the most interesting problem in this work has been the
question of the fate of the graft. We have had the view put forward in
this Section that the transplant graft is in all cases doomed to death
and absorption, that its function is at its best to provide a dead bridge
along which new bone may proliferate as the absorption progresses. I
have been able to make a few direct observations. In one case, in
which there was a bilateral fracture with wide loss of the horizontal
ramus, the left side was first treated by a tibial graft. This wound
behaved aseptically, with good resulting union. The gap on the right
side was subsequently treated by an iliac graft. There was some mild
infection of the wound, which did not necessitate opening it up. The
wires remained in situ, but the graft disappeared completely, scarcely
a trace of it remaining, and the gap was re-established. Complete
absorption may thus take place in the presence of infection. The
behaviour of these two grafts viewed in association with the difference
in their circumstances re-inforces a conviction that absorption is a con¬
sequence of the death of the graft, and results in its complete ultimate
disappearance like that of any other sequestrum. In another case the
graft was exposed after some five months on account of a supposed
mobility at the anterior end. I found the graft completely incorporated
with the end of the jaw, the union having exactly the appearances of an
ordinary united fracture when exposed operatively. The graft showed
no evidence of absorption beyond the smoothing down of its edges, it
was manifestly living and vascular bone. The graft may therefore
survive and be established as a true graft. In a third case, one of two
in which late mild suppuration took place around wires, the wound was
Section of Odontology
99
re-opened. I found the graft apparently loose, and lifted out what
proved oh examination to be the compact cortical layer of a tibial graft.
Underlying this was a firm continuous bridge of bone. In this case I
believe that the relatively non-vascular cortex died, but that the can¬
cellous bone survived and proliferated. I view the case as being exactly
analogous to the separation, in a skin graft, of the superficial epithelial
layers with the survival and growth of the deeper cell-layers. My own
belief is that we are all of us right in various senses; that the graft
may, and in fact generally does, survive as genuinely living tissue, but
that it is not, in its new position, structural bone. Its conditions are
those of the jumbled fragments of a comminuted fracture. They need
not die; they become united to the surrounding bone, but ultimately
they undergo replacement by new bone of structural arrangement,
formed by all the living bone, both main fragments and loose fragments,
until the original physiological structure of the bone is reconstituted.
Because union implies vascularization it is important that cancellous
surface should be exposed on the areas with which the graft is to be in
contact.
Owing to the sudden closure of the Special Jaw Injuries Department
at the First London General Hospital and my own subsequent demobili¬
zation, it has been difficult to present you with many particulars which
would have been easily accessible at' an earlier date. Patients are
scattered, and those still under treatment are at another hospital. I
have gone carefully through the X-ray plates of most of the patients,
but they are so obscure and so little explanatory to those not
personally familiar with the individual cases that it seems a waste
of your time to attempt to present them to you. The results of
this series of cases are, however, I think, fairly summarized in
the following table :—
Total transplant graft operations
Graft survived, apparently alive ...
Graft absorbed in presence of suppuration
Graft partially sequestrated, union already secured
19
17
1
1
Extracted from Dental Surgeons' Reports.
Good union ...
Union satisfactory but with slight weakness at;one end ...
Non-union at one end
Failure (absorption of graft) ...
Dental report missing
13 grafts
3
1
1
1
100
West: Experiences with Transplant Grafts
.Function (Denial Surgeons' Reports).
1 ‘ Fairly good and improving n to * * complete restoration ” ... ... 12
Poor at date last seen... ... ... ... ... ... ... 4
Function not improved ... ... ... ... ... ... 1
No report ... ... ... ... ... ... ... ... 2
On the point of the period of time necessary for union in transplant
grafts I am unable to give particulars for the whole series. I find a
record made only in certain cases, doubtless in times shorter than the
average. The following cases are only of value as showing the sort of
period within which firm union may take place :—
Date of operation
May 14, 1918
July 5, 1918
July 9, 1918
November 13, 1918
Date at which union was hbserved
September 9, 1918
August 30, 1918
August 30, 1918
February, 1919
Such times will, I think, compare not unfavourably with those of
any other method of grafting the ununited mandible.
Section of ©fcOntoloas.
President—Mr. G. G. Campion, L.D.S.Eng.
Case of Gunshot Wound of the Mandible with Extensive
Loss of Tissue treated by the Colyer Method . 1
By F. N. Doubleday, L.R.C.P.Lond., M.R.C.S., L.D.S.Eng.
This patient, Private W., aged 36, was wounded on the Somme, on
July 7, 1916. He sustained injuries ,to his face, chest, and right arm
from machine-gun bullets. For these he was treated in a base hospital
in France until September 2, 1916, when he was admitted to King
George Hospital under my care. The skiagram (fig. 1) shows the
condition on admission. There was an extensive loss of bone corre¬
sponding to the areas of the second premolar and first molar on the
right side. The dental surgeon, under whose care the patidht had
been while in France, sent a letter asking particularly that the
treatment should be continued as before, as he had a special interest
in the case. On this account the splint was left in position until
October 27 when it and the second molar were removed and a new
splint inserted. This was left in position until January 11, 1917,
when it was removed.. Suppuration had ceased about the end of
November, but no union had occurred. The remaining mandibular
molar was then extracted and the posterior fragment allowed to come
slowly forward, being controlled by an apparatus. By February 21
the fragments had come into apposition. The patient was then sent
to an auxiliary hospital for three months, with his jaws immobilized.
Returning on May 6, the splints were removed and firm union had
occurred. His temporo-mandibular articulation was stiff for a few days
but he soon got full use in it and was transferred to the prosthetic
department for the fitting of dentures.
1 At a meeting of the Section, held May 26, 1919.
102 Doubleday : Gunshot Wound of the Mam
y f . ■ v v f--, V . 1 •*. ' ••V'. '/V- ■ .%/!'* i ’ v ; ;■ - f'G'i'tf * >
■yy'W,
• & 4v *' ■' • v *?>£' -y r5 : -VV‘' < >i • *
yN • # i / .♦/ y •> 4 ■ * * ✓ |
Lt
ywjMjWj? AWw’ iinjv
Section vf Qdontoloyy 103
The skiagram (fig 2). and modela (fig, 3), taken on October ol, 1917,
show the result of the case. It will he seen that the condyle % pushed
forward: half* way on to the emmentia artil-ularis, The.'alveolar part-of
the poBteifiOT fragment >s above the level of the anterior porfiou of the
law and the body of the; hone has firmly united with the- anterior
'•fragment,. The patient had firm union, full .■function and no. dyforrurtv.
lit will be seoti fi?bm the position of the raid-line that, the larger fragEneofc
swung very slightly back' and that most of the movement was made by
the small posterior fragment.
The interest in the: ease seems. to, me to He in the fact that it is a
typical one of its kind, and is of o, type which is more common in
ordinary times than the eases in which almost All the .face is'destroyed
•by a hand bomb or softie such. projectile.-■■ In this: ease an extethiiyo
destruction of the mandible had occurred,'but :it'was--.treated. to the most
simple' manner posaibbo by allowing the posterior fragment to came
forwaiil, as waa first suggested by Mr. .1. F. Ccilyer, The results weaje
entirely satisfaefcoyy, firm bony union occurred, the functional result
i» deformity, as may be seen by the bite
on the juocibls. was excellent.
104
Turner and Drew: Bacteriology of Pyorrhoea
An Experimental Inquiry into the Bacteriology of Pyorrhoea.
By J. G. Turner, F.R.C.S., and Aubrey H. Drew, D.Sc.
In a former paper [1] some of the chief features of the general
microbiology of pyorrhoea were dealt with, and this work really forms
a continuation of the work then commenced. Owing to the departure
of one of us (A. H. D) to Australia the work has not been carried out
to the extent we hoped, when we published a short note on it in
the Journal of State Medicine last year, and this present paper is
therefore to be regarded in the light of a preliminary communication.
At the outset we determined to study the following points.
(1) The occurrence of bacteria in living dental pulps.
(2) The presence and nature of the bacteria in the pulp cavities and
dentinal tubules of dead teeth.
(3) The presence of organisms in cementum.
(4) The presence of organisms in the periodontal membrane.
(5) The presence of organisms in the gum.
(6) The presence of organisms in granulomata attached to dead or
pyorrhoeic teeth.
(7) The presence of organisms in the bone in cases of periodontal
disease.
In addition to these points we determined to study the organisms
found by cultural methods, and to endeavour to obtain evidence of
infection by means of such pathological methods as complement fixation,
opsonic indices, blood changes and agglutination. With regard to the
examination of bone we have to express our thanks to Dr. Stebbing, of
Lambeth Infirmary, who very kindly sent us portions of the jaws with
teeth in situ, together with the stomach and adrenals in cases dying in
the infirmary.
Technique .—With regard to the demonstration of organisms, both
in tissues and bones, we were met with the great difficulty at the outset
that the ordinary methods of staining were most unsatisfactory for the
work and frequently failed to show organisms at all. In addition to
this the usual paraffin embedding processes were frequently found to be
unsatisfactory for much of the work. Nearly the whole of the
sectioning has been carried out by one or other of two methods, which,
Hectiov of Ot&ri totogy 105
if properly performed, give extremely good rewults. Teeth, bone.s and
tissues have usually been fixed by at once placing them in 10 per cent,
formol-salihet or in Muller's fluid ; they are then washed and cut with a
freezing microtome, cherry g’utfi being used as the infiltrating agent, The
other method has been to treat with the cherry gum process described
by Salkmcl in the Campt. rend. Roc. rfe 1910, ixxix, p, 811. In
either case the sectiotts are mounted on slides very thialy coated with
1 per cent, gelatine, and arc next exposed to .fortnol vapour for about
one minute, and then placed in 10 per cent, formol. They are then
washed and stained. With regard to the staining methods a modified
Oram’s method, neing Kile blue sulphate, has been found to be the
most generally useful. Nile blue was originally suggested td qg by.
EJr. d. A, Murray, of f-he Imperial Cancer Keseareh -FisoS, and after
a good deal of experimenting we found it Was ; very satisfactory when
used us * Siam process- Sections are fixed sod cut by the methods
already described, and are then stamed for. five minutes in dilute
(1 m 10) carbohfuchsm. They are next washed in distilled water.
UM.- Turner and Mf&W : B&cUriology of Pijorihoia
' ■
and ivre sUifeed fox- two' to twenty* fcrnr -hours m a sp pet cent, Nile;
•blah solution ami again washed, The preparations are then treated
with tTntm's iodine solution lot tea rmtintes, washed iO water .and
then vej;y rapidly decolosixed iu ulcdhhl'acetone (1 in,,5); cleared with
xylol-phenol and motvoted m balsam. Ao alternative method which
•lra-s at times proved useful has been to stain for tun mmutes in dilute
cwdiol-fuchsin und then to wash well in water. The preparation is
then stained foe thirty minutes m % pen. cunt. Nile blue,' 'placed in
carbol golitiafi violet for three itiimites, and then/ip iUugoTs iodine add
4tet»hal ««''in the ordinary Gram's ruetb.odL,.
It is not mopoHedVto give a detailed description of; all the cases
they run into many hundreds hut to confine our attention
examined
to a selection of the .most typical, and for this purpose wo
the; arrangement referred to in deserrbiag the objects of the/.present-
research.
• ( i.) Uacteria in Living Vui />.—Thu living pulp; appears tc# become
SMlwn of Odontology :
.••ifS&diiy,- infected* such infection riot ‘associated with.
this
pulp of
a warn down and .staimwl- bicuspid with •'•chrome ' jpyorrk<seft which
probably w as not concertied in the p)j ip • isfoctihii- The specimen
ahows a diphtheroid infection. A further cum not hero figured showed
an infection by two distinct types of dtphtheroids, a Urge type similar
to the one figured in this case and measuring ‘:Ci> a- to. 4 m in length, and
A
^;.ri:-n V :
1
mmk.
st small type measuring 2'2 f to 3. g it? length, father cases haye. shown
mixed infections, diphtheroids,, streptococci, and at time#, spirochastes
appj staphylococci. These mixed rafeotioris were always associated with
caries to a greater or less extent. Oh fct least one .occasion the Vessels
of the palp hmc been found to contain org&niams—viz., diphtheroids
and cocci.
- iVi> •;„ • Tnf.l.,,rr~. siafo T\£ Mu ■■■ rf*.-. i
m
SMS
108 •■'Turner-.and Drew: Baclsrwhgy pf Pyorrhoea
certain. Fig 2 shows* a heavy infection of the pulp cavity by a diph-
theroid, with direct extension into the dentinal tubules. While prob¬
ably any organisms .existing in the mouth can infect pulp, the
organisms most usually associated with such, dentinal infections
seem to be comparatively few in rmmber—vi*., diphtheroids, cocci,
and spirochetes. ...
(3) Onjanisvis in Cementum .—The ceinentum frequently becomes
infected, and we may distinguish three routes of infection—viz., (i) via
fiq; 3 ;
A, periodontal .toemln-urie.
the pulp cavity and tubules, (n! through the periodontal membrane;
and (it!)'from surface;caries, ,35g. 3)ihows an infection of the cementum
by a streptococcus ; >n this case the periodontal membrane also showed
infection, whilst the pulp and tubules were free. This section seems to
show that cementum mu t*« infected from a living, hot infected, peri¬
odontal membrane. -Wn hsiVc no sections shewing the actual invasion
of cementum by bacteria bywaydentinalytubniies,.bnt fig. 4.
represents a section showing its near approach. Fig. 5 shows surface
m '•rjfl. ' i v’a'J. ■ ’ Ul *’
1 ’ < * : |
? -
> WWfi*ijB) 1
KjjfrV £. J-' •%■
wO'. '<■' (ift 1
'-jir^ 1 . i .: 1
:• ;S
tit ■ ‘ jJUjC'
jpl^ks^Ti 1
j
rSAV? :> S3
110 Turner nr.vl Drew : Bacteriology <{/ Fyorrhmi
caries of .the cement nm. There was a thick growth of bacteria on the
■surrounding - cement surface. • .This Ja,yer of bacteria if. always fcet be
found ott the denuded roots in pytWiheoal pocket;;, and explains the
difficulty of treating pyorrhoea without thorough cleaning of ail such
denuded roots., fkig... G shows this condition,
f# ■Qrgam$,w& iii'PcriMontal MuthLnnie — Fig. ? shows an infection
diphtheroid infection. We have, nnfortunately, no other photographs
of periodontal' membrane infections, but other specimens are shown
\»mler tjie raicroscope . C •,
(ol Organkws hi Ou»i*. —Portions of gum removed from chronic
cakes hhve invariably shown the preseoehnxf 1'iKTteriaj the most frequent
twkrig diphtheroids, streptococci and staphylococci, whilst on nnk occasion,
a heavy infection with a spore-bearing haciihi^ was found Cultures
112
Turner and Drew: Bacteriology of Pyorrhoea
have been obtained in two cases from infected gum tissue. In one, a
chronic case, a diphtheroid was grown ; in the other, an acute case with
ulcerating gum edges, a short streptococcus, which in culture grew into
long chains, was obtained. The diphtheroid could not be distinguished
from the Bacillus septus (Bacillus coryzse contagiosa:), whilst the
streptococcus gave all Gordon’s metabolic tests for the Streptococcus
pyogenes. The patient’s serum gave marked complement fixation in
the case of the diphtheroid, but we were unable to examine the patient’s
Fig. 9.
blood in the case showing the streptococcus. Figs. 9, 10 and 11
illustrate these gum infections very well; fig. 9 shows a diphtheroid
infection of the gum, and fig. 10 is from the case in which a
diphtheroid was cultured. This case showed recurrent gastric crises,
which were greatly benefited by extraction. Symptoms persisted to a
certain extent, a fact which may perhaps be explained by our finding
diphtheroids in the stomach wall in similar cases. Fig. 11 shows an
infection of the gum with a spore-bearing organism. In this case the
gum showed chronic fibrous thickening. There was no pocketing by
■ffl
Sectihn <>j 'Qihrtlatoytj
mm*
•->V
Pio.-ig.
••!■ jj - Wj .*?- [Huf
. -M$iX
MtWm
&sbmsi6&
* ‘ v, ;;.# ■ ■
11*3 Turner and I'mnv : BiteferiWoop »f P#.orrhi?&
destruction of : the aU’folai- deiitai membrane. huh only by > wiling:'inf
the gum, and no ulcer was bo be seen on tM excised piece oi g.uui
Apparently the bacteria gained entrance through a'toereh inflamed'
eprfacf*' 'Pig; Ld is taken from the gurn bap overlying an erupting
wisdom tooth in a man aged 3& ^.ins specimen shows denial sepsis ab
its earliest' possible ludment—'i.« M just as the. gam uncovers tho tooth
and leaven, idie crypts open to itifeetion This supplies the explanation
of teething tronbk**:. A pure diphtheroid lhfeetioii is to he seen running
■
np the lymphatic spaces An exceedingly• interesting point in the
inajpntv of these infections'is the.-entire 'absence of phagocytosis cm tin-
part of the ti.•..:!!!■-
id-) hr,)fiiu.ytn?. it i yrauuhmata '.e~.Section's of gram*.lowata from the
apiceM -.'I teeth have I'xviiriahly shown the presence of. organisms.
fei •-how.-; the straefcore of the- - majority .of such gramiibinatah
jhhmibfse; niiitiheys of plasma ceils together with fibrous tissue form tint
. chWipju't J‘oiyfe*orphhnhdfearsi and lyniphccyth^. only present m.
Section of Odontology ! ! '">
small numbers, anti there appears to he tittle oir, yao- phagoej’tie reactioil
to the bacteria Fig. 14 shows a gvano.loma. infected • With staphylo¬
cocci, whilst fig. 15 shows a diphtheroid tQ(eptiofi,c : :
(•7i 'Organism* in Boar ~--rk?Otit'n.s through 'the jaws with teeth in
Mtf in eases o? advancctl . prOrrhtt-tt. h&ye .shown the pieseneeg’ hf
organism* often in very lat'ge nuviibers iul.ba boiie. a striking fact being
the presence of bacteria within tin •.' Havebjiihi' »> stews. In several cases
of this nature the'same organisms found in t he hone viz., diphtheroids
High poorer. 4 , It.tn^baMO.fBaG*
and 'cocci—haye behn. found in. the stomach wail* bat the total number
of socb cases .examined is not large -enough to enable ua to state that
this condition is invariably present. (Sections exhibiting the eondttkiu
were shown under the microscope,) Fig. 16 is a section of decalcified
tartar showing thru, .tartar is a mass of bacteria solidified by calcium
salts.
Turner and . of-Jfrtorrti
"... ' "
Z'fW »
im
....
mmm
118 Turner and Drew: Bacteriology of Pyorrhoea
The foregoing cases will amply suffice to demonstrate the great
importance of the mouth as a potential source of disease, although we
have not presumed to draw any definite conclusions in the present
incomplete state of the work.
REFERENCE.
[1] Drew, A. H., and Griffin, Una D. “The Parasitology of Pyorrhoea Alveolaris,”
Joum . Roy. Microscop. Soc., April, 1917.
A Demonstration at the Odontological Museum, Royal College of
Surgeons, was given at the Meeting held on June 23, 1919, by Mr. T.
F. Colter, F.R.C.S., Hon. Curator.
PROCEEDINGS
OP THE
l-.WTEl* BY
Sir THIN \\ M aC AL.ISTER
INOf-r I'tlK nu’.f-CTMS r,t
THE EDITORIAL 00 MM ITT E E
-
VOLUME THE TWELFTH
s,'i 1 ‘
SESSION i‘RK i ;
SECTION OF OPHTHALMOLOGY
/• . ,* • , • \ • ’■ /'••• VVi VV v, .'0-' A •%'• • .•••'■’':•• .* - •» * if,v.v] • * , ‘ •' ’ I - : Y ' '< • „•'!"< > -V VS * I* *?)' ,*'*
rV$'!<
»*»'i
LONDON
LONGMANS. GREEN k
.PATERNOSTER ROW
Section of <S>pbtbalmoIog\>
OFFICERS FOR THE SESSION 1918-19.
President —
William T. Holmes Spicer, F.R.C.S.
Vice-Presidents —
Priestley Smith, F.R.C.S.
A. MacGillivray, M.D.
Charles Higgens; F.R.C.S.
H. E. Juler, F.R.C.S.
E. Treacher Collins, F.R.C.S.
William Lang, F.R.C.S.
A. Maitland Ramsay, M.D.
Hon. Secretaries —
Leslie Paton, F.R.C.S.
Malcolm Hepburn, M.D.
Other Members of Council —
Rayner D. Batten, M.D.
Thomas H. Bickerton.
R. H. Elliot, M.D.
Wilfred Harris, M.D.
Arnold Lawson, F.R.C.S.
W. C. Rockliffe, M.D.
P. C. Bardsley, M.B.
Elmore W. Brewerton, F.R.C.S.
L. V. Cargill, F.R.C.S.
C. O. Hawthorne, M.D.
R. Foster Moore, F.R.C.S.
F. G. Thomas, M.B.
W. H. McMullen, M.B.
A. W. Ormond, F.R.C.S.
J. Herbert Parsons, F.R.C.S
G. H. Pooley, F.R.C.S.
T. Snowball, M.B.
Representative on Library Committee —
J. Herbert Parsons, F.R.C.S.
Rejrrcsentativc on Editorial Committee-
Leslie Paton, F.R.C.S.
SECTION OF OPHTHALMOLOGY.
CONTENTS.
November 6, 1918.
W. T. Holmes Spicer, F.R.C.S. page
President’s Address: The Formation of Clear Lines in Nebulie (Abstract) 1
Harvey Goldsmith, M.D.
Angioma of Retina ... ... ... ... ... ... 8
J. B. Christophrrson, M.D., and R. G. Archibald, D.S.O., Major R.A.M.C.
Case of Primary Nocardiasis of the Lachrymal Gland caused by a Species
of Nocardia hitherto undescribed ... ... ... ... 4
February 5, 1919.
A. C. Hudson, F.R.C.S.
Folds in the Internal Limiting Membrane of the Retina ... ... 15
William Lang, F.R.C.S., and Donald Armour, C.M.G., F.R.C.S.
Ivory Exostosis, growing from the Roof of the Frontal Sinus into the
Orbital and Cranial Cavities, removed through an Osteoplastic
Opening in the Cranium by Mr. Donald Armour ... ... 16
J. F. Cunningham, F.R.C.S.
Case of Tumour of the Roof of the Orbit ... ... ... ... 20
E. W. Brewerton, F.R.C.S.
Case of Angioma of the Retina ... ... ... ... ... *20
James Taylor, M.D.
Changes in the Sella Turcica in Association with Leber’s Atrophy
(Abstract) ... ... ... ... ... ... ... 22
William Wallace, Captain R.A.M.C,
Fundus Changes resulting from War Injuries (Abstract) ... ... 24
R. Foster Moore, F.R.C.S.
Sympathetic Ophthalmitis with Fundus Changes ... ... ... 25
IV
Contents
March 28, 1919.
Elmork Brewbrton, F.R.C.S. page
Angeioid Streaks in the Retina ... ... ... ... ... 88
Miss Rosa Ford, M.D.
Congenital Pigmentation of the Cornea ... ... ... ... 84
Harold Grimsdalb, F.R.C.S.
Pulsating Tumour of the Orbit, of Uncertain Nature ... ... ... 85
Raynbr Battbn, M.D.
Symmetrical Disease of Macula (with drawing of Left Eye) ... ... 35
J. F. Carruthers, M.B.
Case of Intra-ocular Growth ... ... ... ... ... 36
A. W. Ormond, F.R.C.S.
Case of (?) Pituitary Tumou r ... ... ... ... ... 37
L. V. Cargill, F.R.C.S.
Pituitary Tumour (Hypopituitarism) ... ... ... ... 41
G. Maxtbd, F.R.C.S.
Case of Malignant Disease of the Pituitary Body, with Comments ... 42
J. Hkrbkrt Fisher, F.R.C.S.
Migraine... ... ... ... ... ... ... ... 49
June 4, 1919.
J. Hkrbkrt Fisher, F.R.C.S.
Drawing of a Transverse Section through the Optic Chiasma and Sella
Turcica to show the Relations of the Pituitary Body ... ... 56
L. V. Cargill, F.R.C.S., and W. J. Lindsay, M.D.
Pigmented Connective Tissue immediately in Front of and Covering the
Optic Disk... ... ... ... ... ... ... 57
F. A. Juler, F.R.C.S.
Obstruction of Central Retinal Artery with Patent Branches, following
Electric Flash ... ... ... ... ... ... 58
R. Foster Moore, F.R.C.S.
Melanoma of the Choroid ... ... ... ... ... ... 60
M. L. Hinh, M.D., F.R.C.S.
An Unusual Case of Ptosis with Bilateral Ophthalmoplegia Externa ... 61
E. M. Eaton, M.D.
The Visual Perception of Solid Form (Abstract) ... ... ... 63
Contents
v
SECTIONS OF
OPHTHALMOLOGY AND LARYNGOLOGY.
y i^y : i ■ r . /
{COMBINED MEETING.)
April 2 , 1919.
DISCUSSION ON INJURIES AND INFLAMMATORY DISEASES
AFFECTING THE ORBIT AND ACCESSORY SINUSES.
The President (p. i); Mr. L. V. Cargill, F.R.C.S. (p. ii) ; G. Seccombe Hbtt.
F.R.C.S., Major R.A.M.C. (p. xi); Mr. Arthur W. Ormond, F.R.C.S.
(p. xxviii); Mr. E. D. D. Davis, F.R.C.S. (p. xxxviii); Mr. H. D. Gilliks
(p. xliv); Mr. D, Leighton Davies (p. xlvi).
April 10 , 191 Q.
Discussion on Injuries and Inflammatory Diseases affecting the Orbit and
Accessory Sinuses ( continued ).
Mr. \V. M. Mollison (p. li); Mr. J. F. O’Malley (p. liii); Mr. G. H. Pooley
(Sheffield) (p. lv); Mr. E. H. E. Stack (Bristol) (p. lvii); Mr. W. Stuart-
Low (p. lviii); Mr. Herbert Tilley (p. lx); Mr. H. Lawson Whale
(p. bd) : Dr. James Donelan (p. lxii); Mr. L. Y. Cargill (reply) (p. lxiii) ;
Mr. Arthur W. Ormond (reply) (p. briv) ; Mr. E. D. D. Davis (reply)
(p. ixiv) ; Mr. G. Seccombe Hett (reply) (p. lxv); Mr. E. Treacher
Collins (p. lxvii); Mr. Herbert Tilley (p. lxvii).
The Society does not hold itself in any way responsible for the statements made or
the views put forward in the various papers.
OPH.
London :
John Balk, Sons and Daniklsson, Ltd.,
Oxford House,
83-91, Great Titchfield Street, Oxford Street, W. 1.
Section of ©pbtbalmoloav.
President—Mr. W. T. Holmes Spicer, F.K.C.S.
PRESIDENT’S ADDRESS.
The Formation of Clear Lines in Nebulae.'
By W. T. Holmes Spicer, F.R.C.S.
[This paper is printed in extcnso , with illustrations, in the British Journal of Ophthalmology ,
January, 1919, pp. 1-8.]
(ABSTRACT.)
A few observations have appeared from time to time in the journals
devoted to ophthalmology on the presence of clear lines in old corneal
scars, but no complete and satisfactory account of their origin has been
given. The first observation, with an attempt at a sketch, was made
in 1896 by the author: since then brief notes and sketches in large
numbers have been made which have shown the essential features of all
these appearances; much information was given by a rough sketch
in a hospital letter by an unknown hand of eighteen years before.
Inasmuch as the changes are dependent on the presence of blood-vessels
in the cornea, a knowledge of the form of such vessels is necessary..
The arborescent form occurs in superficial inflammations and represents
free surface branching unconstrained by the pressure of surrounding
tissues. The terminal loop form appears in marginal superficial
inflammations, and also in the acute vascular form of interstitial
keratitis in which vessels invade the cornea at all depths. The brush
or besom form has deeply placed vessels constrained by the layers of the
cornea in which they run, to a more or less parallel course. The umbel
form is also a deep one ; in it a single vessel grows into the cornea for
1 At a meeting of the Section, held November 6, 1918.
D—7
2
Spicer: The Formation of Clear Lines in Nebulae
some distance without branching, till it ends in a number of radiating
branches like the head of a mop, or the inflorescence of the parsley
umbel.
All these small vessels are to be regarded as capillaries in which the
distinction of artery and vein is retained to the final transition. It is
uncommon for vessels to disappear and leave no trace; even though
without blood contents they may be seen as fine silky threads near the
surface or as clear lines beneath the surface. Vessels keep to their own
layer in the cornea, they do not commonly communicate with those of
other layers ; vessels from one layer may cross those of other layers at
different angles. (
The clear lines divide themselves into two groups, the geometrical
and the mushroom head. The geometrical lines are perfectly straight,
or run in large smooth curves; they are parallel or, run at an angle
with each other, converging or diverging; they are very much yrider
than any possible vessels. They are mostly seen near the centre of the
cornea, and are not visible at the periphery; as they have no visible
structure, they can only be made visible by the opacity in which
they lie.
The explanation of the lines is as follows. After the subsidence of
an attack of interstitial keratitis attended by the presence of deep
vessels in the cornea, these vessels become flattened between the layers
of the cornea, and acquire a greater width than when they contained
blood; at the same time a longitudinal contraction takes place along
their coats, producing a straightening of their course. The effect of
the vessels on the corneal tissue is an interference with its nutrition
so that the cornea becomes opaque or cloudy in the region of the
vessels.
The mushroom head has the appearance of a section of a mushroom
carried through the side of the stalk and head, showing the stalk, and
the crescentic head with gills on the concave edge. The stalk has the
delicate blue colour of a primary nebula, the crescentic head has a dirty
white or buff colour: the stalk is anterior to the head. > The stalk is
the line of scar tissue which results from a fascicular or vascular ulcer.
The head of the mushroom is a secondary opacity depending on
interference with nutrition and separated from the stalk by an interval
of clear cornea; the gills are fingers of opacity dipping down between
the areas supplied by the terminal branches of the capillary vessels.
The same condition may be seen in the form of arches of opacity in
the cornea with their concavities towards the limbus, depending on a
Section of Ophthalmology
3
focus of scleritis situated outside the cornea altogether ; it may also be
seen in dermoids of the sclerotic at the edge of the cornea. The
shortest time in which these secondary opacities have been seen to
come is four months.
Angioma of Retina.
By Harvey Goldsmith, M.D.
A soldier, aged 18f, attended at No. 8 Ophthalmic Centre a
fortnight ago for loss of vision in the left eye of about six weeks’
duration. He states that, when examined for the Army early in
September, he saw better with the left than with the right eye, and
that the examining surgeon noted this.
Present condition : Bight vision = — 3'00 d. sph. = T ° 5 . Left
vision = < c —1'25 d. sph. = —1'25 d. cyl. — not improved.
He has met with no accident.
The upper temporal artery on the disk is double the normal
diameter; it proceeds upwards and outwards with many sinuosities,
apparently increasing in diameter as it courses towards the periphery.
This increase is particularly noticeable where it runs over a broad white
patch, after which it is lost in a large swelling of indefinite form, the
outlines of which cannot be fully made out on account of its situation
so far forward. Above the artery lies its companion vein enormously
dilated. This seems to proceed from the above-mentioned mass and
reaches the disk in a series of wide convolutions, its tributary veins
being much engorged. As to the rest of the fundus the lower temporal
and nasal veins are much enlarged, their corresponding arteries showing
little, if any, departure from the normal. The nerve head is hyper-
vascular. There are several small recent haemorrhages and patches of
doubtful exudate, especially in the macular region, and pearly white
patches along the course of the enlarged vessels, while a large area in
the extreme outer periphery presents the appearance of a shallow
detachment.
Ophthalmoscopic examination of the right eye is negative.
The picture of the case resembles in many particulars that shown
by G. H. Pooley and illustrated in the Ophthalmological Society’s
Transactions, 1910, xxx, plate IX (facing p. 238).
D —7 a
4 Christopherson and Archibald : Primary Nocardiasis
Case of Primary Nocardiasis of the Lachrymal Gland caused
by a Species of Nocardia hitherto undescribed.
By J. B. Christopherson, M.D.
{Khartoum Civil Hospital ),
AND
R. Gr. Archibald, D.S.O., Major R.A.M.C.
(Pathologist, Tropical Research Laboratories, Khartoum).
Introduction.
The disease recorded in this paper represents a nocardiasis 1 or
actinomycosis, in which the causal agent is a genus of fungus,
characterized by having a mycelium composed of fine bacilliform
hyphse growing readily aerobically and producing anthospores.
In all probability it gained access to the lachrymal gland by
settling on the surface of the eyeball, and working its way to the
upper fornix of the conjunctiva, so entering one of the lachrymal ducts.
Clinical History and Description of the Case.
On May 12, 1918, the patient, M. B., a male, aged 22, from
Dongola, was admitted to Khartoum Civil Hospital suffering from a
swelling of the right eye, and an inability to open it. The swelling,
which was of three and a half years’ duration, and was gradually
increasing in size, was attributed to a blow received from a native shoe.
There was, however, no visible scar.
On examination, it was found that the eyelid could not be everted,
but when raised, a thick yellow discharge poured out, and the whole
of the conjunctival surface of the upper lid appeared to be rough and
granular, with deeper ulceration in parts. On palpation, the swelling
was painless, and of a doughy consistency, but without oedema; it
extended between the eyeball and the roof of the orbit, causing a
1 Keratitis produced by mould fungi (kerato-mycosis-aspergillina) has been described in
Fuchs’s “Text-book of Ophthalmology,” 4th ed. (translation), p. 259; also in Pyle’s
“ System of Ophthalmic Practice ” (Path. Bact., Collins and Mayou), p. 411.
Bedim of Ophthalmology
bulging forward of the fornix of the conjunctive; There were no
enlarged lymphatic glands, the eyesight w&a intact, the eyeball itself
was. not invaded, nor were its movements involved, arid there war.
neither photophobia nor 'aehrytnaiiosi. It was therefore evident that
thitre was an intra-orbital growth tying between the eyeball and the
bony t'Oof f chiefly extending into the upper eyelid, and »nvolying all
the structures therein, except the skin and eyelashes, and nlcetatihg
it (most the whole of the palpebral surface of , the conjunctiva..
• A nook after adhiksiofi to hospital, the growth was dissected away
tinder chloroform;. In order to evert the,eyelid, it was necessary to slit
FAS-1.—fi , iuaifl, ;tgtd. sa, LyUat, \4 ilw lachrymal gland.
Upp.H- rvolM iwoiifittiaiilf Unniy Tfarw- vd< 1 *. bait •caw’ duration
Pjl I'i.'woo With cfrijHl iTitlicufty a~ U> expose .is umfth of the growth
m passible. Shows yyuhall prowed ehrnviT : also shows'evoliA invaded.
the externa! cantbns, and so bring the growth into view. It appeared
jtaJj'^yerPOibmencod in the lachrymal gland, and’ to have'grown into, the
tipper lid, invading the tarsal cartilage, and to- have extended to a
certain extent between the eyeball and the bony orbit ah.mg the duets
of the lachrymal gland.
The growth itself was a flatfish tabulated hotly about If id. in
length, add consisted of two ilbdefihed lobes, which were intimately
!> Ohrisfcppherspn said Archibald . Primary NocrmHasi*
connected r the ojie portion consisting of the lachrymal gland and the
extension of growth into the eyelid, and the other probably consisting of
a psirt of the growth and the orbital portion of the lachrymal gland,.
The conjunctiva was exteusivelv affected;
When inspected with a hand lens the growth showed numerous
tight yd low gelatinous areas 'scattered throughout the lachrymal, gland
and the. surrounding .grauulbiOatous-looking tissue. Some of these
gelatinous areas were excised with aseptic preeautiows* a»d tiiaflaferred
to tubes containing sterile normal sajine solution, thoioaghly shaken.
M~ B,, aiHle, aged 22. After removal of lachrymal glftGiJ and grontb
and emulsified. The imutlsioO, was then examined with a lens, and
found to contain .minute. vel^V a soft eonsistehey, somewhat
icyegnlar in shape, and measuring about <J"2 tht&. m diameter. These
were removed with a platinum loop, and subjected to further washing
with sterile normal, selice solution, before being eh suitable
culture media.
The remainder of the growth was then placed >a fixatives, and
embedded lor histological examination.
faction of QpJtiktiMoldgy
PaCTOLOGIGaL HA.STOIit.OY
Sections. showed the morbid bishdogicsil. ; bhangs® rommohly asso¬
ciated with a fungus infection. There was marked, vitreous degeneration
of the Wffsrtes, ^yith of pffc&nia ggjjl?)*' ind ydiinjg connective
tissue Cells 'fig. 4), and io • the vieioity of the lachrymal ducts
noeardia) grains could be seen irregoiariy distrfhrffced., but m most
instances separated from the;sorrottnd)r>g tissue by a clear unstained
ETaia- ?
M
Section shftivii)^ fflun’i# site aac| pluaum cjail itiflliwtioti. (*• 200.)
area (figs. 4 and 5>. No sheath proper coaid be detected In the
tissues the grains showed little structure in detail, owing to the dense
matrix present.
Iej GratO'Weigert stained sections, numerous cellular elements
known as fuchsia or Russell's bodies were found scattered throughout
the gland and adjacent tissue, They retained Oram's stain, were
0M Ohristopber^oii and Archibald: Prinfaijf N&etf0iasis
ebcoJav in shape, and occurred singly or in clumps, and varied in sixe
from 'i ft to 3 ;V t* in diameter tfig-. Their exact; nature is* unknown.
They have been previously recorded as occurring in actinomycosis
and maduromycosis, and there, can. be little doubt. they are fungous
in origin.
Sfeciliw oWwing grain in lachrymaldeeb. (x ICO,)
.SeeUQn of Qpj^h0m^tpgtyi i :
'^■ ■S'^'OCTDIiE OF TUB
■ ' ■
A portion of tfee gtaio ftatteoed betweext a slide .an<i coveryglass.
showed that it -was composed of typical noeardiat baeilUform. hyph©
with roandsd bodies or spores (6g, 7), the whole being held together ih'
it dense matrix, which more or less concealed the. hyphfti and spore
elements of the grata as seen m the tissues.
A portion of a trufehscl ftiJcrt»4i6f gr&hi stained, showing baeithforBi hypfcs.l filaTrt&rtte
; -'Y a»)(i spores. (x 600 ) .
CCfvTlVATJQN. XV-
:
When the grain was -pinged Ofl .Salable media growth readUjt
occurred, arid .-subcultures were carried out ok various media. The
ftthgits obtained from the grain was not only an aerobe, but also a
faetiltative anaerobe. Under aerobic Conditions growth readily occurred
at -2‘2- C and 37 €., but ceased at. od 1 ; C, The ophirmun teinperature
appeared to be 30° C. In young cultures the hypha! filaments ar<d
spores were Gram-positive and acid-fast; in old cultures, however, the
filaments and spores did not retain Gram’s stain, and were tvomfilcohol
fast- Well developed cultures invariahly ,possessed a ; characteristic
ochraeeous orange colour (Itidgway's standards Plate XV, IS, i;G),gave
off no odour, and showed no efflorescence.
10 Cbj'js..f.ophy- 1 'jjOtt anil Archibald : Primary Noeardiaste
In $abiniravii'fi wait a a raised convoluted oetiraceousbrang<^coi>nut-d
growth was; produced without pigmentation of the eurrintindmy medium
(fig. ft}. In' mr-^Ofa^e^ orange {involuted ^growth
occur-'red without pigmentation of the median). In ktuinent
stab cultures ri.t 22° C. showed a grcwish-ecdoum) villous growth along
fchoMiue of thfc si;al>. while the surface gehwth wan convoluted and of a
reddish-yellow colour Neither pigmentation nor liqirefaetioh of this
medium' occurred at the end of six weeks. In 'inspissated ot-blood
■•:'rvw the growth was convoluted, (if a .yaliow colour, and more viscid
Three day# oM culture of rioG&rdja] gram on Sabcmmur* medium
showing him ooiivolufed giowtfr..
I 'ig. 9.—Cuiiure on potato seven days old, Katural size.
in cbariicteT than- in other cultures, Neither liquefaction neis pignidfita-
irioa of the ipediurn was prfcgept. In peptone- iiroth there occuned after
forty-eight horn* a general' turbidity with pellicle formation, and a
luxuriant growth of greyish-fcolomed oobermg fioccuii, followed 'to.ter
hr » yellow pigmentation of the medium- la litfhibi milk neir bet-
acid .formation nor clotting occurred. Old cultures showed a yellow
pigmeotat'ittn of the .medium. On «\j(ir ugur a raised moist ochracooue
-oiatige-colouvcd growth with paler edges was produced, without
Section of Ophthetlmdogy 11
pigmentation of the surrounding medium, The fungus did not show
the same tendency to foirm.-a convoluted .growth. on this medium, as on
glucose or Babouraud's agar, On potato a luxuriant raised viscid
ochraeeous orange-coloured growth: occurred with, pignmntatituP bnt; no
eroding 0 / the mbdlutii (ftg. 9) . Jn ftmd sitgar media thegrowth was
similar to the growth in pepiom broth; Neither acid aov gas formation
oeonfr^ in ^^var^tis.^ug^rs^jf^Qffed.
MyOuTjOOV.
Cultures showed, as in the grain, the presence of non septate fine
hacilliform hyphae with spores ifig, JCi. which appear to be held
Sni'ear ptoWratiOo oi a cfiUurc 1 \sb il&va aid. ( 1,000.1
together by a vseid pigmented substance apparently secreted by the
fungus
Sorue of the hyphal filaments, more espeeuUly <o older cultures
showed irtegtdar bhine'hirtg (tig, 11), and contained within their walls
dark staining areas representing chains of - .Spoi«* (%, -Cii, which
apparently became 'detached or shed as the eutture inereased in age,
Fig„ 13 represents & section -of a culture eight dayi p.b|. Fig. 14
represents a section or a culture twenty-one days old, and shows the
large number .of spores with comparatively few hyphal Biaments.
1‘2 Chriatopbwson and Archibald
Frimanj Nocardiads
Fru. a.
Smear preparation af a culture -even day-old, vhotviufc- the* irregular braiiL'hiinp
of the hyphal filament:*. ($ 1,000,
Smear preparation o£ n eulttyp&;.$]
hvptwU lilaxneale. ( % i ,000:)
Section- of Ophthahmlogn 13
•. ' •
In young cultures the hyphat filaments averaged ‘2 to 4 p in
length an<3 O'5 ji in l>i«adth; 30iue longer filamttalp measuring 12 >
in length were fretjaenfcly present.
The spores, which apparently represented anthospores, were more
or less circular in shapo. and measured 07 /r to 1 ft'm diameter;
of * culture eight d»y« old> showing hypbal pjiitneutd j*nd 4po«fc-. ( v
Section of a culture
filatowkw. { 30O t )
14 Christopherson and Archibald: Primary Nocardiasis
Animal Inoculation'
Experiments to. prove the pathogenicity of this fungus have not
been completed. The result of one experiment showed that it was
not pathogenic for a grey monkey (L. callitrichus), when inoculated
subcutaneously.
Classification of Fungus.
/
The fungus described belongs to Fuckel’s class of Fungi imperfecti
order Microsiphonales, genus Nocardia (De Toni and Trevisan 1889),
section Parasitica (Foulerton 1910). It appears to be a new species
and does not correspond with any fungus described in the literature
available here. Recently Chalmers and Christopherson recorded a new
species of nocardia,. Nocardia convoluta, as occurring in the Sudan.
Nocardia convoluta, however, differs from the above described fungus
in: (1) Being non-acid fast, (2) liquefying inspissated ox-blood serum,
(3) producing efflorescence, (4) 'producing buff-coloured growths.
Conclusions.
The fungus from this case represented a nocardia which was
found parasitic in man. In young cultures it was Gram-positive,
acid-fast, and did not show club formation. It was readily cultivated,
growing aerobically and anaerobically, without odour or efflorescence,
producing ochraceous orange-coloured growths, which were convoluted
on Sabouraud’s medium, glucose agar, gelatin and blood serum. This
nocardia neither liquefied gelatin nor inspissated ox-blood serum, pro¬
duced no diastatic action on sugar media, and did not ferment milk.
As far as it is known it represents a species of nocardia new to
human parasitology, and in view of its characteristic ochraceous
orange-coloured growths in cultures the name Nocardia lutea
(Christopherson and Archibald 1918) is suggested.
Lieutenant-Colonel R. H. Elliot, I.M.S.: There appeal's to me to bo
one feature of special interest in the paper. Actinomycosis is an extraordinarily
common disease in Madura, which is a strong endemic centre of the disease,
and as Madura is in the Madras Presidency and close to the Presidency Town,
I saw many cases of it, but during the whole time I was in Madras I never saw
a case of actinomycosis in the eye or in any part of the orbit. If that region
had been at all commonly attacked, one would have been sure to. have seen
cases of it. Both orange and black forms of actinomycosis are common in
Madura, and I think it must he an extraordinarily rare event for it to attack the
eye or its appendages.
Section of ©pbtbalmoloop.
President—Mr. W. T. Holmes Spicer, F.R.C.S.
Folds in the Internal Limiting Membrane of the Retina . 1
By A. C. Hudson, F.R.C.S.
J. C. T., male, aged 20. Wound of right eye and temple by piece
of shell, October 15, 1918; right eye enucleated the following day.
Total blindness of left eye for a week after injury, with gradual recovery
of vision in three weeks. Subconjunctival haemorrhage on outer side
of left eye noticeable for three months after injury.
Present condition: Margins of Jeft optic disk are somewhat in¬
distinct; excess of connective tissue on surface of disk, with some
hypervascularity. Macula contrasts strongly with surrounding retina.
There radiate from it in all directions, except downwards, a series of
light-reflex streaks arranged in pairs, the elements of each pair of
streaks being continuous with one another through a loop just outside
the macula. Below the macula is a series of similar figures having a
horizontal arrangement, and a striation of the same character is faintly
indicated in the retina internal to the optic disk. Vision of the eye
with + 2'5 D. sph. = f; visual field is full, and colour vision normal.
Remarks .—I am of opinion that the condition is pathological, the
result of oedema of the retina and nerve-head consequent on contusion.
The fact that one pair of striae can be seen to pass in front of a medium¬
sized retinal artery is of importance as evidence for localization of the
light-reflex streaks in the internal limiting membrane of the retina, so
also is the fact that I have observed similar streaks passing in front of
a typical hole at the macula following contusion. In that case, and in a
1 At a meeting of the Section, held February 5.1919.
MY—8
16
Lang and Armour: Ivory Exostosis
case of retinitis pigmentosa in which the striae were well developed, the
appearance was probably attributable to irregular traction. The peculiar
double contour formation is exactly comparable with the appearance
afforded to oblique illumination by folds in the posterior capsule of the
lens after cataract extraction, and it is analogous to the phenomena of
so-called striate keratitis, in which also the double contour of the grey
lines is a characteristic feature.
DISCUSSION.
Mr. Herbert Fisher : In support of the idea that the fundus changes are
of new formation there is the fact that the man was definitely blind in his
remaining eye for a considerable time after he was hit, and that suggests some
definite lesion, probably in the fundus oculi. And as there was ecchymosis on
the anterior part of the globe, the probability of central oedema is considerable.
With regard to the evidences of past oedema in the head of the optic nerve,
the refraction of the eye is 3 or 4 D. of hypermetropia, and the congested
appearances may not be due to recent change, but may be those which are
not uncommon in the hypermetropic fundus.
Mr. ORMOND : I thought, on looking at the disk, that the amount of
swelling was very much greater in the upper than in the lower part of the disk,
and I regarded the condition as pathological. I think a similar appearance has
been recorded in Szily’s book, which was published in 1916.. I have seen
similar conditions where there has been an injury on one side of the head,
without any actual contact lesion on the other, and I looked upon it as due to
the force of the blow. I think this man had a large piece of metal through the
head, which caused a considerable wound. Apparently it was limited in its
passage to one side of the face.
Ivory Exostosis, growing from the Roof of the Frontal
Sinus into the Orbital and Cranial Cavities, removed
through an Osteoplastic Opening in the Cranium by
Mr. Donald Armour.
By William Lang, F.R.C.S., and Donald Armour, C.M.G.>
F.R.C.S.
F. E., aged 19, sent by Dr. Alec. Forsyth, of Chacewater, Cornwall*
had been seen by Mr. Chetwood-Aiken, who diagnosed an orbital
growth. When I saw the patient, a well-grown youth, on February 19„
Section of Ophthalmology
17
1918, there was a displacement of the left globe forwards, downwards,
and outwards, which had been noticed by the friends for six months,
and diplopia had been present for three months. Vision -§ c cyl.
-2 d. ' 170 / ; pupil normal, fundus normal, no limitation of movement.
The roof of the orbit was depressed and felt hard. There was no pain
nor discomfort, but the mother had noticed apathy and want of energy.
Fig. 1.
Before operation. Shaded area shows position and extent of tumour.
(From skiagram.)
Dr. Peter Abercrombie found nothing wrong with the nose or
surrounding sinuses, and an X-ray picture by Dr. Ironside Bruce
revealed a solid mass in the orbit. In September he was in Moor-
fields under Mr. Treacher Collins, who recommended, after the case
had been seen by his colleagues, that the growth should be removed
by a surgeon skilled in cranial surgery. This was done in the National
Hospital on December 7, 1918, by Mr. Donald Armour, who came to
see me with the patient on January 29, 1919.
18
Lang and Armour: Ivory Exostosis
The patient’s recovery was complete and perfect. The globe was
in its normal position; no diplopia. Left vision=§ c cyl. + 0'75 D. 1Q0 «;
binocular vision, no fundus change, no headache, and the patient
appeared brighter.
Fio. a.
After operation. Showing lines of osteoplastic flap. (From skiagram.)
Description of the Operation, by Donald Armour, F.R.C.S.
The surgical problem in this case was one of operative approach,
that is to say in what way the tumour could be reached so as to be
completely removed without doing damage to cranial or orbital contents :
also, at the same time, though this was of secondary importance, to
avoid disfiguring the youth very much. After seeing the skiagram,
I concluded that the best method was by an osteoplastic flap turned
down in the frontal region, as is done in removing frontal lobe
tumours. I made such a flap, with its base at the supra-orbital margin,
19
Section of Ophthalmology
urning down the scalp and bone together. The cranial portion of the
tumour, which was pushing up the under surface of the frontal lobe
covered by dura, was thus displayed. By pushing dura and brain gently
back over the summit of the tumour, one could see the whole extent of
its cranial portion. On examining it and testing its degree of fixity,
I concluded—wrongly, as it turned out—that it was fixed to the supra¬
orbital margin. Therefore I sawed through the supra-orbital margin
on either side of the tumour. But on attempting to remove it this
wedge of bone separated cleanly from the tumour, and remained
attached to the periosteum. The tumour was removed with chisel and
hammer, the roof of the orbit, which was involved, being removed
piecemeal by means of cutting forceps. The operation was completed
by putting the wedge of supra-orbital margin back again, then replacing
the bone-flap and scalp, and stitching it up. There was uninterrupted
recovery. The intracranial portion of the tumour was smooth, white
and ivory-like, while the other portion, below the orbital roof, was
covered by mucous membrane. That, as Mr. Lang has pointed out,
shows it must have been growing from the frontal sinus. There was
no evidence at the time of operation that the frontal sinus had been
opened. On the day following the operation, however, and for two
or three days following it, the patient had an escape of blood from the
nostril.
' (Skiagrams shown by epidiascope.)
DISCUSSION.
The President : Mr. Armour's operation is a brilliant success. The
contrast with the old days comes forcibly into one’s mind, when ophthalmic
surgeons attacked ivory exostoses from the orbit, and broke their drills and
ruined their instruments in the attempt to remove them. What was the point
of origin of the growth ?
Mr. Donald Armour (in reply): The outer surface of it was ivory-like
and composed of compact tissue.* I think it started, as Mr. Lang said, from
the frontal sinus, as the lower portion is covered with mucous membrane.
20
Cunningham : Tumour of Roof of Orbit
Case of Tumour of the Roof of the Orbit.
By J. F. Cunningham, F.R.C.S.
C. F. B., male, aged 67. He has had no pain and has only been
aware of the condition for three months. There is a hard, somewhat
elastic swelling apparently attached to bone, in the upper and outer
part of the right orbit. There is proptosis downwards and forwards.
There is limitation of movement upwards, and diplopia on looking
upwards.
. Right vision : ^ + l'O sph. — § partly c + 4'0 sph. — 1J. Left
vision : T e 5 partly, + 10 sph. = § partly c + 4'0 sph. = 1J ; fundi normal.
Pre-auricular and submaxillary glands not enlarged, small gland in
neck on the right side. There is no history of syphilis; Wassermann
reaction proved negative. He was examined by Dr. Hawthorne, and no
evidence of any general disease was found.
I think the tumour is growing from the periosteum, and I shall be
glad if anyone^ will give me the benefit of their experience in dealing
with these growths. A skiagram shows no affection of the frontal bone.
Mr. DONALD ARMOUR : I would operate on this case, by the same method
as in my own, taking a wide sweep beyond it.
Case of Angioma of the Retina.
By E. W. Brewerton, F.R.C.S.
A. I., male, aged 26. The right eye was inflamed at birth, and
sight was lost three weeks later. The-eye was removed at Bradford
Infirmary when the patient was aged 6, as it was much enlarged, blind,
and painful. The left eye gave no trouble till 1913, when he com¬
plained of floating spots. He went to Bradford Eye Hospital and was
given lotion. The fundus was not examined.
He was called up in 1917, and reported sick in Salonica at No. 50
General Hospital owing to floating spots. The fundus was not; examined.
In September, 1918, he was again at No. 50 General Hospital, and the
Section of Ophthalmology
21
fundus was examined for the first time. He was kept in hospital;
drawings were made of the fundus, and the patient was sent home.
He is now at the Fourth London General Hospital.
The upper half of the fundus is normal. The inferior nasal artery
is much distended, tortuous and varicose, but its branches are normal.
It becomes larger towards the periphery, where it is lost on the lower
nasal side of an oval mass which is about twice the size of the disk.
This mass is slightly swollen and of a pale pink colour, and bordered
above by a dark red rim. From the nasal side of the mass a much
distended vein emerges, this passes upwards in a tortuous manner, and
suddenly becomes contracted just before it opens into the inferior tem¬
poral vein. Below the contraction there is some white exudate on the
nasal side. The common venous trunk remains normal for a short
distance, and then suddenly dilates and remains distended for the rest
of its course. The vision is § partly.
This is an instance of a very interesting class of case shown by
Mr. Wood, of Capetown, who was one of the first to exhibit a case
suffering from this disease. Cases have also been shown by Mr. Pooley
and by Mr. Foster Moore in 1911. The late Mr. Coats classified these
cases in a very interesting way some time previously.
With regard to the pathology of the case, it appears to be a form
of cavernous angioma. I do not think the enlarged blood-vessels are
diseased. It is easy to understand, if there is a cavernous angioma
and arterial blood is pumping through it, that the vein would be
enormously distended on the other side. I think that the vein is
distended for mechanical reasons and that it is not diseased. The case
of the artery is more difficult to understand. But in other parts of the
body we find cavernous angiomata; they are often congenital, and they
usually occur in young adult life. I think there is a congenital fault in
the capillaries of part of the retina, that these capillaries dilate into
cavernous spaces, causing an oval limited area of angioma, the rest
being merely mechanical. The artery is receiving a better.blood supply
than usual. The proof that the artery is not diseased is, that any
branch which it gives off is normal in size and general appearance.
It is, unfortunately, the only eye the lad has got, and I fear that, sooner
or later the vein will begin to leak—it already shows slight exudation at
one point—and that he will suffer from recurrent retinal haemorrhage,
with gradual permanent loss of sight.
22
Taylor: Changes in the Sella Turcica
Mr. A. W. Ormond : These cases are interesting on account of what may
happen to the other eye. I had recently a case of a soldier, who also had but
one eye, and he told me he had had the other eye removed at Derby for a growth
when he was 5 years of age. The surgeon at Derby told me the eye had been
removed for what was considered at that time to be a growth, but it turned out
not to have been a growth. He remembered the case but could not find the
records of the case. That man’s remaining eye shows a condition somewhat
similar to this case, except that it is more diffuse, and more like those which
Coats described as massive exudation of the retina. It had the same large and
tortuous veins and a mass in the extreme periphery and the white appearance
which many of Mr. Coats’s had also. With regard to the remark that these
cases develop earlier, I think these eyes are sometimes removed because they
are thought to be blind, and to be due to growths, and that trouble of a similar
nature may develop subsequently in the other eye.
Changes in the Sella Turcica in Association with
Lebers Atrophy.
By James Taylor, M.D.
(ABSTRACT.)
[This paper is printed in e.rtcnso in the British Journal of Ophthalmology,
May, 1919, p. 193.]
Dr. James Taylor read a paper in confirmation of the suggestions
contained in a paper of Mr. J. Herbert Fisher, which appeared in the
Ophthalmoscope of August, 1916. This suggestion was that the con¬
dition known as Leber’s atrophy—which often occurs at puberty, and
also in later life—periods of sexual development and sexual decay—
might be related to some defect in the pituitary gland—a structure
which is closely connected with sexual activity. If this were so, then
changes might be found in the sella turcica, and from the therapeutic
standpoint, relief might be obtained by the use of organic medication.
Dr. Taylor related the case of two brothers, both sufferers from Leber’s
atrophy. In one the condition had been present for about twelve
years, in the other for only two. In both cases the X-rays showed
distinct changes in the sella turcica—the changes in the case of long
standing being much more extensive and marked than those in the
more recent case.
Section of Ophthalmology
23
DISCUSSION.
The PRESIDENT : It would be very satisfactory if we could know more
about the, origin of Leber’s disease. It is hardly to be supposed that the
changes in the sella turcica are the only cause: there must be others,
and we require more observations and knowledge in certain directions
especially. There was a remarkable series of observations made by Men-
teith Ogilvie some years ago, in which he pointed out the large number of
infantile deaths in families affected with Leber’s disease. What was the
bearing of this?
Mr. J. H. Fisher : Naturally, this paper by Dr. Taylor is of interest to
me, as I was the first to make the suggestion that Leber’s optic atrophy
was probably due to implication of the visual pathways by the pituitary body,
which was undergoing excessive physiological changes in association with sexual
variations, either of development or of decline. Since I published my paper, I
have not come across other cases of Leber’s disease in which X-rays reveal
changes in the sella turcica, though I have encountered other cases of the
disease. I have seen many cases of what would have been regarded as Leber’s
disease if there had been a familial history, and in which the skiagrams
showed slight changes in the sella turcica. I can recall one in a woman
who reached the climacteric prematurely, at 37 years of age. A year or
two afterwards her vision failed, and she had the characteristic changes in
the optic disks, and there was a definite change in the sella turcica. Of.
course there is no reason why, associated with the sexual development or
sexual decline, this disease should not occur in individuals whose families
show no special tendency in the same direction : sporadic cases might well
be met with due to the same cause. There is, not uncommonly in the family
cases, a high infantile mortality, which points to no syphilitic taint. There
is no real explanation of that, but Dr. Taylor was suggesting to me that in
hereditary disease large families are not uncommon ; neither are early deaths.
Whether that is a provision of Nature to meet the difficulty we do not
know : but if it be an established fact that there is a high infant
mortality in families afflicted with Leber’s disease, we may in this associ¬
ation recall the fact that the pituitary body is essential to life; that at least
in function it is intimately connected with that of sperm and germ epithelium,
so that transmission of hereditary defects in it '•may perhaps he the more
easily imagined.
24 Wallace: Fundus Changes resulting from War Injuries
Fundus Changes resulting from War Injuries.
By William Wallace, Captain R.A.M.C.
(ABSTRACT.)
•
A series of forty water-colour drawings illustrating war injuries of
the fundus was shown by Captain Wallace, R.A.M.C. Without the
drawings themselves a verbal description is inadequate, but he intends
to place them at the disposal of ophthalmologists, and a full account of
each will be supplied.
The drawings were made from,cases in the Second London General
Hospital, some discovered in the out-patient department, and others
sent up by the courtesy of Major Ormond, R.A.M.C.(T.). They repre¬
sented appearances seen as early as ten days after the wound, and in
some instances after an interval of three years. For the purposes of
the demonstration they were classified according to the extent of the
visible lesion, and fell into the following groups : {a) Complete avulsion
of the optic nerve, ( b ) peripapillar avulsion, (c) narrow crescentic rupture
of the choroid, (d) gross rupture with amorphous proliferation, (e) star¬
shaped rupture, (/) gross peripheral rupture with concussion changes,
(g) “ holes ” in the macula.
Reference was made to the rapidity with which lesions of rec6nt
date altered in appearance from day to day. One case was of unusual
interest. A drawing was shown of a rupture of the choroid with the
retina beyond it unchanged ; then the same fundus was shown with the
retina detached and thrown into numerous delicate folds—a condition
which must have set in only a few hours before the sketch was made;
and finally the resolution of the detachment, with the retina as seen in
the first drawing. Attention was called to the almost constant presence
in the grosser ruptures of isolated areas of pigmentation resembling the
characters of “ retinitis pigmentosa/’ and the speaker asked if these
might not throw some light upon their occurrence in the latter disease.
No opinion was expressed as to the possibility, in lesions of the fundus,
of their appearance affording a clue to the nature and extent of the
wound, but in three cases of star-shaped rupture the eyeball had been
struck from above downwards. It was suggested that while many of the
cases were beyond remedy as far as vision was concerned, the appear-
Section of Ophthalmology
25
ances, if closely studied and registered from time to time, might help to
explain vascular changes which occurred during the process of repair in
wounds not of themselves ocular. The severity of the lesion did not
invariably indicate the probable amount of sight remaining after the
wound, wide differences being found in cases which appeared to
show a similar extent of damage; but allowance had to be made for
changes too minute for the ophthalmoscope to detect. In one case,
observed with a somewhat imperfect red-less illuminant, delicate
wisps of proliferation were noted which were invisible by the ordinary
means.
DISCUSSION.
Mr. Malcolm Hepburn : With regard to the outlying masses of pigment,
which Captain Wallace commented upon as being similar to those in retinitis
pigmentosa : I do not think they are very difficult to explain if we regard
the changes in retinitis pigmentosa as of vascular origin. If the posterior
ciliary vessels are tied or cut, you see pigmentary changes in the parts of the
retina supplied by these vessels. The posterior ciliary vessel supplying this
particular region was probably ruptured in the injury, whereas the retina
itself was not directly involved.
Mr. Herbert Parsons : This very valuable collection of drawings
should be kept together as a permanent record of war injuries. It would
be most instructive if we could get a collection of ophthalmoscopic drawings
issued as an atlas some time after the war—prices are too high for this to be
done now ; and in course of time the drawings could, perhaps, be added to
from other sources, and thus constitute a permanent record of ophthalmo¬
scopic work during the war.
Sympathetic Ophthalmitis with Fundus Changes.
By R. Foster Moore, F.R.C.S.
•
In spite of very numerous perforating wounds of the eye, sympathetic
ophthalmitis has been of very rare occurrence during the war, and
any case of it appears to be worth recording. The present case has an
additional interest from the fact that fundus changes developed during
the progress of the disease and were visible throughout.
Company-Sergeant-Major D. M. G. M., aged 23, was wounded in the*
right eye, on May 28, 1918, by the accidental explosion of a detonator.
26 Moore : Sympathetic Ophthalmitis with Fundus Changes
He was admitted to hospital on June 2, and was found to have a
penetrating wound of the right globe, with prolapse of the iris and
ciliary body. There was hyphsema and vitreous haemorrhage, no details
were visible with the ophthalmoscope; other small peppered wounds of
the face were present. On June 4 the prolapsed uveal tissues were cut
away and the wound sutured. The eye was excised on June 18.
The earliest indication of there being anything wrong with the left
eye was on July 8, when the patient noticed the vision was a little
misty. I first saw him on July 10.
Left eye: There was slight circumcorneal injection, slight tenderness
on palpation and a very fine deep haze of the lower part of the cornea.
The pupil dilated quite fully to a mydriatic, leaving no pigment adherent
to the lens capsule. There was a single dot on the back of the cornea
which one suspected was of the nature of punctate keratitis, and it
became clear later that it was so. The retinal veins were unusually
full, but in other respects the fundus was normal. The vision was
£ partly. Tension was now normal.
In the right socket the central part around the stump of the optic
nerve was so dark as to make one suspect the presence of uveal tissue.
I therefore removed the stump the same afternoon under general
anaesthesia, cutting through the optic nerve and preserving the portion
removed. Colonel Lister kindly had this examined and found that the
eye had been removed quite cleanly; there, was no uveal pigment left.
On the day following there were three or four fresh spots of K.P.
[jest by any chance the trouble might be due to a minute foreign body
which had entered the eye at the time of the accident, and was only
now beginning to cause trouble, I had him examined by X-rays and put
the eye up to the magnet: both investigations were negative.
A differential blood count made by Captain W. Holland was normal
in every way, there being no increase in the large mononuclear leucocytes.
The Wassermann test was negative.
July 14: There was a distinct increase of the K.P., which was all
of the rather fine type. The corneal striae had increased. Tension was
— 0'5. The pupil remained fully dilated, the retinal veins were engorged,
but otherwise the fundus was normal. Lieutenant-Colonel Ffrench,
O.C. of the Venereal Hospital, was good enough to undertake a course
of “ 606 ” for the patient, and injections were given on the following
dates: July 14 and 23, August 13 and 23, and September 11.
. July 17 : The K.P. had entirely disappeared ; new vessels on the
iris were first noted.
Section of Ophthalmology
27
July 22: There was still no K.P. and the fundus was normal.
August 10: There was now again a considerable crop of K.P., the
retinal veins were full but there was no choroidal nor retinal lesion.
Tension: Soft, normal.
September 9: The iris was now more vascular, coarse vitreous
opacities were present, and on this date for the first time I observed a
considerable number of spots in the periphery of the fundus below.
September 21 : K.P. was less ; Mr. F. A. Juler kindly made the
appended drawing (see figure, p. 31) on this date.
September 25 : The spots at the fundus were unchanged. Vision
under atropine, + 1‘5 as- My note on October 6, the day before his
dispatch to England was: “ The eye is almost white. Tension normal.
Vision, + 1’5 /jj, under atropine. The pupil is fully dilated, there are a
number of fine synechiae. The fundus changes are unaltered, I should
estimate roughly that there are from 150 to 200 spots in view. The
vitreous opacities remain.”
Owing to the manner in which the injury was sustained, it was
technically a self-inflicted wound, and it was for this reason that his
stay in France for so long was compulsory.
Major Fenwick brought him to see me at hospital on January 15,
1919; he had had him under his care for many weeks, during which
time he had greatly improved. The eye was now white, and the tension
normal. The pupil dilated fully with a mydriatic leaving no synechise.
The vision with + 1 cyl. was r 6 ff complete, three letters of T %. There
were present about half a dozen spots of shrunken K.P., and whilst
there was a good deal of exudate in the vitreous, it had not increased
since last I saw him. The spots depicted in the drawing had con¬
siderably increased, and whereas, when last I saw him these spots
were present only in the periphery below, they were now present
towards the periphery all round (vide infra).
The following are the chief points of interest in the case : The time
from the date of the wound to the excision of the damaged eye, that is
the “ first interval,” was twenty days, and the “ second interval ”—i.e.,
the time fro'm the excision to the first symptom of sympathetic
ophthalmitis—the day on which the patient first noticed his sight was
misty—was also twenty days.
. The pupil was maintained fully dilated throughout the attack
without trouble. The K.P. at one time completely disappeared and
then appeared again. The fundus changes were first seen two months
after the onset of the disease.
28 Moore : Sympathetic Ophthalmitis ivith Fundus Changes
The Committee of the Ophthalmological Society which was formed
to investigate this disease, 1 state that when sympathetic ophthalmitis
sets in after enucleation of the exciting eye, it is usually mild, thus out
of thirty cases complete recovery occurred in eighteen.
The present case is in accord with this finding. The Report states,
that “ many cases have been observed where inflammation of the retina
caused almost, if not quite the first visible change, but almost without
exception, disease of the vitreous, iritis, or K.P. has been noticed within
a few days.” In the present case, which was seen quite early, the signs
were slight deep localized haze of the cornea, one spot of K.P., and
somewhat turgid retinal veins.
Six cases in which retinal or choroidal changes are described were
considered by the Committee, but they state that “they differ so much
amongst themselves, that we should hesitate to include them all under
one title, or to ascribe them all to the influence of the other eye.”
The justice of this comment will be appreciated on looking through the
cases referred to. As remarked by Fisher ( vide infra), these cases
almost all recovered. Fisher reports an interesting case in the
Moorfields Reports, vol. xv. 2 He speaks of his case as sympathetic
uveitis, the most posterior segments of the tract bearing the brunt of
the disease. The fundus changes were severe, the ophthalmoscopic
appearances suggested general infiltration of the choroid, the veins
were turgid, “ in the peripheral parts of the retina are to be made out
small circular dead-white spots, not glistening, the whole retina is hazy
and oedematous.” The tension was — 1, and the vision fell at one time
to c.f. at 2 ft.
A later note says : “ I see a group of circular exudative spots; the
others, found mostly in the nasal half, remain unpigmented and brightly
glistening.” With regard to these spots, Fisher refers to a case of
v. Graefe’s in which disseminated spots of choroidal disease appeared
towards the end of the disease, to a case of Krause’s in which choroidal
patches were noted in the lower part of the fundus, and to one of
Galezowski’s, in which the choroid had undergone change in the shape
of obvious disseminated atrophic patches.
In the Proceedings of the Royal Society of Medicine , vii, 1914
(Section of Ophthalmology, p. 95), Lang reports a case in which
he had performed extraction of the lens and iridectomy in an old
1 Trans. Ophthal. Soc. } 1886, vi, p. 170.
2 Roy. Lond. Ophth. Uosj >. Repts ., 1903, xv, p. 91.
Section of Ophthalmology
29
sympathizing eye, and in which “extensive and somewhat superficial
choroidal atrophy can be seen over the fundus.” In the present case the
fundus has been under observation from July 10—i.e., two days after
the onset of symptoms till the present date, January 15, 1919, six
months in all, and during this time it has been for the most part clearly
visible, except in so far as a varying degree of vitreous exudation has
obscured the view. •
The changes which were present form the special point of interest
in the case. When first seen the retinal veins were unusually full, and
there was no other change. The fundus was examined on the following
dates and there was no other abnormality discoverable with the
ophthalmoscope on July 10, 14, 22, and August 10. On September 9
the changes to be described were first seen—i.e., two months after the
beginning of the disease. They took the form of a group of spots,
scattered irregularly over the lower part of the fundus well towards the
periphery ; none were visible in the other parts of the periphery at this
time. In colour they resembled that of the dots in Tay’s choroiditis.
They were quite irregular in shape, and there was no disturbance of
pigment around them. In several places retinal vessels passed over
them quite unobscured.
The drawing made by Mr. Juler, on September 21, represents the
portion of the fundus vertically below the disk, with a portion of
the lower temporal vein; the arteries are omitted. Mr. Juler was
at considerable pains to include every spot which was visible in this
area, and to place them accurately with relation to themselves and the
vessels, with the idea that any particular spot could afterwards be
identified, and any alteration in it, or any increase in the spots, could
be made sure of. During the time he was in France there was no
discoverable change in the spots, but on examining him on January 15
considerable changes had occurred. Whereas before, the spots were
visible only in the periphery below, they were now to be seen all round,
although they were much more plentiful below. There was a notable
increase in the number of the spots below, and changes in the area
depicted in the drawing were easily made out. The spot in the drawing
immediately to the nasal side of the bifurcation of the vein below,
shaped somewhat like a Wellington boot, was now represented by
a group of about six irregular spots of similar type. The irregu¬
larly shaped spot, on about the same horizontal level with the above,
but on the opposite side of the vein, was now represented by a
cluster of five or six spots, and similarly with regard to other spots.
30 Moore : Sympathetic Ophthalmitis with Fundus Changes
On the other hand the highest spot in the drawing deep to the vein was
now only just visible. On seeing these spots for the first time, one
might have wondered whether they were old, and not causally related
to the disease, for their edges were fairly clearly defined, and there was
no marked evidence of oedema of the overlying retina. It became clear,
however, later, as evidenced by what has been said above, that they
were an integral part of the disease.
As to the anatomical position of these spots, they were deep to
the retinal vessels, and Mr. Greeves pointed out to me that at a point
or two a choroidal vessel appeared exposed crossing the spot. I
believe, therefore, that they were placed superficially in the choroid ;
there was no pigmentary disturbance in connexion with them.
It is a little difficult to judge how far these spots are to be identified
with the changes described by other authors, but judging from the
descriptions they might quite well be of the same nature as the changes
described in the cases of v. Graefe, Krause, Galezowski, and Fisher. In
all of them the changes are described as being towards the periphery of
the fundus, and in the superficial layers of the choroid, and in none of
them does there appear to have been any pigmentary disturbance or
proliferation.
As regards the general treatment adopted—viz., mercurial inunctions
and neosalvarsan, I do not think any particular benefit was derived
from them, for, as already stated, the keratitis punctata was of the
benign type, the deposits being small though somewhat plentiful, and
as stated by Fisher, and as exemplified by his case and by the six cases
included in the Committee’s Report, this type of case almost always
does well. We may repeat the Comjnittee’s statement with regard to
mercurial inunction that “ they (and ‘ 606 ’) had no decidedly bad effect
upon sympathetic ophthalmitis.”
The normal differential blood count is in accord with my previous
experience.
Description of the Drawing.
The changes in the fundus consist of a number of spots or small
areas distributed towards the periphery all round. The area here
depicted wds situated vertically below the disk, and the drawing
represents as accurately as possible the position, shape, and colour
of every spot that was visible over this small area on September 29,
1918 : at this time the greater part of the periphery of the fundus
was normal and quite free of spots.
• :' , fflvif iion -of 31
When s«ei) a few dsys ago at hospital. the details of the area
depicted were readily identified ; the opots had much increased in
number Thus, previous si'cgic- spots were now' represented .by ft j^rovip
of five nr six separate spots, and fresh spots had appeared in many
places ; io addition, groups of them were; how preseal towards the
periphery all round. They were rpdte irregular., -in shape,- and - did
not show any parttpula? relation to; the Vessels., They,w.wi/beluw
in tiny • superficial Intfsrs of the chuiokl Vitreous opacities were
present. There was no pigmentary disturbance around them, and
32 Moore: Sympathetic Ophthalmitis with Fundus Changes
very little, if any, evidence of oedema, and indeed, but for the evidence
of increase and alteration whilst under observation, one would have
had some doubt from their general appearance, as to whether they
were not of old standing, and- therefore not causally related to the
disease.
Mr. Frank JtJLER : The final result of this case is excellent. I endorse
the statement Mr. Foster Moore has made about the course of the case, as I
had the opportunity of seeing it in France in its earlier stage. When I last
saw the patient in France, in October, the vitreous opacity was very marked
indeed, so that one could not make out, very definitely, the exact outline of the
spots of choroiditis. I saw the patient again, at hospital, a few weeks ago,
and the vitreous opacity had then almost entirely cleared and the K.P. had,
I think, almost entirely disappeared. When I saw this case in its earlier
stage, there were many fluctuations in its progress.
Section of ©pbtbalmoloflp.
President — W. T. Holmes Spicer.
Angeioid Streaks in the Retina.
By Elmore Brewerton, F.R.C.S.
Patient, a female, aged 36. Her sight has been failing for three
months, chiefly in the right eye. She has worn glasses for short sight
for nine years. Vision: Eight, c —3'5 d. sph. = 2 6 ¥ ; left, c —3‘5 sph.
= § partly. In both eyes brown hands are seen radiating from the
disks and becoming narrower as they reach the periphery. The
horizontal band on the nasal side of the right disk bifurcates a short
distance from the disk. There are degenerative changes at the right
macula. In the left eye the bands are very broad, with irregular
edges. They meet in a brown area surrounding the disk.
I brought this case before the Section because of the extensive
character of the changes. In the literature it is difficult to find any
references to the subject. Ward Holden considered the streaks to be
remains of haemorrhage diffused in a linear direction through the layers
of the retina. I cannot, however, imagine how blood can follow along
lines in the retina, except in the nerve-fibre layer, and these streaks are
not in that layer, but posterior to it. Therefore I cannot accept that
statement. Lister believes them to be vestiges of new vessels, along
the course of which are arranged exudates which have undergone
secondary pigmentation. I do not think the streaks in my case are
new vessels, because in the left eye the streaks meet in a lake or pool
round the disk, and you can scarcely have a vessel which extends all
the way round the disk. In Zentmayer’s case a horizontal extravasation
of blood was present while he saw the angeioid streaks. Pagenstecker
1 At a meeting of the Section, held March 28, 1919.
au —28
34 Ford: Congenital Pigmentation of the Cornea
reports two cases; he watched the streaks of blood develop later into
these typical streaks.
I think they must be remains of haemorrhages between the retina
and the choroid; that is the only place in which blood could form and
remain as streaks. Their colour is that of haematin. Usually they
seem to have been associated with some form of chronic inflammation.
The PRESIDENT : So far as I know no satisfactory explanation has been
given of this appearance. I have shown one case here in which the condition
seen was the same in a brother and sisterit was the same in all four eyes*
The pigmentation in my case was much greater than in this, and the edges
much sharper. In my two cases I think it would have been impossible to
say that t^e streaks were not blood-vessels: they seemed to have the
colour of veins, although the colour was due to pigment. There must have
been a blood-vessel at the centre. With regard to Mr. Brewerton’s view
that the condition is due to vascular disease, my other case was one in
which a man suffered greatly from haematemesis and had become very
anaemic, and it is likely the condition arose as part of his anaemic condi¬
tion. I have very little doubt as to the situation of these streaks. They
are not on the surface of the retina, because the retinal vessels run so clearly
over them. I think they must be between retina and choroid.
Congenital Pigmentation of the Cornea.
By Miss Rosa Ford, M.I>.
Mrs. C., aged 42. A line of brown dots about the level of Descemet's
membrane, in both eyes, near the centre of the cornea, sloping down and
inwards. The patient has never sought advice for her eyes before, and
now complains only of slight discharge and of presbyopia. Vision =^
both eyes. Eyes otherwise normal except for congenital punctate
opacities of both lenses.
The President : I remember seeing two cases like this, and those only at
long intervals between them, so the condition must be very rare. In each of
them the line was vertical as in the present patient. The pigment was distinctly
granular, and resolvable into separate dots, quite deep in the cornea. One
patient was a woman, aged 30, who had never had any affection of the eyes ;
the other was a man, aged 26, who had had sore eyes in childhood, and whoso
brother had had interstitial keratitis but in whom there were none of the
stigmata of congenital syphilis. The presence of staining, apart from ulcera¬
tion, is not uncommonly met with in nebulae the result of ulceration, which
has not always been attended by the presence of blood-vessels, and is quite
superficial.
Section of Ophthalmology
35
Pulsating Tumour of the Orbit, of Uncertain Nature.
By Harold Grimsdale, F.R.C.S.
Patient, a boy, aged 13. I have only seen him once before at the
hospital. He has a tumour just above the orbital margin, spreading up
under the skin for half an inch. It seems to be connected with the
supra-orbital vessels. It ceases pulsation when one compresses the
carotid on that side. The boy is otherwise healthy and has had no
accident. The sensation felt when the tumour is palpated suggests
the presence of a number of dilated arterial, or at least pulsating
trunks, in fact of a cirsoid aneurysm.
Postscript .—The provisional diagnosis of cirsoid aneurysm was proved
to be correct at the time of operation. My colleague, Mr. Fedden,
kindly took the boy under his care. He made an incision just below the
orbital margin and, after some trouble, secured the enlarged supra¬
orbital artery. Through other small incisions above the swelling, he
secured three other branches connected with it from the upper side, one
of these was certainly connected with the anterior temporal: the pulsation
ceased for two days and returned ; Mr. Fedden then tied the anterior
temporal, and cut down and removed the main sac, which was thin
walled and about f in. in diameter. Some twenty small arterial trunks
were secured during theVlissection. Since this second operation there
has been no return of pulsation.
Symmetrical Disease of Macula (with drawing of
Left Eye).
By Rayner Batten, M.D.
Patient, a girl, aged 17. She has probably had acute papillitis at
the onset. Three years ago she lost the sight altogether in the course
of a fortnight. Three months later she had recovered partial perception
of light. She now has opaque white disks and symmetrical disease of
the macula. There was no acute illness at the time. I have seen
a fair number of these cases of symmetrical disease of maculse, and
one point of interest seems to be the frequency with which the onset
occurs at about puberty in both sexes. This girl had had no menstrual
period for a year, and she attributes the onset of her trouble to that.
Both' disks are pale and atrophic and opaque. Both maculse are
36 Oamithers: Case of Intra-ocular Growth
occupied by a small white arc surrounded with &darker pigment ring
The changes are most, marked in the left eye. Vision - Bight,
Field—small central inside, 10°; Left, hand-movements only.
mm
DISCUSSION
The PRESIDENT: Does Mr. Batten think the macular disease ia secondary
or Hoparate from the optic nearitif: V
Mr Batten : 1 think it is part of the same process.
Case of Intra-ocnlai' Orowth
By j. F. Cabruthees, M.B.
The case has been rather a puzzle. He was sent over from the
Rhine Front, with no definite history, though I believe he has beeu
seen by Colonel Lister. He came without any medical papers. When
* .
■;V.
Section of Ophthalmology
37
he arrived his left eye was greatly proptosed. A skiagram showed
more shadow in the left orbit than in the right. The Wassermann
reaction was negative. The man says it commenced three months
before I saw him, that is, four months ago, and the, changes have
come about fairly quickly. There was no pain nor trouble of any
sort until the onset of diplopia, the method of onset of which I do
not know. The growth has been hard all through. When I first saw
him the most noticeable feature was optic neuritis, of about 2 D. when
first seen, and it increased to 4 d. I asked Mr. Lawford to see him
in consultation, and he suggested that before any radical operation
was thought of he should be given mercury and iodides. Three days
after I had commenced the administration of full doses of mercury
and iodide a remarkable chemosis occurred, which was entirely lym¬
phatic : there was no congestion nor vascular engorgement. The cornea
seemed to be at the bottom of a pit. That condition lasted forty-eight
hours; there seemed to be no indication to interfere and I did not
do so. The subsidence set in and the growth became flat, and with
that there was a reduction in the optic neuritis. I hoped, therefore,
it would prove to be gumma, and therefore curable. After subsidence
had persisted for a week, however, it remained in statu quo, except for
the continued reduction of the optic neuritis, which is now only J to f D.
Within the last week a little keratitis punctata has appeared: it was
not there previously. Captain Wallace pointed out that when one puts
a little pressure on the top of the eyeball the superior vein straightens
and the whole disk blanches. I do not know whether that possesses
any significance. I have had the nose and the antrum examined, apd
the report is that the sinuses are normal.
Case of (?) Pituitary Tumour.
By A. W. Ormond, F.R.C.S.
Patient, a female, aged 26. Married five years. Two children,
aged 2 and 4.
History .—August 12, 1918: Came to Guy’s Hospital. Complained
of inability to see with right eye and also aching; vision in upper half
of field only. About a month ago when patient was having a meal her
eyes started twitching and then her present condition set in. Scintil¬
lating scotoma (?). Rheumatic fever three times. In hospital fourteen
months.
38
Ormond: Case of (?) Pituitary Tumour
Right Eye ... ... ... ... ,' 5 e - 1 cvl. = ,y
Left Eye ... ... ... ... e - 1*25 sph. = {.
Both optic disks red and neuritic. Ozaena. Bad smell in nose.
Suspicious streak of pus in nasopharynx. Exploration of sinuses
advised; this was carried out. Bight posterior nares (? pus).
September 30, 1918 : Exploration of right antrum, nil. Left
antrum, nil. Exploration of right sphenoid, nil. Left sphenoid not
entered. Staphylococcus aureus. Anterior of each middle turbinal
removed.
March 10, 1919 : Pain at root of nose and over inner canthus.
Headaches. Discharge from both nostrils, blood-stained. Attack of
misty vision of both eyes. Pupils react to light. Optic neuritis with
ensheathing of veins of both eyes.
March 13, 1919: Smell in nose is less offensive, but the discharge
has still a bad smell. The operation has made no difference. There is
still discharge in throat and in nose. Headaches persistent and bad,
recurring almost daily. Complains of revolving phenomenon before
sight goes; still gets attacks of loss of sight. Is putting on flesh.
Bight pupil rather larger than left; both active, but right more
sluggish.
March 14,1919. Vision: Bight eye — < , T V Sees above and to outer
side, but not to nasal Bide at all. Optic neuritis with ensheathing of
vessels.
March 21, 1919. Vision: Left eye = with —1‘5 = §. Field
full to fingers, but things are not seen as clearly on nasal side
as on temporal. Optic disk is red and slightly neuritic. Pituitary
tumour (?).
X-ray taken. Sella turcica very much enlarged. Fields for colour
taken. Bight eye : Macula is involved, blind in lower and nasal part
of field. Left eye : Macula is not involved. General contraction most
marked on nasal side. Fields for red and blue similarly contracted:
red smaller than blue.
This case is interesting from the point of view of diagnosis ; on the
whole, I think, it is probably a case of pituitary tumour. When I first
saw the patient, in August last, I looked upon it as a case in which the
optic disks were involved secondarily to some nasal trouble, and I handed
her over to my colleague, who examined her nose, and explored both
antra and the sphenoid, and removed the anterior end of each turbinal
bone, but without finding anything very definite. She did not
improve very much, and when I saw her again I reconsidered my
Section of Ophthalmology
39
idea and had a skiagram taken of the skull. The sella turcica is very
much enlarged, so much so that the body of the sphenoid seems to be
eaten away to a great extent. The fields, also, are atypical, as the
hemianopia seems to be more on the nasal than on temporal side, and
rather below. The presence of optic neuritis on both sides, the fact
that she is putting on weight, and the skiagram all seem to suggest
pituitary tumour, probably malignant.
Chart 3.
169
Chart 4.
40 Ormond: Case of (?) Pitmianj Tmm nr
Would any niesober advise puncture of the tumour in the hope that
it may prove to be cystic, and so give the patient the chance of
amelioration f If it were sarcomatous this Would not do good, but we
should get some further clue as to the nature of the tumour.
iSSJPP
i&X
(?) Pituitary tumour*
Mr. J. R FisaKrt ; l saw thk case tmmcdfy; biifc I should agree with Mr.
Ormond fchM fehfe'-fe fjfoh&bly. a malignant g^o'Wtih 'fit’ll very extten&ive desfcrtie-
tion of the sella turcica. The complete absence of tbo typical signs of pituitary
tumour—Le,,• a’- Uicmnr .starting in the pituitary body^ and the i>.bBeoce^ of the
body, seem -'strongly to favour the view that it in uiabgnanh The belda ttira
not those which would bo expected as the aecpmpariiment of a large pituitary
tumour, 'fjtero is but little chance.of ■Sealing. with this case by surgery *
l i-.i. .... -l ' v v ,^>4. v' ' j-L: t? *
■
> «>v!f t‘
Section of Ophthalmology
41
Pituitary Tumour (Hypopituitarism).
By L. Y. Cargill, F.R.C.S.
Patient, a male, aged 22, soldier. Duration of disease not stated.
History of Case .—Family history unimportant. Is eldest of six.
No eye trouble in family. Previous history : Always had good health.
History of present attack: Was working at a telephone switchboard
last Christmas when he discovered, in consequence of getting tobacco
smoke into the right eye, that he could only see half the board with the
left eye.
Complete temporal hemianopsia left eye, the nasal field being
encroached upon some 15° from vertical below. Wernicke’s sign
present. Eight field contracted; to temporal side especially. Both
optic disks pale—simple atrophy. Looks younger than his age, having
the general appearance of a youth of 16; very little hair on face ' r
weight, 5 st. 2 lb. Sexual organs and pubic hair normal.
Radiograph shows enlargement of sella turcica in antero-posterior
diameter; depth about average. Anterior clinoid processes undermined;
posterior clinoid processes look partly effaced.
Cranial nerves (apart from optic) normal. Speech normal. Motor
power, co-ordination and sensation good. Arm and abdominal reflexes
good. Knee-jerks exaggerated. Left ankle clonus; none right. Plantar
reflex not obtained. No sphincter trouble. Chest, nil.
Photograph, radiographs, and field of vision charts exhibited.
DISCUSSION.
Mr. J. H. Fisher : This case is much more like one of primary disorder
of the pituitary body than the case Mr. Ormond showed. Although in
Mr. Cargill’s case the general phenomena are not particularly marked, there
are disturbances of the secondary sex characteristics, and the erosion of the
sella turcica is of a much more typical character. I think this is a disorder of
the pituitary in which the onset occurred after adolescence was completed.
I have a case under my observation which I have been seeing for many years,
and the patient is now 35. In his case the disease started rather earlier,
though the condition has remained in abeyance for eighteen to twenty
years. He has infantilism coupled with secondary sex characters remaining
undeveloped. We should try to distinguish between cases of tumour of the
pituitary body itself, and those in which the tumour is in that region. I think
Mr. Ormond’s case is extra-pituitary, primarily because of the way in which it
has involved the visual pathway : in this respect it rather suggests a growth
infiltrating the ocular pathways after destroying the base of the skull.
42
Maxted: Malignant Disease of Pituitary Body
Dr. James Tayloe : I agree with Mr. Fisher that this is a case of hypo¬
pituitarism which may, possibly, depend on destruction of the pituitary body
by a cystic growth. And it is one of the cases in which, I think, before
anything else is attempted, one would be inclined to feed the patient upon
pituitary extract, in order to see whether the condition can be corrected or at
least modified. If that should be successful, the case might be explored, in
the hope that, if the condition were cystic, it might be relieved by operation.
Case of Malignant Disease of the Pituitary Body, with
Comments.
By Gr. Maxted, F.R.C.S.
The notes of this case are very imperfect; many observations that
might have been made are lacking ; nevertheless the case has given one
an opportunity, too often unobtainable, of investigating some points
about malignant disease of the pituitary body.
The patient, a well-nourished man aged 25, was admitted to hospital
on convoy from France, on March 11, 1918, on account of an annoying
diplopia which had persisted for about a month before admission. This
diplopia was preceded for about eleven months by slight and occasional
attacks of epistaxis which had never been severe and of which little
or no notice had been taken. The diplopia was also preceded by
intermittent headaches which up to the time of admission had never
been very severe and had not incapacitated him.
The onset of the diplopia was said to have been sudden, and on
examination the right eye was seen to be divergent and there was
crossed diplopia; the movements in and down of the right eye were
deficient; the palpebral fissure on the right side seemed to he slightly
wider than on the left. The patient stated that at the beginning of
the attack, in January, 1918, the divergence of the right eye was
extreme, and that it was now much less than at the commencement.
The right pupil is semi-dilated and fixed, and there is no concensual
reaction. The throat was examined, and- the epistaxis reported to be
due mainly to a chronic pharyngitis. The Wassermann test of his
blood on March 20, 1918, gave a negative result. It was noticed that
the patient was looking anaemic and he was given an iron tonic.
On April 19, 1918, a note was made stating that his headaches were
becoming more troublesome, and that pus was coming from the back of
the nose or throat somewhere and on re-examination it was noticed
Section of Ophthalmology
43
that he had a markedly deflected septum, was a mouth-breather, and
the chronic pharyngitis was persisting and was considered to be the
source of the muco-pus in the throat.
The first week in May the vision was recorded as follows: Right
eye ^ 6 ? , with + 1*50 sph. = § ; left eye = §. Both disks a little
pale but no appreciable pathological change except the slight pallor.
On May 23 operation for deflected septum tvas undertaken: after the
operation it was noticed that there was a good deal of oozing of blood
for some days, but no importance was attached to it at the time, and on
June 11 the patient was sent to an auxiliary hospital for five weeks,
during which time he was not seen, but complained of the now almost
continuous bloodstained mucus from his throat, and produced as
evidence, a handkerchief with many bloodstained patches upon it.
On his return to hospital he still also complained of headaches, the
diplopia persisted and he wore a shade over the right eye in consequence,
and the right pupil remained dilated and fixed ; still no decided patho¬
logical change in the disks was apparent. Further examination of
the nasal sinuses showed no further evidence of sinus suppuration.
The anaemia, if anything, seemed to have become more severe.
On August 12 it was noticed that there was some weakness of the left
external rectus muscles as well as the partial third nerve paralysis of
the right eye, and a lumbar puncture was done, when it was noticed
that the cerebro-spinal fluid escaped in a stream from the needle as
though under pressure, although it was quite clean and revealed no
44 Maxted : Malignant Disease of Pituitary Body
pathological changes on clinical and bacteriological examination; the
Wassermann reaction of the fluid gave a negative result.
On September 2 there was still considerable discharge from the
nasopharynx and the patient complained for the first time of dizziness;
further examination of the nose revealed some hypertrophy of the
posterior end of the left middle turbinal and it was decided to explore
the sphenoidal sinus; on September 12 the patient was given an
anaesthetic : the sphenoidal sinus on the right side of the mid-line was
found to be full of a soft, very haemorrhagic, mass resembling growth,
with destruction of the posterior wall of the sinus ; a small piece
was removed, and sent for microscopical examination which revealed
a sarcomatous growth, probably a tumour of the pituitary body. On
recovering from the anaesthetic the patient noticed that he was almost
blind and by the following morning the blindness was complete, with
no perception of light of either eye; both pupils were dilated, and did
not react to light, and both disks showed a decided pallor; the edges
were not sharply defined, and the lamina cribrosa not visible, in fact
they had the appearance rather of commencing secondary atrophy than
of primary, but no swelling could be seen. The blindness was complete
for five days, and then began slowly to disappear, and ten days after the
operation, vision right eye and vision left eye Four days
later, vision right eye gb, vision left eye 3 %, and by October 9 (four
weeks after operation), right vision left vision fj, with + l'O D.
sph. T ° 2 .
On September 23, stereoscopic X-ray view showed destruction of
the sella turcica with the anterior and posterior clinoid processes and
lack of definition of all that area of the base of the skull. The fields of
vision, charted for the first time on September 22, after recovery from
the period of blindness, showed a very striking bitemporal hemianopia,
the nasal side of each field remaining nearly full. On recovery from the
post-operative attack of blindness, the diplopia returned, but the pupils
remained semidilated, the right one continued quite fixed, but the left
one reacted again very partially to light; accommodation too, remained
almost completely paralysed. The headaches were considerably relieved
by the operation : the disks became slowly and progressively more pale
and atrophic, but when last seen about a fortnight before the patient’s
death they were far from being completely atrophied such as is seen in
the bluish white disks of tabetics. The haemorrhagic discharge from
the nose continued and the patient’s anaemia became more severe,
but not extreme.
Section of Ophthalmology 45 .
On December 5 be was again anaesthetized, the nose explored in the
sphenoidal region, and soft vascular growth removed ; a fresh opening
was made tn the sphenoidal sinus and 100 mg. of radium inserted for-
three hours. On December 10 the tenijjeratare went up, ba became
delirious, collapsed rather suddenly and died.
Malignant disease of the pituitary body,
'■ - At the post^aiortetnthe condition was as follows; On removal of
the cerebrum a large growth was .exposed »n the region of the sella
turcica, with much erosion of the surrounding structures; the optic
chiasm and the optic nerves were stretehed over if and ilattened out,
|5|p
’:,V V;- -y“" 4 i; l
v
46 Maxted: Malignant Disease of Pituitary Body
resembling pieces of tape; one lobule of growth occupied the angle
between the two nerves and was compressing the right nerve rather
more than the left; the left sixth nerve was stretched over another
lobule of the growth; these lobules were a deep purple in colour and
nearly spherical in contour, looking not unlike a ripe grape in appearance
and size. Both cavernous sinuses were distended to about three times
their normal size with masses of the tumour and formed a bulging mass
on either side in the middle fossa of the skull; the growth had not
penetrated their dural sheath, which was stretched smoothly over them.
The anterior clinoid processes had disappeared, and the lesser wings of
the sphenoid were becoming eroded, more especially on the left side.
On an attempt being made to dissect away the growth from the base of
the skull, it was found to be impossible to remove it en masse as it was
so soft as to become confluent directly it was incised; it was very
haemorrhagic throughout, and the colour almost of chocolate hue.
When it was removed it was seen that the erosion of bone was very
extensive, as was suggested in the last X-ray prints taken before death
all the clinoid processes, the sella turcica and its walls were completely
destroyed, and no trace of the pituitary body as such was visible ; there
was a large hole in the bony wall of the sphenoidal sinus to the right of
the mid-line through which the radium had been inserted; the front
part of the dorsum sell® was involved in the eroding process, its surface
being rough and discoloured, and even the apex of the left petrous bone
was becoming eroded. There was recent h®morrhage into the growth,,
which was the probable explanation of his comparatively sudden collapse
and death.
Pathological Report .—The section of the growth removed at the
operation shows a carcinomatous tumour of the pituitary body under¬
going cystic degeneration, a condition commonly seen in tumours of
this region; there is also much h®morrhage into it. Sections of the
tumour removed post-mortem showed a similar condition.
Comments.
No possible causal factor in the case was discoverable, there was no
history of injury, no hereditary tendency, no previous infectious disease,
all of which have been quoted as possible predisposing causes. Many
of this patient’s symptoms are worth while remarking on in greater-
detail ; the one most troublesome, apart from the diplopia, was the head¬
ache, which was severe and persistent, mainly over the vertex, and was
Sectim (teWialirfalhgtf
presumably due at first to distension of the glandular sheath, and later
to the rise in intracranial pressure, although there Was not at any time
any appearance of choked disks to bear out this suggestion: but the
lumbar puncture with the cerebtc-sptnal fluid obviously under pressure
wits in favour of the rise of intracranial pressure being the cause of the
headaches
Fig, 2.
Malignant disoaae at tho pituitary body.
As regards visual disturbances', although at tbe post-mortem both
optic nerves were so obviously depressed and flattened out by the
tumour,, the main visual disturbance Was the diplopia rather titan the
vision remained
failure of vision, and up to the time cif hit deatby the
48
Maxted: Malignant Disease of Pituitary Body
at least g 5 0 in the worse eye. The divergence of the right eye being at
first extreme, and subsequently becoming less obvious, was one of the
reasons for the delay _in making a correct diagnosis, the improvement in
the divergence of the eye at first leading one to think that the condition
might be one of basic meningitis, possibly of syphilitic origin, although
the negative Wassermann made this less likely. Both disks became
atrophic, but at a comparatively late stage, and neither of them ever
showed any appreciable swelling in spite of the direct evidence of
increase in the intracranial pressure.
Apparently it is quite the exception for complete blindness to result
in these cases, for in a series of nearly fifty cases mentioned by Cushing,
only once did blindness ensue. The visual fields show a' fairly
symmetrical bitemporal hemianopia, the symmetry of the fields being
somewhat unusually accurate, a condition that was present in only
three of twenty-two cases mentioned in Cushing’s book, and is certainly
less common than generally supposed.
The total blindness, coming on almost immediately after the
decompression operation, was unexpected and rather alarming. It was
thought at the time that vision would not return, but fortunately in
about four or five days it began slowly to return until it reached the
same degree as before operation; the cause of the temporary blindness
was presumably haemorrhage or oedema in the growth resulting in a
temporary increase of pressure on the optic nerves; during this period
of blindness the disks did not alter in appearance and showed no
signs of any swelling.
The epistaxis was another symptom which unfortunately was
misinterpreted for a considerable time, it being explained as being
due to chronic pharyngitis possibly associated with sinus disease, a
condition which was another possible source of the origin of diplopia.
The true origin of the trouble was not discovered until the anterior
wall of the sphenoidal sinus was opened, when masses of the tumour
were revealed. It was noticed quite early that the patient was a mouth-
breather and as he had a very deflected nasal septum it was thought
advisable to remove it.
The trans-sphenoidal decompression had an excellent effect upon
the headaches, which were very greatly diminished by the operation,
and never again became severe. The effect of the inserting of radium
into the tumour was rather disastrous, producing as it did softening and
necrosis of the substance of the growth, which was associated with
haemorrhage into it, causing more or less sudden rise of intracranial
pressure, rapidly followed by the death of the patient.
Section of Ophthalmology
49
So far as can be ascertained there were none of the signs associated
with interference with the secretions of the pituitary gland, but the
drowsiness of the patient, who often used to sit doing nothing for
long intervals, the tendency to an abnormally slow pulse, which was
usually between 50 and 60 per minute, associated with a subnormal
temperature, which was persistently about 97° F. when taken, were
perhaps suggestive of a commencing state of hypopituitarism.
I wish to thank Captain G. W. Goodhart, who did the pathological
work in connexion with the patient, and Captain W. G. Howarth, who
performed the operations, for valuable assistance in publishing this
account. I also wish to thank Major Ormond for placing the patient
at my disposal.
DISCUSSION.
Mr. J. H. Fisher : My remark on this case is, that there was early
diplopia, which was probably due to involvement of the third nerve in the
cavernous sinus on the right side. I think diplopia is liable to be an early
sign in these cases of malignant pituitary tumours. In one of my own cases
that was one of the earliest signs, being preceded only by sexnal impotence.
That patient was a planter from the West Indies, and he had difficulty in
seeing properly the various rows of plants, and in crossing the Atlantic to
come to England for advice, he saw two-funnel steamers as vessels with four
funnels. I wonder whether there have been sex phenomena in this case.
Perhaps it illustrates the need for early use of the perimeter ; it is possible the
case might have been diagnosed earlier if the perimeter had been used.
Mr. G. Maxted (in reply): I could not ascertain whether this patient’s
sexual function was affected.
Migraine.
By J. Herbert Fisher, F.R.C.S.
The primary classical symptoms of migraine are the scintillating
scotoma, followed by localized and usually unilateral headache, which
culminates in nausea or in actual vomiting; but there are others
which are generally recognized, and as I have myself been the victim
of migraine headache all my life, I can speak of at least two of them
which are in my case constant. These two, apart from the extreme
feeling of general depression, are
(1) A marked reduction in the pulse-rate.
au —29
50 Fisher: Migraine
(2) A striking increase in renal activity, which results in a copious
secretion of pale urine.
In many migrainous subjects one or more of the type symptoms
may be absent, and personally I have never experienced any disturbance
of vision. My headache is invariably localized in the same left temporo-
frontal position, nausea is usual, and vomiting not infrequent. I have
been subject to the trouble certainly from 12 years of age. Whereas
in my earlier life a night’s sleep invariably ended the attack, the
tendency in the last few years has been for the attacks to be a little
less severe, but certainly of longer duration, so that at my present
age of . 51,1 am not free until nearly forty-eight hours after the onset
During my attack there is a certain amount of variation in the
severity of the headache, and it is always very noticeable that when
there is, for a short period, a mitigation in the severity of the headache,
there is associated with it a slight increase in the pulse-rate; at my
worst, the latter has been to my knowledge as slow as forty-six beats per
minute. All digestive and absorptive processes in the alimentary
canal appear to be in abeyance in a severe attack, presumably in con¬
sequence of the lethargic circulation.
There is a familial tendency often in the disease; both sexes are
liable; there is a periodicity about the attacks; my present interval is
about fourteen days. In the female subject the attacks often coincide
with the menstrual periods; they often cease during pregnancy, and
usually terminate for good and all with the climacteric; in the male
subject the liability to migraine commonly also ceases when the patient
reaches about 50 years of age.
The migraine spectrum, on an average, lasts from twenty minutes
to half an hour; the visual aura of epilepsy, on the other hand, for a
few seconds only; the former is a lowly organized subjective visual
phenomenon; the latter is a more highly perfected visual sensation, and
presumably originates in the cortex of the visual centres, whence th©
disturbance rapidly spreads to the motor and sensory cortex. The
migraine aura must have a different explanation. The migraine
spectrum is always symmetrical: it may be represented by a scotoma
expanding from the central point of vision : it may first appear in the
temporal periphery of the fields, or affect the homonymous halves of
the two fields of vision. If flashing light sensations appear* homony-
mously, they will be followed by hemianopic loss of vision in the half
fields implicated, and the headache will develop in the opposite side of
the head.
51
Section of Ophthalmology
The lowly organized visual spectra could, I conceive, be produced
by irritation of the visual nerve fibres at the base of the brain;
implication of them at the chiasma would explain the expanding central
scotoma, or the bi-temporal scotoma. When one or other optic tract is
involved, we should get the homonymous spectrum; presumably the
crude impulse initiated in the basal fibres would be to some extent
elaborated by the grey matter of the visual cortex.
That the hemicrania develops on the side opposite to the homony¬
mous scintillating scotoma agrees well with the idea that the latter is
initiated in the optic tract.
There appears to be only one region where a lesion, slightly varying
in incidence, can reach the various parts of the basal fibres, so as to
explain all varieties of the migraine scotoma; this region is the inter¬
peduncular region, and I am going to be bold enough to suggest, what
I believe has never been put forward before among all the suggestions
hitherto advanced on the pathology of migraine, that the pituitary body
is the exciting agent. It is well worth considering. Very slight swell¬
ing of the hypophysis would enable it to exert sufficient pressure to
irritate the visual fibres in any of the required positions. The cessation
of migraine during gestation, when the pituitary body undergoes pro¬
found modification, and at the climacteric, and in males at the period
when sex powers begin to wane, are very suggestive; are there any
other points in favour of the new suggestion ?
The headache, slow pulse and vomiting, are the general signs
accompanying raised intracranial pressure; swelling of such an intra¬
cranial structure as the hypophysis, would have this effect, especially if
its over-activity caused an increased production of fluids by the intra¬
ventricular choroid plexuses. It is, however, also known that reduction
in the rate of heart beat follows the injection of pituitary extracts in
animals. The increased renal activity is very well explained on the
pituitary body theory. This gland secretes a hormone which is proved
to exercise a direct effect upon the renal epithelium, so that, in spite of the
lowered blood-pressure, a great increase in the amount of urine secreted
results when it is experimentally injected into animals. The hormones
pass primarily into the stalk of the pituitary body to join the intra¬
ventricular fluids. If the hypophysis be over active, and accordingly for
the tijne tumefied and enlarged, an increased supply of the hormones
necessary to stimulate the renal activity would presumably result. Such
hormones might also stimulate the activity of the intra-ventricular
choroid plexuses, and raise the intra-ventricular pressure.
52
Fisher: Migraine
The familial tendency of migraine, the periodicity of the attacks,
their abeyance during pregnancy, their cessation at about 50 years
of age in both sexes, would all be in agreement with the pituitary
body theory. If the central, bitemporal or homonymous scotoma
became permanently established, there would, I imagine, be little
difference of opinion as to the site of the lesion ; surely the indication
is not less, but rather more, convincing when the manifestations are
periodic and in any given case invariable, although transitory. Differ¬
ences in effects on the same fibres leave room for argument as to
nature of lesions, but not as to their situation. I believe a periodic
temporary swelling accompanying functional over-activity of the pituitary
body explains migraine better than any other hypothesis. I am treating
some migraine subjects by glandular therapy. I have had their sella
Aurcicas examined by X-rays, with negative results, but I should expect
mo bone changes in these cases.
I suppose we shall not yet attempt to treat migraine by decom¬
pression at the sella turcica, but I believe it would be efficacious.
DISCUSSION.
Dr. GORDON Holmes : I am very interested in Mr. Fisher’s communica¬
tion, though not fully convinced. In order to relieve him from the invidious
position of putting forward any theory as to the causation of migraine in the
twentieth century, I think I can find a reference to an earlier communication
setting forth similar views. His arguments seem to lack force, and I do not
believe the facts he has put forward will convince many that migraine is due to
the mechanism he suggests. If it were, one would expect to find migrainous
phenomena fairly frequently, in cases of pituitary tumour, or in any enlargement
of the pituitary body associated with various physiological conditions. But, as far
as I know, these phenomena have not been observed : I have never observed them
in association with pituitary enlargement, whether malignant or physiological.
Again, I know of no evidence that irritation of the optic tract can produce such
positive subjective sensations as the typical teichopsic phenomena. I have
seen cases in which the optic chiasma has been compressed by tumours, bub
these never present the symptoms which characterize migraine. And if the
•explanation put forward by Mr. Fisher of headache holds, can we expect to
have such localized reference of the pain in these cases ? In Mr. Fisher’s
-own case it is always in the left temporal or the left temporo-frontal region.
I have suffered from migraine for years, and I have experienced all the pheno¬
mena which Mr. Fisher has, except that in nine cases out of ten I have
marked visual changes. I do not see how you can explain headache of this
nature if it is due to increase of the cerebro-spinal fluid filling up the
Section of Ophthalmology
53
ventricles, since the cerebro-spinal fluid escapes from the ventricles and is
absorbed by the circulation very quickly. In my case the pulse-rate rises as
soon as the headache begins: therefore I do not think a slowed pulse is a
characteristic of these attacks.
Dr. James Taylor : Has Mr. Fisher tested his blood-pressure during
the attacks ? That would be a more definite guide in reference to pituitary
influence than is the pulse-rate. I have no personal experience of migraine*
but in the cases I have seen the pulse-rate has been more rapid as a rule. I
should hesitate to accept the phenomena of migraine as evidence of anything
more than cortical irritation. I was interested in Mr. Fisher’s remark that
women subject to migraine are often free from it during pregnancy, because
in that respect it is analogous to epilepsy. It is notorious that during
pregnancy epileptic patients are often free from fits, but I do not think you
can associate this fact with any influence on the part of the pituitary body.
I believe migraine to be a cortical affection, but I am prepared to accept further
evidence of Mr. Fisher's suggestion.
Mr. Leslie Paton : I am extremely interested in this subject personally,
as I began to suffer from migraine when I was 19, and did so until I was 35.
During the last ten years I have occasionally had scotomal symptoms without
Very severe headache. There are a considerable number of types of migraine*
apart from that which Mr. Fisher has described, which would need explanation
on a similar hypothesis. He speaks of the visual aura of migraine not being
so organized or elaborate as that of epilepsy. The first prodroma I had which
alarmed me was a typical central scotoma with whirling balls of light, and
in my first attack blindness was almost complete. In many of my subsequent
attacks, my visual aura was much more organized : a dream state with a very
definite visual aura, the picture being practically the same each time. I have
had a visual aura when I was lecturing, and I. have asked my listeners
whether they noticed any hesitancy or abnormality in my delivery, and the
reply has been in the negative. As I always got very pale down one side of my
face, my wife could tell when an attack was imminent. At one time a friend
subject to migraine was staying with us, and during attacks I watched his
disks, from the onset of the scotoma until his state got too violent for the obser¬
vation to be continued. At the onset I noticed no change in the blood-vessels
at all, but when the headache was commencing, there was marked engorgement
of vessels in both eyes. As the prodromal stage passes off in my case I have a
feeling of unusual well-being, with some sweating down the side of the face
which was pale : then in five or ten minutes the headache commences. There
is one type of migraine which commences with paraesthesia on the side of the
tongue, and sometimes in the fingers of one hand. One patient of mine always
has paramnesia, a memory of having lived in the same conditions before.
Another friend of mine has a paranosmia as his prodroma. The migraine
attack, in another case, starts with acute pain in the wrist. All these different
forms of prodromata must be taken into account in any theory which would
64 Fisher: Migraine
seek to explain migraine, and it is difficult to see how pituitary swelling can
account for them all.
Mr. M. S. Mayou : I know of two cases in women whose migraine is
worse during pregnancy. There are several other symptoms of migraine
which Mr. Fisher has scarcely touched upon. One is the digestive disturbance
which usually comes on after an attack. In my case these symptoms are very
constant, and last for forty-eight hours. Many people exhibit a large quantity
of oxalates in the urine, severe attacks of migraine occurring before an attack
of renal calculi. This happens to myself, and as a “ cure ” I was enjoined to
drink large quantities of ContrexSville water before breakfast, with the result
that my migraine has almost ceased. I have recommended the same course
to other people similarly affected, and in many instances they have much
benefited thereby.
Mr. J. H. Parsons : Is the scotoma associated with migraine the ordinary
central scotoma? I have had, migraine, and I remember discussing this
question with Mr. Nettleship. My experience is that the scotoma is not
central, it is the centre of the field which escapes : that is, if you alter your
point of fixation, you can always, momentarily, see what you look at, though
I admit it quickly becomes clouded. It is difficult to explain the aphasia of
people who are subject to migraine, on any but a cortical hypothesis. It would
be difficult of explanation on a pituitary hypothesis.
Mr. J. B. Story : I know one case, of a lady who gets attacks of teichopsia
and frequently suffers from partial aphasia: she has difficulty in saying what
she means when attacks come on. Personally I have had scotoma scintillans
often enough, and it has been excentric: the macula lutea was never involved
and headaches were never unilateral. I have had an attack while golfing, and
I played no worse than usual.
The PRESIDENT : I also have suffered from this migraine. One phenomenon
from which I suffered for a time very definitely consisted in severe attacks ot
giddiness at the onset of the migraine. I do not know now whether I had
nystagmus or not.
Mr. J. H. Fisher (in reply): I am not surprised to hear that I have failed
to convince any one. I did not expect to do so. I am not sure that I have yet
convinced myself. At all events, I have made a suggestion which has been
received with interest. In answer to Mr. Hugh Thompson, the pituitary body
is capable of producing homonymous hemianopia, and the migraine scotoma is
not always homonymous: sometimes it is central, sometimes bitemporal,
sometimes lateral, but in all cases it is symmetrical. In answer to Dr. Gordon
Holmes, it is surely conceivable that a rapid tumefaction will give rise to
violent headache, while it may produce over-secretion of intraventricular fluids
as a further cause of increased intracranial pressure ; if the swelling developed
notably to one side I take it the headache would be localized, and that
Section of Ophthalmology
55
would correspond with the headache developing on the side opposite to the
homonymous scotoma. Dr. Gordon Holmes maintains that cases of pituitary
tumour pressure do not produce symptoms of scotoma such as we meet with in
migraine. This does not appear to be convincing as against the idea that
a rapidly-swelling pituitary body, as a transitory phenomenon, might produce a
variety of irritation of the visual pathways different from that which a more
slowly-growing tumour would cause by expansion and consequent pressure on
the same visual pathways. More importance should be attached to the fact
that the phenomena are those of involvement of the visual pathway than to
the exact nature of the visual phenomena which result from the implication
of those pathways. I should have thought that an organic stimulus of the
visual pathways in the interpeduncular region would initiate changes which
the cells of the cortex might elaborate to a higher degree. With regard to
Mr. Paton’s remark on the retinal circulation, I should imagine that that
indicated some impediment to venous return, suggesting a raised intracranial
pressure of a transitory kind. The other phenomena, such as aphasia, would
be sequelae of disordered cerebral circulation. Laterally the pituitary body is
practically in contact with the carotid artery on either side as it rises out
of the cavernous sinus, and the slightest swelling of the gland would exert
pressure on the artery and produce grave disturbance of the cerebral
circulation. The question is, what is it that primarily initiates these dis¬
turbances, which are nearly always introduced by certain visual phenomena,
that are periodic, that frequently develop with the sexual phenomena,
and that cease at the age of decline in sexual life? Taking the matter as
a whole, I do not think there is a better explanation than that afforded by
the pituitary body hypothesis. I was not aware that it had ever been brought
forward before and if there is a reference I should be glad to be told of it.
It is possible that in course of time many conditions at present grouped
together as migraine will prove separable into different categories when
knowledge increases.
Section of ©pbtbalmolooE
Presided—-Mr. W. T. Holmes $pj/?eb
Drawing of a Transverse Section through the Optic Chiasma
and Sella Turcica to show the Relations of thejPitUitary
By j. JrlEHBF.HT PlSHEB, RR.C.S
. The drawing is one of a.n anatouiicat speeitnei). prepared in the
shape of a vertical coronal section through the optic., chiasma, the
pituitary body, and the cavernous- sinus on either aide, and the
sphenoidal air cell.
Vw$jphJ coronal action tbrough th-s optic -omas.iim, tbs- pituitary body on either
% Oac pwernoxis :?inos uuvi the irplionoidai »<r st?H> stac,}
The .fcUlk of tbs pituitary body• parses ^oraewhat; torwijiK^ipj
downward course, -and is cut in the sectionabove it is seen the ; optic;
ehiastmi, at the 'outer end of -which on either side is the ophthalmic
artery The internal carotid artery having' come forward in the flour
of the cavernous sum*,, and made its bond with the conwjoty forwards.
y&r % .wii'eting oi ; i&e Seriion, field ^unc’.4, : W19,.
Section of Ophthalmology
57
is cut on either side as it ascends out of the sinus, to pass on the mesial
aspect of the anterior clinoid process.
The section shows that the sella turcica has no lateral boundary,
and reveals, what is perhaps insufficiently recognized, that the carotid
artery, where it begins to ascend, is lying in immediate contact with
the lateral surface of the pituitary body. It is obvious that a very small
amount of swelling of the pituitary body would be capable of producing
an immediate pressure upon the internal carotid artery, and would in
this way be capable of exercising a profound effect upon the cerebral
circulation. That such interference might be likely to produce some
of the distant symptoms associated with migraine seems to me quite
reasonable. At the same time, the diversion of the blood-stream into the
external carotid artery would afford a satisfactory explanation of the
tense, distended, superficial temporal artery on the same side as the head¬
ache, with which sufferers from migraine are so constantly familiar.
Pigmented Connective Tissue immediately in Front of and
Covering the Optic Disk.
By L. V. Cargill, F.R.C.S., and W. J. Lindsay, M.D.
Patient, a male, aged 22 ; soldier.
History of Case .—He was sent home from France as a case of “avulsion
of optic nerve.” He was struck in the face by some small fragments of
shrapnel on October 26 last; but was off duty only three days. On
enlistment it was noted on the medical history sheet—“ Bight vision, f.
Left vision, g.” He states, “ left eye was never any good.” No history
of any illness but measles. No disease of nose or accessory sinuses.
X-ray report: “ No evidence of orbital fracture or other abnormality.”
Wassermann reaction negative. No history of eye injury previous to
enlistment.
Bight eye normal. Left optic disk hidden by a pigmented mass of
connective tissue in front, which projects forwards 3 D. to 5 D. from the
level of the fundus. The most anterior extremity is delicate and filmy
with slight floating movements like the remains of hyaloid sheath, but
there is a spot of pigment near the extremity. From the mass, white
glistening bands radiate out into the retina like the bands of retinitis
proliferans, and from beneath some of them, as they gradually taper off,
58
Juler: Obstruction of Central Retinal Artery
retinal vessels appear, the bands seeming to blend with the vessel coats.
Some of the bands anastomose with one another forming an open
meshwork to some extent. There are one or two outlying spots of
pigmentation to the temporal side. The left eye is normal in all other
respects ; but it is blind.
This is an interesting case of a soldier from the Fourth London
General Hospital. His right eye, as already stated, is normal. In his
left eye he has a very unusual appearance in front of the optic disk, of
which Mr. Wallace has made a drawing. After receipt of his injury
the condition was labelled “ avulsion of the optic nerve,” but I think
all here will agree that the appearance is not that of avulsion of the
optic nerve. •
With regard to causation there are three possibilities: (1) That it is
some anomaly in development; (2) that it is due to some trauma ; (3)
that it is inflammatory. Weighing the probabilities one is inclined to
the view that it may be due to foetal inflammation or some massive
haemorrhage in front of the disk. Evidently it is not due to injury at
the time the small shell fragments struck his face; and he has no
recollection of other injury to the face or head, or of a blow upon the
eyes, His mother reports that his birth was particularly easy, so that
the question of haemorrhage from instrumental delivery is excluded.
Obstruction of Central Retinal Artery with Patent Branches,
following Electric Flash.
By F. A. Juler, F.R.C.S.
S. L., aged 32, attended St. Mary’s Hospital on May 27, 1919, for
blindness of right eye since May 19.
History: On night of 19th inst. while passing up through a man¬
hole in semi-darkness, there was a bright flash of an arcing between
two forks of copper strips some 6 ft. from his head. The light was
intense, from a 480 voltage and continued for about half a minute until
he could reach the switch to turn off the current. His sight was
unaffected at first, but two hours later a mistiness in the right eye
started, and reached a maximum in a quarter of an hour, when the eye
was quite blind. It remained so for two hours, and then in the course
of the next two hours almost completely recovered. Half an hour later
Section of Ophthalmology
59
lie went to sleep, and awoke two hours afterwards to find the eye again
blind. Since then it has remained in the same condition.
Past history: Previously he had good sight, and was a gunlayer in
the Royal Navy for nine years, using his right eye for sighting. In
January, 1918, he had attacks of pain in the chest lasting a few minutes.
Later he got rather short of breath, and was in various hospitals until
April, 1918, when he was discharged from the Navy. He has had no
further trouble until now. He has not had rheumatic fever, and denies
venereal disease. He never had any obscuration of vision before.
Eyes: Vision—left, f, fundus normal; vision—right, barely.
Right fundus shows the white opacity of the retina which is associated
with recent obstruction of the central retinal artery. The macula is
evident as the usual liver-coloured spot, and a strip of retina from the
disk outwards nearly to the macula has escaped owing to the presence
of a small vessel probably cilio-retinal in nature. The retinal vessels
look normal and of full calibre, perhaps the central reflex streak on the
arteries is not quite so marked as in the left eye. Digital pressure on
the globe does not appear to elicit pulsation in the arteries more easily
in one eye than in the other. The field of vision corresponds with the
area of intact retina.
Heart: Dr. F. S. Langmead reports as follows: Impulse heaving.
Cardiac dullness 1 in. outside nipple line. Apex beat, sixth space,
systolic murmur conducted to spine, diastolic also. Base: Loud rasp¬
ing systolic, loudest in second inner space on right side, but heard all
over base, and towards apex. No aortic second sound. Diastolic
murmur heard only on the left of lower half sternum up to apex. The
basal systolic is accompanied by a forcible thrill, well heard in the back
on both sides, and conducted up into the carotids. Pulse full, regular,
and somewhat collapsing. He adds that the lesion of the heart is
probably congenital, and may be of the nature of a foramen between
the auricles.
This is a case of embolism of the central artery of the retina,
which shows some unusual features. The first of these is, that there is
a part of the retina, to the outer side of the disk, which is not opaque,
and looks healthy, and there is a small vessel, obviously of cilio-retinal
origin, supplying this part of the retina. This is not uncommon in
cases of obstruction of the central artery. The second interesting point
is the nature of the obstruction. The man has an extensive heart
lesion, upon which Dr. Langmead kindly reported, and Dr. Langmead
thought that possibly it was of congenital origin, owing to the extensive
60
Moore: Melanoma of the Choroid
nature of the murmurs of the heart. In addition, the retinal arteries at
this date—‘a fortnight after the onset of the disease—are quite patent,
and their calibre is full in comparison with that of the retinal arteries
of the other eye;
As already stated, the patient was engaged in his electrical work,
when there was a sudden flash due to an electrical arcing, at about 6 ft.
from him. Two hours later the eye was gradually going blind, but an
hour later still, his sight came back almost completely. After that,
he went to sleep, and when he awoke two hours later, the eye was
again blind. This is the sort of history which one gets with intermittent
attacks of obscuration of vision in many cases where there is end¬
arteritis causing thrombosis of the central artery, but I do not think it
is the usual thing in a case of pure embolism. However, having regard
to the heart lesion, one must assume that there was an embolus, and it
is possible to imagine that the clot which lay in the central artery
shrank, and allowed the vessels to become patent again: and during
sleep, when the blood-pressure was lowered, blockage of the artery again
became complete. The other explanation is that an anastomosis
between the ciliary and retinal vessels at the optic nerve head has
dilated up, and allowed the latter vessels to All with blood.
The question of compensation is another feature of interest in the
case. The man was at work, and this electrical flash occurred close to
him, and shortly after it he became blind: so I think there must be some
causal relation between the flash and the blindness.
Postscript .—Later note, June 10, 1919: The retinal arteries show
definite pulsation now, and their calibre is smaller.
Melanoma of the Choroid.
By R. Foster Moore, ^.R.C.S.
This man shows a melanoma of the choroid in the right eye, a
drawing of which was made by A. W. Head five and half years ago, and was
published in vol. xix, part iii, of the Royal London Ophthalmic Hospital
Reports 1 : it is now exhibited. If the ophthalmoscopic appearances be
compared with the drawing, it will be found that the growth is quite
unchanged in every way. It shows the characteristic homogeneous
1 Roy. Land. Ophth. Hosp. Rep., 1914, xix, Plate VII, facing p. 414.
Section of Ophthalmology
61
“ blue ointment ” colour of these tumours, with a defined edge, which
is not quite hard and sharp, but is somewhat feathered. There is no
disturbance of pigment over the growth nor around its edge. These
features supply a characteristic ophthalmoscopic picture, which differ¬
entiates them from a very early melanotic sarcoma. They give rise
to no symptoms, and are discovered on routine examination.
I also show you by the epidiascope sections from a melanoma which
were published along with the coloured plate referred to above. They
were obtained from a patient who died of myasthenia gravis ; .the
tumour was discovered a week before he died. They show how heavily
pigmented are these growths, and how sharply limited they are in the
choroid ; the chorio-capillaris and sclerotic are not infiltrated. This
specimen also shows a collection of heavily pigmented cells in the
ciliary muscle, a feature which, according to de Schweinitz and
Shumway is very common in negroes.
There was one other case which I published in the first number of
the British Journal of Ophthalmology. 1 The patient died of a cerebral
tumour, and the appearances, both ophthalmoscopic and microscopic,
were precisely similar to those of the above cases.
These growths are not exceedingly rare ; I have seen a very large
one, which was six or eight times the area of the disk. It is of course
highly important to recognize them, lest an eye should be enucleated
for what after all is no more than a pigmented mole, and there are few
of us, I suspect, who have not somewhere on our bodies a growth of
such a nature.
An Unusual Case of Ptosis with Bilateral Ophthalmoplegia
Externa.
By M. L. Hine, M.D., F.R.C.S.
R. B., aged 18, was brought to the Royal Westminster Ophthalmic
Hospital on May 28 last, to see whether anything could be done to
improve her vision by raising the lids.
Family history : Father alive and well; mother died twelve months
ago in an asylum of “ pulmonary tuberculosis,” after being an inmate for
seven years; three brothers alive and well; two sisters alive and well.
1 Brit . Joum. Ophthal., 1917, i, p. 26.
62 Hine: Ptosis with Bilateral Ophthalmoplegia Externa
History of present illness: Four years ago both of the patient’s
upper lids began to droop, and at the same time she was unable to
move her eyeballs. She was taken to the Royal London Ophthalmic
Hospital in September, 1915, to see whether her lids could be raised,
but no operation was advised. The fundus was not examined, and her
father states that her sight has always been good. No change has taken
place in the condition during the past four years. She has a violent
temper, and “ father sometimes fears she will end, like her mother, in
an asylum.”
Present state : Right vision, T8> left vision, tV Under H. and C.:
Right vision, c oyf.'w = A > left vision, c +4 sph. = T ° 2 . With post-
mydriatic correction (0*5 sph. less than above) she reads J2 at 6 in. with
either eye, showing there is no loss of accommodation. There is almost
complete ptosis, and also external ophthalmoplegia, with a slight range of
movement in each eye, as indicated below, rather greater in the left
eye than in the right. Range of movement as shown on perimeter :—
Right eye
Left eye
Internal
. 5°
10°
External
. 8°
2°
Upward
. 3°
5°
Downward
. 2°
4° (down and in)
No diplopia is complained of when both lids are raised. Pupils equal
and active to light and accommodation. Both fundi Bhow fine, scattered
lesions of old retino-choroiditis. No vitreous opacities. No other
stigmata of hereditary specific disease. Wassermann reaction
negative.
Dr. Gordon Holmes reports that her reflexes generally are
diminished, but otherwise considers she must be one of the rare cases
of localized nuclear paralyses.
Mr. McMullen, in vol. xxxii of the Transactions of the Ophthal-
mological Society, reported a similar case in a man aged 34, in whom the
ptosis and ophthalmoplegia developed at the age of 8, and, like his case,
the present case would appear to belong to the group of chronic nuclear
atrophies described by Wilbrand and Sanger, and in the larger text¬
books on neurology.
“ Orbital ridge ” spectacles, kindly suggested by Mr. Rayner Batten,
with the appropriate correcting lenses, have been ordered for the
treatment of this patient.
Section of Ophthalmology
63
The Visual Perception of Solid Form.
By E. M. Eaton, M.D.
(ABSTRACT.)
[This paper was printed in extenso in the British Journal of Ophthalmology ,
August and September, 1919, pp. 349, 399.]
It is almost universally accepted that binocular vision is the essential
factor in stereoscopic vision. I am convinced that this view is erroneous,
and in the following paper I hope to satisfy you that it has no justifiable
foundation. This will involve a restatement of the principles of binocular
fusion on a basis of less intimate organization of the two eyes than that
commonly accepted. There are two principal theories of binocular
vision—namely, the theory of corresponding points and that of projec¬
tion. Both involve serious inconsistencies. The theory of projection,
with appropriate expansion, can be so formulated as to be entirely
consistent with the facts however. The mechanism of binocular vision
as I conceive it may be summarized as follows :—
(1) The vision of each eye remains physiologically independent
except as regards fixation : apart from this the unification of the two
images has reference to the object perceived, not to the means of
perception.
(2) The physiological axes of vision are interpreted as occupying
their actual positions, the lines passing through the point of fixation
and the nodal points of each eye.
(3) The perceptive axis of vision lies between the fixation point and
the middle of the interocular space. Its use involves a psychic modi¬
fication of all visual angles similar to that which enables us to interpret
foreshortened images in accordance with their true values.
(4) The perception of position in three dimensions is a function of
the sense of directional projection of the two eyes. The perception of
relative position in three dimensions is a function of the sense of
relative directional projection of the two eyes.
(5) Double images result from a certain degree of perception of the
subjective element in the sense of sight, with consequent alteration of
the foregoing relationships.
This theory denies the existence of physiologically corresponding
retinal points. As there is no specific type of sensation involved in
64
Eaton: The Visual Perception of Solid Form
binocular vision I conclude that there is no reason on subjective grounds
to differentiate between the stereoscopic perception of binocular vision
and that of uniocular vision. It can be shown also that there is no
valid reason on objective grounds, for whenever the amount of informa¬
tion apparently made available by binocular vision becomes appreciably
greater than that available to one eye, that is in the sense of our being
in a position to see around an object, we get either duplication or
suppression of a part of one retinal image.
The sense of perspective is dependent on the same fundamental
sense factors as the binocular function, and it is analogous to this
function in its mental relationships. It is more stable and less liable to
illusion in average circumstances, for larger differences of angles are
available as the basis of judgments by its means.
There are many other factors in stereoscopic vision but none is
universally essential. Much of the effect obtainable from stereoscopic
photographs is due to stereoscopic lustre. In relation to such pictures
this factor derives an augmented importance from the incidental
circumstance that photographs do not reproduce natural lustre
convincingly. The perception of lustre is dependent on apparent
incongruity of light intensities and thus results from similar causes
whether observed with one eye or with two.
The requirements for the perception of solid form are that the
appearances should contain in sufficient degree any of the charac¬
teristics of solidity such as perspective, shadow effects, or differing
binocular images, and that observation of the characteristics presented
should be habitual. In the case of projection representations it is of
course necessary that they should not contain inconsistencies of a
degree sufficient to cause effective antagonism.
The loss of one of the accustomed characteristics on closing one eye
places the observer at a disadvantage, but this is in great part due to
his habit of seeing with two eyes. The loss of any factor to which we
are accustomed will reduce the vividness of the mental image, but this
does not imply alteration in the perception of form.
PROCEEDINGS
vEblffet) BY
M.uALISTER
m JOHN Y. W
twuiitt nit ninecVmx of
EDITORIAL C 0 ,M MIT TEE
VOLUME THE TWELFTH
SESSION JUJK-10
SECTION OF OTOLOGY
LONDON
LONGMANS. G'REBN A CO., PATERNOSTER ROW
19 tO
Section of ©tologs
OFFICERS AND COUNCIL FOR 1918-19.
• ■ President —
Hugh E. Jones.
Vice-Presidents —
J. S. Fraser, F.R.C.S.Ed.
Dan McKenzie, M.D.
Herbert Tilley, F.E.C.S.
Hunter F. Tod, M.D., F.R.C.S.
Hon. Secretaries—
J. F. O’Malley, F.R.C.S.
H. Buckland Jones, M.B.
Other Members of Council —
H. J. Banks-Davis, M.B., F.R.C.P.
E. D. D. Davis, F.R.C.S.
P. G. Goldsmith, M.D.
J. Dundas Grant, M.D.
A. A. Gray, M.D.
Somerville Hastings, M.S.
H. J. Marriage, F.R.C.S.
W. M. Mollison, M.Ch.
D. R. Paterson, M.D.
N. H. Pike, M.B.
Representative on Library Committee —
George C. Cathcart, M.D.
Representative on Editorial Committee —
Dan McKenzie, M.D.
SECTION OF OTOLOGY.
CONTENTS.
November 15, 1918.
Herbert Tilley, F.R.C.S. page
Acute Osteomyelitis of Right Temporal Rone in a Boy; Operations;
Recovery ... ... ... ... ... ... ... 1
W. Stuart-Low, F.R.C.S.
Extensive Symmetrical Lupus Erythematosus ... ... ... 5
W. M. Mollison, M.Ch.
(1) Case of Double Facial Paralysis due to Bilateral Tuberculous
Mastoiditis... ... ... ... ... ... ... 6
(2) Case of Necrosis of the Internal Ear, causing Sequestration of the
Labyrinth; Recovery. (Sequestrum shown) ... ... ... 8.
(8) Case of Acute Mastoiditis followed by Thrombosis of the Internal
Jugular Vein as far as the Clavicle ; Recovery... ... ... 10
J. Dundas Grant, M.D. •
Two Cases of Radical Mastoid Operation for Cholesteatoma, with Preser¬
vation of the Matrix (Fourteen Years and Six Months after
Operation respectively) ... ... ... ... ... 12
John F. O’Malley, F.R.C.S.
Chronic Middle-ear Suppuration ... ... ... ... ... 18
January 17, 1919.
Hugh E. Jones (President).
Deafness associated with the Stigmata of Degeneration ... ... 17
IV
Contents
February 21, 1919.
J. S. Fraser, M.B., F.R.C.S.Ed., and W. T. Garretson, M.D.Iowa, F.R.C.S.Ed. page
The Radical and Modified Radical Mastoid Operations: their indica¬
tions, Technique and Results, with Notes on the Labyrinthine
and Intracranial Complications of Chronic Middle-ear Suppuration 20
Hunter Tod, F.R.C.S.
Septic Infection of the Lateral Sinus accidentally injured during the
Operation of Mastoidectomy ... ... ... ... ... 02
March 21 , 1919.
Richard Lake, F.R.C.S.
Particulars of a Case of Vertigo ; Labyrinthotomy; Obliteration of the
Semi-circular Canals and Part of Cochlea by Rone ... ... 77
W. Stuart-Low, F.R.C.S.
(1) Epithelioma of the Left Auricle after Operation (Specimen of
removed shown) ... ... ... ... ... ... 78
(2) A Female with Fibroma of the Auricle at the entrance of the Meatus 79
John F. O'Malley, F.R.C.S.
Vertigo; (?) Labyrinthine or Cerebellar ... ... ... ... 79
Sir Thomas Wrightson, Bt., and Professor Arthur Keith, M.D., F.R.S.
Demonstration on a New Theory of Hearing... ... ... ... 80
May 16, 1919.
P. Watson Williams, M.D.
Case of Chronic Adhesive Otitis ; Myringotomy and Partial Ossiculectomy 95
J. F. O'Malley, F.R.C.S.
(1) Case of Circumscribed Labyrinthitis ... ... ... ... 99
(2) Case of Labvrinthectomy ... ... ... ... ... 101
J. S. Fraser, M.B.
(1) Two Cases of Fracture of the Base followed by Otitis Media, Menin¬
gitis and Death ... ... ... ... ... ... 103
(2) Otosclerosis associated with Otitis Media ... ... ... 115
(3) Otosclerosis associated with Fragilitas Ossium and Blue Sclerotics,
with a Clinical Report of Three Cases ... ... ... p>(5
The Society does not hold itself in any way responsible for the statements made or
the views put forward in the various papers.
.John Bai.f, Sons A Daniflsson, Ltp., S3-D1, Great Titolifleld Street, London, W. 1.
Section of ©toloap.
President — Mr. Hi gh E. Jones.
Acute Osteomyelitis of Right Temporal Bone in a Boy ;
Operations ; Recovery . 1
By Herbert Tilley, F.R.C.S.
The patient was admitted to University College Hospital for acute
suppurative otorrhoea (right) of some six weeks’ duration, associated
with pain, pyrexia, sleeplessness, and malaise. The mastoid antrum
and adjoining cells were explored in the ordinary way, the roofs of the
antrum and tympanum were found to have been destroyed by disease,
the dura was replaced by a mass of granulation tissue which permitted
the tip of the little finger to be passed into the adjacent region of the
temporo-sphenoidal lobe. The wound was left wide open and dressings
applied. During the following three or four weeks the soft tissues in
the temporo-mastoid regions became swollen and oedematous.
At the second operation, the squamous and mastoid portions of the
temporal bone were freely exposed and were found to be so softened by
inflammation that large portions could be scraped away with “ sharp
spoon ” or removed with forceps. Theldura mater was so thickened and
unlike the normal structure that it was difficult to recognize it or to
differentiate it from surrounding infiltrated [tissues. During the subse¬
quent and long convalescence‘herniae cerebri made their appearance on
three occasions in the original wound over the mastoid, and on each
occasion they were removed by division of the stalk which seemed to
d—8
At a meeting of the Section, held November 15, 1918.
2 Tilley: Acute Osteomyelitis of Right Temporal Bone
depend from the brain in the neighbourhood of the defective roofs of
the antrum and tympanum.
After a long convalescence the patient is now practically well, except
that a small sequestrum appears to be making its way to the external
opening of a fistula in the lower part of the post-aural wound. In the
experience of the exhibitor acute spreading osteomyelitis of the
temporal bone is rare, and he believes that most of the recorded cases
have proved fatal. It is possible that the very wide removal of inflamed
bone in this case accounts for the successful issue.
DISCUSSION.
Mr. TlLLEY: There is still some suppuration in this case, and if you pass a
probe through the fistula in the post-aural wound you will find a spicule of
bare bone. I felt it there a fortnight ago, and the patient is down for admission
to hospital in order to have it removed, after which I do not doubt there will
be sound healing. He has a large right tonsil which will be dealt with at the
same time.
The President : What interests me most in Mr. Tilley's case is the
treatment of the hernia; it seems to have disappeared completely. Hernia
has always, in my experience, been the most difficult complication of brain
abscess to treat, probably because it is associated with increased intraventricular
pressure.
Mr. W. Stuart-Low : During twenty years’ experience I have had a few
cases like this. The earlier cases gave me trouble, but since I have used a
shield in order to avoid pressure on the wound, I have not had trouble. A large
shield would cover the whole of even such a large wound, and the bandage
and dressings would then be adjusted over the shield. I think the narrowdng
of the meatus is entirely due to the bandaging. The meatus is unusually
narrow, which militates against a good result. This is accentuated by the
meatus being pushed forward from behind by the bandage pressure. With
the use of a shield, drainage is facilitated and congestion is prevented;
moreover the granulations which are often caused by irritation from the
dressings are never redundant where the shield has been made use of through¬
out the after-treatment.
Mr. HUNTER Tod : Osteomyelitis is extraordinarily rare, as Mr. Tilley
has said. It is not the result of operation, but of a definite germ infection
corresponding with the osteomyelitis sometimes met with in the frontal bone.
The patient is usually young. Following middle-ear suppuration, a boggy,
oedematous swelling spreads slowly over the temporal and parietal regions,
even extending to the eye ; but not so much over the mastoid. These patients
Section qf Otology
3
do not get a very rapid pulse, nor a temperature higher than 101°F. When you
operate you find marked periostitis, the whole bone comes away in masses,
and, beneath, the dura mater, although much thickened and covered with thick
gelatinous-looking granulations, is such a protection that meningitis does not
occur. I have had three cases: two proved fatal from sinus thrombosis with
secondary meningitis, the other recovered. In the London Hospital Museum
there is a calvarium from a patient operated upon some years ago, the disease
having spread over the whole of the vault of the skull. The treatment consists
in recognizing the condition early, and then removing a large area of bone well
beyond the infected area, otherwise osteomyelitis is a progressive and fatal
disease.
Dr. Perry Goldsmith : The zygomatic cells have probably been well
developed for a child of this age, and the extension has taken place after those
cells have been involved. When osteomyelitis of the bone outside the mastoid
takes place, the extension occurs from these cells after they have become
involved. The case illustrates the necessity of early and very wide operation.
If operation is postponed the chances of recovery are lessened.
Dr. D. K. Paterson : Has Mr. Tilley any explanation to offer as to the
difference between the extreme rarity of osteomyelitis of the temporal bone and
its more frequent occurrence in the frontal bone, more particularly after
operative procedures ? The only case of acute osteomyelitis of the temporal
bone I have seen occurred secondarily to frontal trouble. A considerable area
of both temporal bones was affected. The disease had travelled back from the
frontal bones, and I think I removed most of the squamous portions of both
temporal bones. The course of the case extended over some fifteen months,
during which time there were several operations.
Dr. Kelson : Have Mr. Tilley or Mr. Tod seen a case of this trouble in
which there has been definite osteomyelitis before operation ? Ip the frontal
bone it is very rarely seen until after operation. Is this a point of difference
between the two ? My impression is that in these very rare mastoid cases
the mortality is not so high as in the frontal cases. Do others share that
opinion ?
Mr. Mollison : In reference to what Dr. Kelson has just said, I have
seen two cases of acute osteomyelitis of the frontal bone which occurred
before any operation had been done, and both those patients recovered.
Mr. Hunter Tod : In the three cases which I have seen the infection
was pre-operative. There was no true meningitis directly from involvement
of the bone, but as a final stage, secondary to the sinus infection, the path of
extension of the infection appears to be the venous channel in the diploe. It
is a type which is so rare that it is not always recognized. It must not be
confused with simple necrosis, which is localized to the mastoid bone and is
occasionally met with in severe mastoid disease.
4 Tilley : Acute Osteomyelitis of Right Temporal Bone
Mr. Tilley (in reply): The description of the case is somewhat imperfect;
the notes I took have been lost in the hospital. The father says the boy was
admitted three days before last Christmas Day, and I operated on the day
following admission. On the day of operation the tissues were swollen and
cedematous over the mastoid region, and I think the osteomyelitis had com¬
menced at the time of the operation. When the antrum was opened the roof
of the tympanum was found to be destroyed and its place taken by granulation
tissue, so that one could pass a probe straight into a subdural or even a
temporo-sphenoidal abscess. The patient was put back to bed, but, instead of
the oedema disappearing in a few days, it became more marked, and spread,
so that in two or three weeks it had extended over the greater part of the left
temporal, parietal, and occipital regions, and the general condition had become
worse. He had a slight temperature every night. Therefore we decided to
open the wound again. It was then that I found the squamous portion of
the temporal, and a part of the lower posterior portion of the parietal bone,
and the occipital bone in the region of the mastoid process involved. The
bone was soft. I cut away into healthy tissue in all these regions. The
strange feature was the extraordinary appearance of the dura mater, which
looked like pale bacon rind, and I dared not go through this lest I should
expose the pia or enter the cortex. He had no meningitis. I left the dura
to take its chance. In the course of some weeks it settled down, and I think
his dura is now in a more or less normal condition. I must try Mr. Stuart-
Low*8 cage, for it seems to have advantages. I think, however, with Mr.
Moliison, .that the narrowing of the meatus had nothing to do with the
dressings in this case. The patient was in hospital some six months, and the
septic condition of the wound was extreme, and lasted for weeks. I think
any soft cartilaginous tissues would be apt to become necrosed, and that the
present anatomical conditions would be accounted for by the severity of the
inflammation and consequent cicatrization which occurred. Mr. Tod pointed
out what probably most of us have noticed in osteomyelitis of the frontal bone
—viz., the low degree of pyrexia. This boy had no rigors, and his temperature
was never anything remarkable. Dr. Paterson asked why osteomyelitis
occurred more in the frontal bone than in the temporal region. It may
possibly be explained by the fact that the vascular supply in the temporal
region is much more free than is that in the frontal bone. If you open the
frontal sinus in a chronic empyema and clean out the mucous membrane for
twelve days you see nothing there except a mother-of-pearl-like appearance on
the posterior wall. On the tenth or twelfth day red spots begin to appear,
and in four or five weeks the frontal sinus will be full of granqlation tissue,
whereas, in the case of the mastoid antrum you can see plenty of granulations
at the end of a week. There is a better vascular supply, a better leucocytic
infiltration, and a better defence against infectious organisms. Dr. Kelson
asked if osteomyelitis occurred in the temporal bone without a previous opera¬
tion. In this case the osteomyelitis had started when we opened the wound,
because the roofs of the antrum and tympanum were already destroyed, and
Section of Otology
5
the condition spread until the second operation was performed. Acute osteo¬
myelitis, independent of operation, does occur in the frontal sinus, and I have
published a record of such a case. 1 At the time I operated on that patient the
osteomyelitis had spread to such an extent that in a week or two we had to
take away nearly the whole left frontal bone. The patient recovered. Never¬
theless nearly all the cases in the frontal bone which I have seen have been
post-operative. I have seen only the one case of mastoid osteomyelitis which
I show to-day, and hence my experience of the complication in this situation
is (fortunately) rare.
Extensive Symmetrical Lupus Erythematosus.
By W. Stuart-Low, F.R.C.S.
A male, aged 45. No family history of tuberculosis, but of cancer on
the mother’s side, and in the case of one of his sisters at the age of 47.
He has had a very hard life, having had to maintain himself at the age
of 15. The skin condition has been present ever since he can
remember, but has extended more rapidly during the last few years,
especially on the scalp. The crusting on the edge of the left auricle has
only existed for six months : it began over a small bean-shaped area,
and has always had a blackish-brown colour. As the crusts are removed
they rapidly re-form, and destruction has been marked during the last
two months. Suspecting that there might be an element of epithe¬
lioma at this place a piece has been removed by Dr. John MacKeith,
whose patient he is, and submitted to Dr. Wyatt Wingrave for micro¬
scopic examination. Dr. MacKeith has very carefully studied the case
from the point of view of possible tuberculosis, but has found no
corroborative evidence of tubercle bacilli.
Liquor arsenicalis has been administered in increasing doses since
Dr. MacKeith first saw him in August last, and locally the ulcer has
been touched up at intervals with acid nitrate of mercury. He
complains of pain in the ear, especially in cold weather. There is
a large patch of lupus erythematosus on the outer side of the left thigh.
DISCUSSION.
Mr. W. Stuart-Low’ ; Dr. Wyatt Wingrave’s report on the specimen from
this case states that it is a most unusual Case of epithelioma being grafted on
to lupus erythematosus. In my experience, this is unique. I would like an
1 Brit . Med . Journ. y July 7, 1917, p. 7.
6
Mollison: Case of Double Facial Paralysis
expression of opinion as to the best treatment. I intend to amputate the
auricle, and will show the patient at a subsequent meeting.
Dr. H. J. Banks-Davis : I thought, judging from a case which I reported
in the Proceedings in 1914, that this looked like epithelioma of the helix apart
from the lupoid condition on the face. I removed the entire helix, but none of
the glands, as I could feel none. The patient was a very old man, and I did
not remove any glands at the time of the operation. Several members predicted
a recurrence—but such has not taken place. Two years ago I showed another
similar case in an old man. The eroding surface was considered gummatous,
but it proved to be an epithelioma and the atiricle was removed.
Mr. J. F. O’Malley : Is the diagnosis of lupus erythematosus definitely
established ? Can ordinary lupus vulgaris be excluded ?
Mr. W. Stuart-Low (in reply) : There is little doubt about this being
lupus erythematosus, the symmetry and chronicity are in favour of this
diagnosis.
Case of Double Facial Paralysis due to Bilateral Tuberculous
Mastoiditis.
By W. M. Mollison, M.Ch.
A child, aged 13 months, was admitted to Guy’s Hospital on
October 12 of this year. Otorrhoea began at the age of six months, and
has been considerable ever since. A swelling was noticed over the left
mastoid process the day before admission; the change in the face was
only noticed four days previously. From both .meatuses there was
profuse foul otorrhoea; there was considerable swelling over the left
mastoid process and the* «kin over this was red. The face was without
creases, and crying produced no change.
At operation the mastoid process was found to be soft and necrotic,
and a series of sequestra were easily scraped out with a “ sharp spoon ” :
the dura mater of the middle" fossa was exposed and covered with
granulations.
Six days later the right mastoid was operated on and a similar
condition found.
The child has made a good recovery.
Section of Otology
7
DISCUSSION.
Mr. HUNTER Tod: How was this infant fed? Was it breast fed ? If not,
was the milk boiled ? It is now recognized that tuberculous mastoiditis is
nearly * always due to infected milk. It is most unusual to get double
tuberculous mastoid disease. Were there any enlarged glands ? Generally
the pre-auricular and cervical glands are affected, and then the question arises
as to whether they should be removed. What is the experience of Mr. Mollison
and others with regard to facial paralysis ? Tuberculous disease of the middle
ear frequently begins in the region of the facial canal, and if facial paralysis
occurs, recovery seldom takes place. Has this mastoid completely healed?
If so, there cannot any longer be tuberculous disease. These cases are difficult
to treat, and we know comparatively little about the prognosis, except that the
disease cannot be said to have been eradicated until the mastoid cavity has
remained completely healed for a considerable period.
Mr. W. Stuart-Low : Have tubercle bacilli been found in the discharge?
There are many cases, even more pronounced, in which tubercle bacilli cannot
be discovered. External fomentation with Tidman’s sea salt—or with sea¬
water if the patient is at the seaside—is a good method. Iodide of lead
ointment should also be rubbed in for a considerable time.
Dr. Perry Goldsmith : Mastoid suppuration in very young children is
often loosely termed 'tubercular. Sometimes the tubercle bacillus cannot be
found in children or even in adults. In a fairly large number of cases under
my care the time of healing was far prolonged beyond the six weeks taken in
this case. The mastoid cells are scarcely developed in a child of this age.
This could hardly have been a mastoid abscess as it healed up so quickly.
The PRESIDENT : I recall a somewhat similar case, in which the question
of tuberculosis was a prominent one. There were really two cases, tfwins,
10 months old. For two months before I saw them they had each suffered
from double otorrhoea and enlarged cervical glands. The source of the milk
was inquired into, and was supposed to be quite beyond reproach : the cows
were kept by a gentleman farmer, who specialized in supplying milk to babies,
and had his cows periodically examined. My opinion was that the disease was
tubercle, and inoculation of guinea-pigs proved it to be correct. We put the
Medical Officer of Health on to the track q! the milk, and it was traced to a
tuberculous cow in this “model dairy.” Another case cropped up in the
practice of the physician who saw my case in which the child died of meningitis,
and the milk was traced to the same cow. In these twins, there was only one
of the four facial nerves paralysed, and perhaps that was partly my fault, for it
occurred some days after the operation; however, the case recovered. Three
mastoids were operated upon.. Both those children put on weight during the
whole of the treatment, and never went back. Tuberculin injections had
8
Mollison: Case of Necrosis of the Internal Ear
apparently, if anything, an •unfavourable effect on the children. I think most
temporal bone cases in babies are tuberculous, and are due to the milk, and I do
not regard facial paralysis, though frequently occurring, as by any means a
necessary concomitant. The glands were removed three or four months
afterwards by a general surgeon : tonsils and adenoids were removed by myself.
These children are now, after several years, fco.th strong and healthy.
Dr. Kelson : The fact of rapid recovery need be no argument against the
condition being tuberculous. I have had several such cases, and they have
healed with marvellous rapidity, even when the disease has been extensive.
But the trouble is that the disease is apt to reappear after a year or so.
I showed here one case which was operated upon by myself three or four times,
at intervals of two or three years, the first being at the age of six months.
Mr. Mollison (in reply): We did not find tubercle bacilli, but the case
was tuberculous clinically. There was a thin foul discharge from both ears,
there was no pain, and it was only by accident that the swelling over the
mastoid was discovered at all. There were many glands on both sides :
pre-auricular and infra-mastoid. With regard to the feeding : One child
I know about had been fed on the milk of one cow, which had been kept
specially for it and tested by tuberculin. The child developed typical tuber¬
culous mastoid disease. The second case was that of* the eighth child in a
family, which had been breast fed. This child was 8 months old and the
mother and all the other children were healthy. This child developed what
appeared, clinically, to be tuberculosis of the middle ear : another aural surgeon
had seen the child, and had diagnosed it as tuberculosis, advising immediate
operation. There may be other paths of infection besides ingestion with the
milk.
Case of Necrosis of the Internal Ear, causing Sequestration
of the Labyrinth; Recovery. (Sequestrum shown.)
By W. M. Mollison, M.Ch.
W. S., aged 60, attended in the aural out-patient department at
Guy's Hospital on account of pain in the left ear. For years he had
suffered from left-sided otorrhoea ; for three months he had had head¬
ache and attacks of vertigo, but had continued his work of a bricklayer
till three weeks ago when he felt too ill. Recently he had been some¬
what delirious at night. There was a large polypus in the left meatus
with a foul otorrhoea. There was no swelling over the mastoid process
but a little tenderness on percussion. He looked old for his age and pale.
9
Section of Otology
He was admitted and operation performed. On opening the mastoid
process, pus was found and a sequestrum ; on exposing the antrum all
anatomical landmarks were absent, the region of the external semi¬
circular canal was eroded and separated posteriorly by a line of necrosis
and granulations ; further investigation revealed this trench, as it were,
surrounding the labyrinth, and the whole labyrinth was found to be
movable, and a very slight pull brought it away whole. The deep hole
thus revealed was found to be bounded above by granulations on*the
dura mater of the middle fossa, and behind by granulations on the
dura of the posterior fossa. The facial nerve lay across the hole on
granulations, and was damaged at some stage of the operation. The
patient still has paralysis. For a few days the patient was mildly
delirious, but, as can be seen, has made a good recovery.
The condition was not tuberculous.
DISCUSSION.
Dr. D. E. Paterson : To what extent ought one to undertake cutting
away of bone for the delivery of the sequestrum ? In three or four cases I
have had considerable difficulty: the petrous bone is too hard to break up in
situ. I contented myself with loosening it under an anaesthetic, and leaving it
for a time. It was impossible to deliver it without cutting away bone con¬
siderably, and I have always had in mind the possibility of a connexion with
the carotid canal, or thought that the sequestrum might, in its inner part, be
attached to the auditory nerve, and be in communication with the interior of
the skull. Loosening it in three or four sittings, made it possible to deliver it
safely. I do not know how far one can venture to go in the forcible extraction
of such sequestra.
Mr. J. F. O’Malley : Can syphilis be entirely excluded in this case ? If
not, the case must be regarded as one of septic necrosis* It is rather unusual
for an ordinary sepsis to isolate the labyrinth in that way. It is more likely to
follow syphilis.
The President : In a case I reported to the old Otological Society many
years ago, the whole labyrinth and cochlea came away complete. In that case
the original trouble followed scarlet fever, the child being also the subject of
congenital syphilis. The fact that the facial nerve recovered afterwards was
surprising to me : I should have thought the whole part of the facial nerve
which is included in the temporal bone would have been destroyed. The
recovery was first noticed because the girl had had double facial paralysis,
and yet complained, three weeks after the operation, of her face haying
become crooked. This was due to a return of power on the operated side.
10
Mollison : Case of Acute Mastoiditis
Case of Acute Mastoiditis followed by Thrombosis of the
Internal Jugular Vein as far as the Clavicle; Recovery.
By W. M. Mollison, M.Ch.
A. F., female, aged 8, was operated on for acute mastoiditis. The
temperature, which had been 103*6° F., fell to normal in two days.
On the third day after operation it rose to 102° F., and for some
days fluctuated between 100° and 102*5° F., till on the eleventh day
the patient had a rigor.
Operation was performed. On opening the wound, pus was found
about the lower part of the lateral sinus; the sinus was opened and
found thrombosed. The jugular vein was exposed in the neck and
found to be solid with clot as far down as the clavicle. A piece of vein
was excised and is shown. There was never any stiffness of the neck,
and two days after the operation the child sat up in bed. Before
recovery she had several rises of temperature. She was treated once
by injection of 1 c.c. of collosol manganese, but it is difficult to say
whether the subsequent fall of temperature was a result of the treat¬
ment or merely a coincidence.
. DISCUSSION.
Dr. H. J. Banks-Davis : Some years ago I showed here a girl whose
internal jugular vein I had to excise for a similar disease. It was mistaken
for enteric fever. She was sent into the hospital from one of the fever
hospitals, with a large swelling in the neck. The sloughing wound in the neck
was treated with “ soap solution,” for the formula for which I am indebted
to Dr. Dundas Grant. It is made into an emulsion, and cyanide gauze is
dipped into this, packed into the wound, and it is astonishing how it clears up
the condition. The formula is : Potash soap, 1 dr.; soda soap, 1 dr. ; olive oil,
1 dr.; water to 2 pints.
Dr. Perry Goldsmith : Acute mastoiditis in which there is a temperature
of 103° F., falling to normal in two days after operation, and subsequently
rising to 102° F., with remissions, always, in my experience, means exposure of
the lateral sinus. Often there is a peri-sinus abscess, which has been unnoticed
at the operation. Some American surgeons say that in all mastoid operations
the lateral sinus should be exposed as a matter of course. I do not agree
with that,* but peri-sinus abscess occurs often after such operation. • In the
Section of Otology
11
note ifc says the temperature fluctuated between 100 ^ F. and 102'5° F., till the
eleventh day, when the patient had a rigor. One w T ould expect an unexposed
sinus 1 case to have a rigor by that time. With regard to ligature of the
jugular, a person can have thrombosis of the lateral sinus which will look after
itself and may not be discovered except by accident. In two cases I have
operated upon the lateral sinus has been exposed, and there has been old
obliteration without trouble, except periodical attacks of old mastoid symptoms.
If one is careful to get the flow of blood from behind and from below, it will
not always be necessary to ligate the vein in the neck. It must be remembered
that in curetting the bulb so as to get a flow from below, we are liable to shift
the clot in the inferior petrosal sinus, which is a protection against the cavernous
sinus becoming involved. With regard to removing a portion of the vein, it
does not seem g6od surgery to remove a small portion of the vein. What can
be the object of taking out an inch or so ? Either ligature it alone, or take
out the whole vein. If it is ligatured at the lower end, the upper part should
be brought out of the wound : otherwise there will be a bag containing a clot,
which is sometimes, though not always, septic.
Dr. D. R. PATERSON : I have had a similar experience in a chronic case.
Septic matter was traced away down into the cervical region, and it was
impossible to follow it below the clavicle. I passed a probe a considerable
distance down the vein, and satisfied myself that it was quite empty for some
distance into the'chest. The vein was excised, because it was in a very foetid
condition, and the patient was returned'to bed with very little hope of it
doing well. Nothing was applied afterwards, except an ordinary dressing, and
yet the child did excellently.
The President : I am glad to hear that Dr. Goldsmith does not go as
far as some of his neighbours in the United States. The impression I have
had of most American otologists is that they invariably remove the whole
vein in the neck, and occasionally dissect out the bulb. '
Mr. Mollison (in reply): I agree with what Dr. Goldsmith says about
the lateral sinus: if the temperature is raised in a case of acute mastoiditis
the sinus should always be exposed.
12 Grant: Radical Mastoid Operation for Cholesteatoma
Two Cases of Radical Mastoid Operation for Cholesteatoma,
with Preservation of the Matrix (Fourteen Years and Six
Months after Operation respectively).
By J. Dundas Grant, M.D.
*
Case I .—The first is a gentleman, aged 56, on whose left “ mastoid ”
I operated fourteen years ago in the presence of several French colleagues,
who agreed with me as to the singular resemblance of the matrix to an
unusually delicate skin-graft. The progress of the case was very rapid.
The patient only came under my notice again in July of the present
year on account of deafness in the other ear with jingling noises and
giddiness. The ear formerly operated on is now his “ good ” one, and
he hears with it a whisper at 16 ft. The cavity is a typical “ radical
mastoid ” cavity, but smoother, drier and whiter than I usually secure.
Case II .—The second is the lady whom I brought before the Section
at the meeting last May about a fortnight after the operation. It was
then nearly dry, the osseous ridge being alone uncovered. It has kept
quite dry.
DISCUSSION.
Mr. J. F. O’Malley : Dr. Dundas Grant had an excellent result in the
case of the lady whom he has shown here before. A week or two after that
occasion I got a case, upon which I operated, and found a huge cavity filled with
cholesteatomatous material; the facial ridge was destroyed, and no landmarks
were left. The cavity was lined with a beautiful smooth filament. Acting on
Dr. Dundas Grant’s advice, I left it completely intact, and with the most
excellent result. The only delay in healing was at a spot posteriorly on the
inner aspect of the wound in the mastoid. There were a few granulations
here which I had to suppress by applying caustic. Where the membrane
covered the cavity the healing was perfect.
Dr. PERRY Goldsmith : I was present when Dr. Dundas Grant operated
upon this man. The French visitors discussed, with a good deal of vigour,
the leaving of the matrix behind at all. Others have not had the same good
results from leaving the matrix. W T hy should the matrix be left to cover the
disease which is beyond ?
Section of Otology
13
Dr. D. R. Paterson : Following Dr. Grant’s suggestion, I have left the
matrix behind. In one case a boy had very extensive disease on both sides,
long-continued, and a very large cholesteatoma. At the radical operation I
left the matrix in both, and there was an excellent recovery, with good hearing.
In the dry class of case, leaving the matrix turns out excellently, because there
is not a huge cavity to line and one escapes the vicissitudes which accompany
trying to line it by grafts. '
Dr. Dundas Grant (in reply): The speakers in discussion have confirmed
my views. Much depends on the appropriateness of the cases. You cannot
have this formation unless the case is of very old standing ; the cases are not
now allowed to continue without treatment so long as formerly. Dr. Gold¬
smith has referred to the question of disease being still below the matrix. If
this were so, the formation of the matrix, w r hich is a homogeneous membrane,
would be interfered with; if it is white and adherent one can be pretty sure
there is no active disease there. The question has often been discussed, and
critics have quoted Kirchner, who contended that the cholesteatoma extended
into the bone. He had made onjy one observation, and published it, but
what the nature of the case was nobody knows. Katz, among others of his
countrymen, opposed his views, and showed that it was not an ordinary nor
even a possible occurrence. I think everyone is now agreed that the chole-
steatomatous membrane is an attempt at dermatization, and is, as a rule, a
very successful attempt. When it is complete it should be retained. Mr.
O’Malley has referred to the spot where he had a little trouble ; that is just
inside the posterior margin of the wound. Those with experience of radical
mastoid operations will always be on the look-out for that. If the little mass
of granulation tissue there is taken away the cavity dries up. The best way
to deal with that is to puncture it with a fine galvano-cautery as recommended
by Stacke in his original work. It causes a limited area of sclerosis in the
inflammatory tissue. One does not know how far the contraction is going to
extend if nitrate of silver be applied.
Chronic Middle-ear Suppuration.
By John R O’Malley, F.R.C.S.
Private I. M., aged 20. Left ear discharging constantly for over
two years; no history of disease in childhood. “Pain for about eight
months in bone behind ear, worse at night.”
This case is shown for the purpose of eliciting expressions of
opinion on the following important points :—
(1) For the purpose of a pension award is one justified in stating
that this trouble began two years ago and not previously (see right ear) ?
14
O’Malley: Chronic Middle-ear Suppuration
(2) Assuming that he has been in the Army oyer two years, should
his condition be attributed to (a) military service, or (6) only aggravated
by it, or (c) not affected by it ?
(3) -Is a radical mastoid operation positively indicated ?
(4) What is the surgical prognosis, apart • from the function of
hearing ?
DISCUSSION.
Dr. Perky Goldsmith : This man has been in hospital a considerable
time, and it is necessary to assume the idea that it is a psychic case. There is
no objective evidence in regard to his pain, and he is coming before a Pensions
Board, and he knows he will be paid if his deafness is due to service, or if it
has come on after the war commenced. One hesitates to question the good
faith of an individual, but I do so in 99 per cent, of cases, otherwise we may
have pitfalls. This man says his trouble came on after the war started, but he
admits that he always sat in the front at the theatre, and he would not be
likely to do so unless he could not hear, sight being normal. He says that
within a short time of enlistment he was bathing and got some water in his
ears, and from one ear he had a discharge without pain a few days later.
That is not the course of acute middle-ear suppuration, but of ordinary chronic
middle-ear suppuration in which there is perforation lit up by the presence of
water in the middle ear. I therefore think his condition was aggravated by
war service, and that it existed before the war. The radical operation does not
seem to be indicated, but I do not think he will get rid of the pain until some
operation cutting the skin is done. His pain I regard as largely psychic.
If you make the pressure greatest on the right ear, he will still have pain in
the left. There is possibly some chronic sclerosis of the mastoid which clears
up after operation. If he has a cholesteatoma and a matrix, the surgical
prognosis is very good. I see no reason for regarding the prognosis as
unfavourable, though, before operation takes place, it would be well to know
how far the labyrinth is capable of function and what is the perception for
high tones.
Dr. Dundas Grant : It is unfortunate that, from the nature of things,
men had to be taken into the Army without being examined closely as to the
condition of their ears. If that had been done, many in the Army would Pot
have been there. We have to give the man the benefit of the doubt, and unless
we feel yery confident that the condition is an old-standing one, we are bound
to accept the man’s statement that his ears were well before enlistment. This
man has one good ear, and “ sclerosis ” changes in the other. If there was old
trouble, it must have been very slight. This detracts much from the force of
Dr. Goldsmith’s argument, for when he sat in the front at the theatre he had
one good ear. I agree with Mr. O’Malley, that he had an old-standing condition
which was re-awakened since he joined as the result of his exposure, and I do
Section of Otology
15
not think we are justified in penalizing the man on that account. He has,
I imagine, a disability of about 20 per cent. Everything shotild be done to
cure the suppuration. Perhaps 30 per cent, would be fairer than 20 per cent.
I think one would have to say his trouble was aggravated by military service,
that, beginning as disease, it was aggravated by injury. He gives a definite
account of shell explosion, but that it would produce such pain as he has had,
I think doubtful. I hardly suppose that would wake up inflammatory changes.
I expect everything has been done to cause the discharge to cease. I examine
such cases with a suction speculum, and sometimes with a bent probe, such as
Mr. Hunter Tod’s. But I cannot say whether the discharge here comes from
the antrum, or from the direction of the Eustachian tube. If from the antrum
—and one sees the formation of well-marked cholesteatomatous products—it
would indicate old-standing disease, and operation would be justifiable. I do
not know what the hearing in the affected ear is. If it is very bad, a mastoid
operation will not make it worse: if it is fairly good, the operation will leave
the hearing only moderate. The presence of pain would be a further indication
for operation.
Mr. W. Stuakt-Low : We have seen Very many of these cases. If a man
had discharge from the ear, he was put back to Grade 3. If the ear dried up,
the man would perhaps be taken into the Army. Such men ought to be
cautioned not to bathe. This man’s trouble was re-started by bathing. I do
not doubt that/ the condition has been chronic for years. I would operate
because the discharge has gone on so long, and is likely to continue. Every¬
thing should be done to favour the discharge drying up ; I would have mouth
and teeth seen to. If he is not right in three months, he should certainly
have the radical mastoid operation performed on him.
Colonel A. D. Sharp : There should be no difficulty in answering the
questions here set out. The disability was certainly contracted in the Service,
and as certainly was it aggravated by service. But I do not think it is
attributable to military service. Dr. Grant has summed the case up correctly,
but the percentage I would award would be 15. If the man says he will not
be operated upon, and as he has the right to refuse, his refusal should not
influence the Board in determining his pension claim.
Mr. J. F. O’Malley (in reply): The only difference of opinion expressed
by speakers relates to the question of an operation. We seem all agreed that
the man had disease in the ear prior to two years ago, and also that the
condition has been aggravated by military service. The fact of an antecedent
discharge would enable one to exclude the heading “ Due to military service
alone,” and one would assess the disability lower than if it had been entirely
due to military service. The man showed no objection whatever to an
operation. He came to me and said he could not sleep. After questioning
him pretty thoroughly, I put the question to him, “ Are you bad enough to
undergo a severe operation ? ” He did not hesitate, but at once said he would
16
O’Malley: Chronic Middle-ear Suppuration
like it very much. One can see a distinct focus of chronic inflammation, with
caries in the attic, and a fairly large mass of granulations, dependent from the
meatal roof. I think he has sepsis and granulation trouble in the aditus also,
and possibly in the antrum. I should operate to get rid of it. I asked the last
question because, apart from function, I wanted to know if others agreed with
me as to the site of the lesion. A localized lesion in these cases enables one
to give a more promising prognosis, for one is likely to be able to remove the
whole of the disease.
Section of ©toloap.
President — Mr. Hugh E. Jones.
Deafness associated with the Stigmata of Degeneration.
By Hugh E. Jones (President).
The subject uppermost in my mind just now is one that has not
received much public attention from aural surgeons, and one upon
which there may be many differences of opinion. On the one hand, it
may be objected that “functional” or “neurotic” deafness is known to
all and recognized as such by otologists; on the other hand, that I bring
very little direct evidence and not any of a histological kind in support
of my speculations. This paper is an attempt to run to earth those
vague terms and to associate with them certain visible signs of
diagnostic value.
Let me make it clear that in using the term “ stigmata of
degeneration ” 1 2 * 1 am not dealing with extremes, with malformations
or perversions and arrests of development on a large scale, nor am
I dealing directly with the stigmata which affect the face, nasopharynx
and middle ear, and which cause direct interference with the conduction
of sound—a subject too large and important to include in this paper—
but with the more subtle signs and effects of degeneracy which come
under one’s notice every day—and which may materially affect the
practice and reputation of our specialty.
I suggest that there is a kind of deafness due to inborn degeneration
of one or more sets of the neurons which connect the ganglion spirale
with the brain cortex and that this degeneration is associated with
1 At a meeting of the Section, held January 17, 1919.
2 An excellent account of the major and minor malformations of the ear will be found
in Ballantyne’s 44 Ante-natal Pathology and Hygiene,” * 4 The Embryo,” pp. 436 et seq and
in Talbot’s 44 Degeneracy.”
M —10
18 Jones : Deafness associated with Stigmata of Degeneration
degeneration of other more or less remote epithelial tracts: that
these associations have diagnostic value. If you consider that these
speculations are worth discussing I hope you will contribute many
facts, criticisms and suggestions which will be helpful in the elucidation
of a difficult problem.
In 1909 I read a short paper at the annual meeting of the
British Medical Association. 1 This paper contained an analysis of
210 consecutive new hospital ear out-patient cases, at the Liverpool
Eye and Ear Infirmary—135 of these cases, i.e., 64 per cent., showed
auricular defects such as are associated with degeneracy. ThiB in itself
was a high proportion, but in the cases of chronic tympanic catarrh and
otosclerosis (I couple these together as the diagnosis may not always
have been correct) the proportion was forty-nine defective auricles
to nine good ones, while in nervous affections of various kinds the
figures were twenty-two to three. In what may be termed accidental
affections the proportion was thirty-five bad auricles to forty-one good.
In the discussion which followed it was quite properly pointed out that
statistics, especially when the numbers w'ere small, were notoriously
fallacious and that until the proportion of defective auricles to good
ones was established the figures given could not be regarded as proof.
It might be thought that after this criticism I would have immedi¬
ately set to work to collect statistics in all directions, but unfortunately
my zeal for this form of research had reached its limit, and I regret that
even now I cannot provide any large body of figures. I have, however,
been keeping my eyes open and by classifying and counting ears in
trams, trains, and public assemblies, from time to time, have satisfied
myself that defective auricles do not occur oftener than one in five
of the general public. I believe the proportion is considerably lower.
On the other hand, among ear patients, without making regular notes
of the feature but having it always in mind, the last nine years’ practice
has confirmed me absolutely in the belief that the analysis given
exhibited a general truth.
Two Sundays ago I took part in a Church parade of volunteers ;
while seated in the front row, and painfully conscious of the things
I had left undone, I analysed the auricles of the choir boys. There
were twenty-eight boys and every one of them had well formed auricles
and so had the organist and clergyman who preached. At the church
door I looked at my fellow officers’ ears and found four defective
Brit. Med. Joum. , 1909, ii, p. 1137.
Section of Otology
19
auricles (pairs) out of about thirty. As the men, to the number of
about 200, filed out of the church I glanced at them and about one
in five had defective auricles. This proportion I regarded as a high
one, but it must be remembered that a proportion of these were C3 men.
If anything can be deduced from the correctness of the form of the
choir boys’ auricles it is that the combination of a good ear for music
and executive power are associated with good auricles and perfect
functional continuity of the organ of hearing.
Now take 158 consecutive eye patients examined a few days ago:
129 had good lobules, fourteen had doubtful ones which might be
counted either way, while fifteen only had definitely defective auricles—
of the latter, three had interstitial keratitis, three senile cataract, one
glaucoma, two asthenopia, one congenital cataract, one congenital ptosis,
one myopia and cataract, one convergent strabismus, one astigmatism,
and one muscse volitantes. If I weight the evidence against myself by
counting doubtful auricles, twenty-nine patients out of 158 had defective
auricles—in round numbers pne in five. The hearing was not examined
but none of these patients was actually complaining of deafness.
On the same day I went into the ear department and examined
ten consecutive cases. Four of these had good auricles: one deflected
septum, one pharyngeal ulceration, one tonsils and adenoids, one suppu¬
rative otitis media. One case was doubtful, with chronic suppurative
otitis. Five had definitely defective auricles: one otosclerosis and
? functional deafness, three chronic suppurative otitis media, one loss
of bone conduction on both sides (cleft helix, attached lobule and
Darwin’s tubercle). That is, amongst the actual ear cases one had
good lobules, there was one doubtful, and five had definitely defective
auricles.
Taking these figures therefore for what they are worth—amongst
individuals generally with sound and defective hearing the proportion of
good to bad auricles is about five to one—but taking the deaf alone the
proportion is over 60 per cent, defective auricles, while if degeneration
deafness cases are alone taken the proportion rises to at least five
defective auricles to one normal.
I now come to the case which may be said to form the text of my
paper (and to which I shall refer as the text case). A boy, aged 17,
wished to enter the merchant service but was afraid that deafness
and imperfect sight might interfere with his career. He had already
consulted five aural surgeons in various centres, and had been under
treatment of one kind or another for several years, and finally, at the
M—10a
20 Jones: Deafness associated with Stigmata of Degeneration
suggestion of one of the aural surgedns, his parents had taken the boy
to a medical electrician and had spent £150 on electrical treatment
without benefit. His father had died at the age of 45 and his
grandfather at the age of 43, but no family history of deafness was
obtained. The boy had narrow, attached lobules. No enlargement
of tonsils or adenoids. He was of a somewhat “ neurotic ” type, but
distinctly intelligent, if erratic.
Hearing.
Right
Left
Acoumeter
5 in.
6 iu.
Bone conduction, C 1 (256)
‘JO
3115
20
Air conduction, C* (256) ...
40
«o
4 0
so
C 3 (16), C*(32), Ci( 64), heard by both ears.
Galton-Edelmanti
05 mm.
03 mm.
Sight.
Right vision ... ... ... ... T ° ff c — 1-75 d. = J.
Left vision ... ... ... ... T * H T c = V* partly.
No night-blindness complained of. Examination by the ophthalmo¬
scope showed pigmentary degeneration of the peripheral zone of each
retina, but not of the type of retinitis pigmentosa—i.e., there were no
spider-patches of pigment. My diagnosis was correlative degeneration
of the auricles, one or more auditory neurons and the pigment layer
of the retina—all epiblastic tissues. The symptoms were in many
respects like those of senility.
You will observe that the hearing has -a good range—that there
is no total loss of perception at either end of the normal scale, that
the defect is nearly equal in the two ears, that there is a distinct
loss of bone conduction' and that the loss of air conduction is not
more than could be accounted for by the former reaction. There
was no paracusis Willisii. The fatigue reaction which I generally
find prominent in these cases was not present, and the boy appeared
to be giving me his attention. This absence of fatigue reaction
probably meant that the excitability of the neurons was permanently
low, or the synapse substance permanently defective or that recovery
of function was too slow for the time allowed for the experiment.
He was an only child, an interesting lad and keen to enter the
merchant service, a choice of profession which was probably due to
heredity and a restless disposition. His stepmother said he was
difficult to manage and not a success at school. He did not show
any evidence of congenital syphilis unless the degeneration described
could be so interpreted. His father and grandfather died at an early
Section of Otology
21
age, and I would here point out that the ear symptoms bear a similarity
to those of senile deafness, and may perhaps be regarded as caused by
presenility.
* I have taken this case as a text because it is rarely that one finds
the conditions under discussion uncomplicated by or unassociated with
other lesions of the organ. I say “ uncomplicated by ” because I believe
degeneration to be the underlying condition and predisposing cause of
many diseases of both the middle and internal ear : that it makes the
organ more vulnerable and less amenable to treatment.
The Sites of the Main Degeneration Lesion . — The absence of
paracusis and loss of low tones probably exclude otosclerosis, though
Professor Albert Gray’s fine work has proved that this condition is
itself an idiopathic degeneration, and my statistics go to show that it
is frequently associated with degenerate auricles. Fortunately, for my
purpose, it is not necessary to decide whether sound is analysed by the
cochlea or by the cerebral cortex, for the power of analysis in my text
case is good, and it is not conceivable that one cochlea or both and cortex
could be seriously impaired without the sound analysis being affected.
The defect must therefore be somewhere between these parts. If
we accept the neuron theory as completed by Professor Sherrington’s
“ Synapse ” the explanation of the phenomena becomes simple. Dr.
F. W. Mott 1 in his Croonian lectures says: “The neuron, like other
cells, nourishes itself and is not nourished, and it depends for its
development, life and functional activity upon a suitable environment.
It must also possess an inherent vital energy. In the neuropathic and
psychopathic individual it may be conceived that in some portions
of the nervous system, especially the brain, there may exist communities ,
systems or groups of neurons, with an inherited low power of storage
energy, rapidly becoming exhausted and especially liable to depression
of function,” and, again : “ Morphologically, I conceive that the process
of primary degeneration is an evolutional reversal commencing in the
structures latest developed, namely the myelin sheath and the terminal
arborisations and collaterals of the neurons,” and, one might add, in the
hypothetical synapse of Professor Sherrington. Sir William Milligan
and Colonel Westmacott applied this explanation to the mutism caused
by war shock, and Colonel Hurst 2 gave a demonstration of its applicability
1 Brit . Med. Journ ., 1900, i, p. 1517, &c. ; see also Allbutt and Rolleston’s ‘‘System of
Medicine,” 1910, ^i, p. 173 et scq.
- Proceedings , 1917, x, Sect. Otol., p. 11*5
22 Jones : Deafness associated with Stigmata of Degeneration
to concussion deafness. I think, however, in these cases that the true
psychical or cortical elements must nearly always be invoked. Let us
assume then that the defect of hearing in my case results from
degeneration of the neurons connecting the mid-brain with the cortex,
'causing imperfect contact or a rapid exhaustion of their vitality or of
that of the synapse substance, or a permanent low degree of excitability
and of power of transmission. This supposition removes the necessity
for any attack on the brain cortex. So far from showing signs of
mental degeneracy, many of my patients have brains of a relatively
high' order. In using the term “ stigmata of degeneration ” I do not
imply that I agree with the criminologists that all or even many
individuals exhibiting minor defects of the pinna have criminal
tendencies or defective mental powers; on the contrary, my suggestion
is that such defects of the pinna are associated mainly with localized
actual or potential degenerations of the auditory nerve tract.
The occurrence of progressive and regressive variations will be
discussed later.
Embryological .—I may be asked what possible connexion can the
lobule of the ear—a mere piece of skin—have with the auditory nerve ?
Precisely because the lobule of the ear, the main site of visible
variation is a piece of skin—without cartilage—in other words, is of
epiblastic origin. How far mesoblastic tissue enters into the consti¬
tution of the pinna the embryologist does not tell us—but the pinna is
clearly developed from tissue lying outside the “ cleft membrane ” in
contradistinction to the structures of the middle ear which are hypo-
blastic and mesoblastic in origin. About the time that I saw the text
case I examined a child with microphthalmos and coloboma of iris and
choroid. The pinnse were very well developed and the hearing was
perfect. This was clearly a case of defective development of mesoblastic
structure. When the crystalline lens is the subject of congenital or
lamellar cataract the enamel of the teeth is usually defective; when there
is malformation of the whole auricle, fusion or maldevelopment of the
ossicles, associated perhaps with cleft palate and facial asymmetry (as in
the case reported by me in the Transactions ©f the Otological Congress
in 1899),’ .the failure of development concerns hypoblastic and meso¬
blastic tissues, while those of neuroblastic origin are unaffected. I
think, therefore, it is fair to assume that failures of development and
localized degenerations are apt to pick out one or other of the great
1 Trans. Sixth Internat . Otol. Congress (1890), 1900, p. 403.
23
Section of Otology
embryonic layers and different parts of the same layer which are
functionally related, though failures are not necessarily limited to one
layer. From the point of view of the evolutionist they are correlative
variations.
Evolutional .—Professor Ray Lankester in “The Kingdom of Man,”
p. 132, says : “ Whilst natural selection may be favouring some small
and obscure change in an unseen group of cells, such as the digestive,
pigmentary or nervous cells, and that change a change of selection value,
there may be, indeed often is, as we know, a correlated or accompanying
change in a physiologically related part of far greater magnitude and
prominence to the eye of the human onlooker. This accompanying or
correlative character has no selection value, is not an adaptation—is, in
fact, a necessary but useless by-product.” Hugo de Vries writes as
follows: “ As soon as a plant deviates from its type it will be disposed
to do so in more than onh character. This type rule holds good for
rare and casual abnormalities as well as for the more normal so-called
fluctuating deviations from the type. Useful qualities are subjected to
it as well as those practically useless, which are usually studied merely
on account of the valuable indications they so often give for comparative
science.” Haeckel asserts 1 that while the pinna is a more or less
useful implement in the lower mammals it is quite useless in the
anthropoids and man, the conduction of sound being scarcely affected
by the loss of the pinna, and that in this loss of function we have the
explanation of the extraordinary variety in the shape and size of the
shell of the ear in different men. Even if that be true, the
degeneration of the lobule or some other part of the pinna may
serve as an indication of degeneration of correlated structures which
are of functional importance. Regarded as biological variations I take
it that these changes would be described as “minor,” “continuous,”
or “ fluctuating,” and are therefore not specifically hereditary. The
tendency to vary is hereditary, and ' the particular direction and
degree of variation depends on nutrition and environment. In
this respect they differ from the grosser malformations which are
“ major ” or “ discontinuous ” variations, and are heritable. The
question may now be put : Are these variations progressive or
regressive ? “ Progressive and regressive variations take place in the
same individual, giving rise to that inequality which characterizes the
development of the so-called degenerates. Thus one and the same man
1 “The Evolution of Man” (translation), 1905, ii, pp. 708, *309.
24 Jones : Deafness associated with Stigmata of Degeneration
may have a hare-lip or a club-foot and yet be a genius.” 1 If this be
true of major it is equally likely to be true of minor variations. In
the latter the result is largely determined by nutrition and environment.
May it not be that we are witnessing a gradual differentiation of men
into definite types which are adapted for different forms of activity—
the man of action, the student and so forth, much as ants are
differentiated into workers, soldiers and the group which propagates
the race ? The development of the higher brain centres is inimical to
instinctive actions. Deep thinking necessitates switching off the
special senses. The “ brown study ” and “ absence of mind ” may
become a fixed habit, and as senile degenerations take place the
switching off, which may have begun as a voluntary action, becomes
involuntary, and its prevention requires a conscious effort of the will.
The charge is constantly made against the subjects of senile and other
forms of degenerative deafness : “ He hears well enough when he wants
to.” Amongst soldiers whom I have examined either as patients or for
discharge from the Army, I have been struck with the prevalence of the
defective lobule. These men, notwithstanding the patriotism and the
keenness of the majority, were not fitted to stand the hardships or the
sound-concussions to which soldiers are subjected, and consequently
became deaf. It may be objected that deafness as a consequence of
progressive evolution of one part of the brain is absurd. It must,
however, be remembered that the path of evolution is strewn with
wreckage, and that “degeneration” is not peculiar to slum-life.
Treatment .—I must pay my respects to this time-honoured heading ;
and, after all, much may be done for the individual. As has been
remarked, the condition specially described is rarely uncomplicated, and
the otologist can at least treat the complications.' The degenerative
factor can only be treated on general lines, and these require the co¬
operation of the physician. Nutrition, choice of work and environment
are the main points to be considered.
Preventive Treatment .—This brings us into the domain of sociology
and politics. The aim of treatment should be to influence the nutrition
of the child from its conception, and its nutrition and environment from
its birth. It takes into its scope not only the child but the health and
habits of the parent. Whether or not the germ-plasm can be affected
by the life and habits of the individual there can be no doubt that as
soon as embryonic life begins nutrition plays an important part.
* Hastings Gilford, “The Disorders of Post-natal Growth and Development,” p. 120.
Section of Otology
25
In conclusion, I should like to ask if we, as a society of otologists,
could not, or ought not, to extend and deepen our influence in regard
not only to the treatment of the individual but also to the solution of
the sociological problems upon which I have touched.
DISCUSSION.
Mr. W. Stuart-Low : I have listened to this address with great interest;
it has made me think, and I have learned a good deal from it. I have always
been taught to observe things, but my observation has been thrown into the
shade compared with the minuteness and thoroughness of that displayed by
Mr. Jones, such as observing the ears of people in church. I have never,
until now, attached great importance to the abnormalities in the external ear.
I should like the President to give us in greater detail the points about the
auricles which he has noticed, and their association. The lobule running into
the ear is very characteristic in some people, but I have not noted it specially
in connexion with deafness. One distinguished soldier, a patient of mine, has
such a lobule. Criminologists say it is a criminal indication, but that is far
from being the case in this particular instance. I also know a most estimable and
amiable lady with the same type of ear. I once had to deal about a motor car
with a man who had a pointed pinna, an indication of acquisitiveness, and I felt
he would drive a very hard bargain. What is the significance of Darwin’s
tubercle? None of these individuals, as far as I know, were at all deaf. I look
upon such peculiarities of ears as accidental, without any association neces¬
sarily with defective character. I should say there are more likely to be
anatomical disturbances in the nose than in the auricle. In future I shall
look out for these abnormalities in the external ear. We are aware of the
variations there are in the length of the fibres of the tympanic membrane.
I have been told that in those who have a sensitive musical perception the
tympanic membrane is highly specialized. Does anything simijar bold good for
the auricle ? There is, of course, an intimate connexion between the neurons
of the different parts of the brain. We all know the placid face of the deaf
person who loses even the ordinary facial expression. Deaf patients find the
hearing better after a good laugh, and for such reasons I find it beneficial to
order them to listen to such comedians as George Eobey, the object being, not
only to convulse the facial muscles by laughter, but the movements of the
auricle are considerable during this exercise, which has an improving effect
on the hearing. The tympanic membrane, too, is stretched during laughter
through the tension put upon the tensor tympani muscle. The probability is
that just as the nerve terminals in the muscular fibres are acted upon so
similar influences may affect the neurons in the nerve centre through the
tendrils which join them all together. I have certainly found that listening to
music and singing, and laughing freely practised and indulged in, have an
improving influence on the hearing of my deaf patients.
26 Jones : Deafness associated with Stigmata of Degeneration
Dr. H. J. BANKS-DAVIS : Since I received the abstract of this paper I have
made a point of noticing people’s ears everywhere. I have never appreciated
the possibility that any loss of hearing might be associated with a degenerated
or malformed auricle, but I have often observed people “ prick up ” their ears,
in the way animals do, when being tested with the tuning fork. Lately a naval
officer whom I was testing with forks delayed his responses in a marked
manner, and on being asked the reason said he must have time to “ prick up
his ears,” which I observed he really did. I think the auricle must have
something to do with the sense of hearing: otherwise it would not be there.
With regard to otosclerosis, especially in women, I have often been surprised
to notice how beautifully formed the auricles of these people are. Will the
President draw on the board a diagram of what he means by an abnormal and
degenerate auricle, for the point is really one of great interest.
The PRESIDENT drew on the board sketches representing his views, and
said : The lower portion of the lobule is epiblastic in origin, and it does not
contain cartilage. Another defect is too deep a cleft between the lobule
and cheek, which, carried to an extreme, would be a cleft between the tragus
on the one hand and the antitragus lobule on the other hand. The “ Morel
ear,” which is specially associated with criminality, is a narrow ear with a
fairly long lobule attached along its whole anterior border. But extreme
malformations are not what I refer to in my paper: I speak of the minor
defects. I have seen bad types of auricles in extremely intelligent people.
Genius is often associated with degeneracy, but degeneracy is so subtle, and
takes so many forms, that it is almost impossible to say whether a man is
degenerate or not unless there is some objective evidence of it. ,
Mr. T. GUTHRIE : May I ask whether the diminished secretion of
wax, which is supposed to occur in otosclerosis, might not have some bearing
on the subject ? The meatus is part of the external ear, and perhaps the
decreased secretion of wax indicates degeneration of the ceruminous glands.
Dr. Kelson* As regards degenerate conditions, not only has the lobule
adherent anteriorly been noted, but a Frenchman first showed that in
tubercular persons the tissues of the lobule were so weak that ear-rings often
cut out; whilst in the postero-superior part of the helix Darwin’s tubercle has
been associated with asinine or Simian characteristics and a pointed projection
higher up with those of a satyr. Are any of these conditions really associated
with maldevelopment or degeneration of the nervous system or internal ear ?
Mr. Somerville Hastings : If your type case is typical, Sir, and if your
theory is correct, it is curious that there should be both a middle-ear and an
internal ; ear deafness. Clearly, the internal-ear deafness would be due to
degeneration of epithelial structures, but I do not see how the middle-ear
deafness could be of that origin. In the case you cite, the deafness is mixed,
that is to say, partly middle-ear; and I wish to ask whether that is the usual
thing in these cases.
Section of Otology
27
Mr. .W. M. Mollison : These cases of quantitative loss of hearing seem to
be extraordinarily rare, and that is my difficulty. I take it your type case
is one of quantitative loss of hearing: it has a normal lower tone limit and
upper tone limit, but the hearing is diminished very much through the whole
scale. I recognize that type of deafness but I have not been able to associate
it with any particular deformity, though I admit I have not looked specially
for it. I have attributed this type of deafness to a degeneration in the patient’s
family.
The PRESIDENT (in reply): I am glad of the very kindly, though severe,
criticism which my paper has evoked. I wanted to know whether otologists
did attribute importance to minor abnormalities in the auricle. It is true that
my figures are small, but they are true, and I cannot get over their indication.
I am sure that among the general public' the proportion of abnormal to normal
auricles is about one in seven or eight, but in my ear out-patient clinic the
proportion is at least half, taking all the cases which come to that department.
When one comes to deal with such conditions as otosclerosis and nerve
deafness, the proportion of abnormal auricles is very high, about five imperfect
to one perfect. Assuming these proportions to be correct, either there is
something in the association, or there is not. If there is something in it,
what is it ? It is in order to set other minds thinking about the matter that
I have brought this communication forward. If there is anything in my
submittal, I think it must have a large bearing on our practice. Mr. Mollison
has pointed out that pure cases like my text case are very rare. I also pointed
out in my paper that that was the reason I selected this case as my text:
it seems to me to be more or less a pure case. Mr. Somerville Hastings did
not seem to think it was pure. In my opinion it is a case of neuron deafness:
it cannot be cochlear and it cannot be cortical. There was no difficulty in
sound-analysis, so that whether you accept Sir Thomas Wrightson’s theory,
or Helmholtz’s, the lesion must be in the neuron or synapse. Rinne’s
test was 20 seconds positive: normal hearing with this fork would give
Rinne + 30 seconds. [Mr. HASTINGS : Would you not think that showed
some impairment of air conduction ? I should think there was some impair¬
ment or change in the drum or ossicles.] If the cochlea is switched off from
the cortex the result of the Rinne test is bound to be affected: if the patient
hears nothing it is of no use discussing Rinne. My patient heard sixteen,
thirty-two and sixty-four double vibrations, and Galton up to the limit:
notwithstanding this the boy was distinctly deaf. I should say his cochlea
and cortex must be nearly or quite normal. I say the condition shown by
this boy underlies a large proportion of deafness, renders the organ more
vulnerable, and perhaps explains some of our difficulties with regard to the
Rinne test. The matter is worth thinking about, and that is all I claim :
my paper is simply speculative. The question is asked, 11 Why should the
middle ear be affected as often as it is?” I reply, 11 Why not?” If
degeneration does pick out different parts of one layer of the embryo, it is not
28 Jones : Deafness associated ivith Stigmata of Degeneration
necessarily limited to one layer. You may find epiblastic changes associated
with hypoblastic and mesoblastic changes exhibited in the septum, nasopharynx
and middle ear. But after you have removed adenoids, straightened the
septum, and treated the middle ear, there is often a residual deafness with
which you can do nothing. That is where my suggestions come in. I would
not like to advise anybody to spend £150 on electrical treatment of such a case.
It is partly as a protest against advice of that kind that I have brought the
matter up. I was interested in Mr. Stuart-Low’s remarks concerning the
advantage of making deaf people laugh, and prick up their ears. The question
of musical people is a very interesting one. It is generally said that acuteness
of hearing has nothing to do with a musical ear, but I should think otherwise.
I can understand a deaf man sitting in his study writing music, but I cannot
understand an executant or conductor not having good hearing. He must at
least have perfect power of sound-analysis. With regard to the insane, it is
perfectly well known that the insane and criminal have more deaf among
them than has the ordinary population. This subject is only an extension
of wbat I have been trying to bring forward, but I have dealt with minor
variations only. The cases I have brought forward are subject to the influence
of environment, and therefore amenable to a certain amount of control: the
others are hereditary and only in a small degree affected by environment.
I thank you very much for the way in which you have received my paper.
It is sometimes advisable to break new ground, even if it is badly done.
Section of ©toloo\>.
President — Mr. Hugh E. Jones.
The Radical and Modified Radical Mastoid Operations : Their
Indications, Technique and Results, with Notes on the
Labyrinthine and Intracranial Complications of Chronic
Middle-ear Suppuration.
(Based on an Analysis of 306 Cases of Chronic Middle-ear Suppuration,
as follows: Radical Mastoid Operations, 338 ; Modified Radical Mastoid
Operations, 17 : Labyrinthitis, 36 ; Intracranial Complications, 36 .) 1
By J. S. Fraser, M.B., F.R.C.S.Ed., and W. T. Garretson,
M.D.Iowa, F.R.C.S.Ed.
(From the Ear and Throat Department of the Royal Infirmary , Edinburgh , under
the charge of A . Logan Turner , MI)., F.R.C.S.EdF.R.S.Ed.)
This paper is a continuation of one written by Captain Milne Dickie
and the operator (J. S. F.), 2 or rather of the second portion of that
paper (B) which deals with chronic middle-ear suppuration and its com¬
plications. In the former publications seventy-eight chronic cases were
reported, including nine fatal cases (11*5 per cent, mortality). In the
present paper 306 cases are dealt with and the fatal cases number
sixteen (5‘3 per cent, mortality).
The cases now recorded include all those of chronic middle-ear
suppuration and its mastoid, labyrinthine and intracranial complications
operated on at the Royal Infirmary, Edinburgh, at Leith Hospital, and
in private practice between 1911 and 1918—i.e., the chronic cases
a—9
1 At a meeting of the Section, held February 21, 1919.
* * hum. Laryngol 1912, xxvii, pp. 133, 191.
30 Fraser and Garretson : Mastoid Operations
operated upon since the publication of the previous paper. (The only
cases not included are (1) five cases at the Royal Infirmary, of which
the records have unfortunately been lost: none of these cases ended
fatally. A case of temporo-sphenoidal abscess operated on six months
before the War by an otologist who joined up at .once. On admission
the patient was suffering from septic oedema of the brain and meningitis.
The abscess was reopened (J. S. F.) but the patient died soon after
admission. A second fatal case not included was one in which the
patient suffered from chronic suppurative otitis media (right) with
cerebellar symptoms. . Autopsy showed that death was due to a
cerebellar tumour on this side. (2) Fifteen cases operated upon at the
Edinburgh War Hospital, Bangour. These included one recovery
from purulent leptomeningitis and one death from metastatic abscess
following septic thrombosis of the sigmoid sinus. Total chronic cases
not included, 22, with three deaths.)
Radical Mastoid Operations : 238 Oases ; 248 Operations.
Sex. —Of the 238 patients, 118 were males and 120 were females.
Age (in decades).—1 to 9 years, 25; 10 to 19 years, 92; 20 to 29
years, 74; 30 to 39 years; 27 ; 40 to 49 years, 13; 50 to 59 years, 4 ;
age not given, 3 ; average age, 20 years.
Residence. —Edinburgh and district, 104; country, 134.
Side. —Bilateral, 10 ; right, 106 ; left, 122 ; total, 248 operations.
Cause. —The statements of the patients and their relations as to
the causation of chronic middle-ear suppuration are as a rule very
unsatisfactory. Most of the patients have forgotten the date and origin
of the discharge; The most common causes appear to be scarlet fever
and measles. Not infrequently the aural discharge is attributed to a
blow on the ear, but in many of these cases examination of the other ear
reveals a dry perforation or a scar in the drumhead, and it is hard to
believe that the school teacher, who is usually blamed, has struck the
child first on one ear and then on the other and that chronic middle-ear
suppuration has resulted on both sides. In only 66 cases did the
patients or their relations remember the cause of the ear trouble,
as follows: Measles, 26; scarlet fever, 25; pneumonia, 3 ; whooping-
cough, 1; mumps, 1; small-pox, 1; teething, 2; cold, 1; injury,'6.
As showing the distribution of chronic purulent otitis media and
its complications between the wealthier and poorer sections of the
population, it may be of interest to state that out of the 306 chronic
Section of Otology
31
cases operated on in the last seven years, and dealt with in this paper,
only nine were performed in private practice.
On inquiry, the acting superintendent of the Royal Infirmary
informed us that probably about 80 per cent, of the population of
Edinburgh and the South-east of Scotland (from which the infirmary
mainly draws its clientele) would come to charitable institutions such
as the Royal Infirmary for operations like thp radical mastoid operation.
According to this calculation 20 per cent, of the cases, instead of 3 per
cent., should have been operated on as private patients. It would thus
appear that chronic suppurative otitis media i6 not only absolutely but
also relatively more common among the poorer sections of the com¬
munity than among the more wealthy.
If cases of severe acute suppurative otitis media were properly
treated when they arise—e.g., in fever hospitals, there would be very
little chronic middle-ear suppuration and consequently the radical
mastoid operation would seldom be called for. Unfortunately Public
Health Authorities have so far turned a deaf ear to the remonstrances
of otologists in the matter. At the Seventeenth International Congress
of Medicine in 1913, the Sections of Laryngology and Otology
unanimously carried the following resolution: “ That it would be
greatly to the advantage of the community if experts in otology and
laryngology were attached to the special hospitals for the treatment
of epidemic diseases.” The resolution was subsequently handed to
Dr. Herringham, the General Secretary, by Mr. Arthur Cheatle and
Mr. Sydney Scott, and by him transmitted to the Permanent Committee
of the International Congress.
Duration .—According to the statements of the patients, this varied
from five months to twenty or thirty years. Here again patients’
statements are unreliable—e.g., several have said that one ear has only
been discharging for two or three weekb and deny that the other ear
has ever discharged at all, and yet examination showed the results of
old suppurative otitis media on the latter side.
Nose .—In 47 cases the condition of the nose was not noted. Of the
remaining 191 cases, 63 were normal; 2 showed a dry perforation of
the septum; 59 deviation of the septum; 29 acute or chronic nasal
catarrh ; 28 hypertrophic rhinitis and 6 atrophic rhinitis. One patient
had nasal, polypi and three suffered from maxillary antrum suppuration.
Several of the patients who had deviation of the septum also had nasal
catarrh or hypertrophic rhinitis. We have not systematically examined
the maxillary antrum and other nasal sinuses in cases of chronic middle-
32
Fraser and Garretson: Mastoid Operations
ear suppuration at the time of the radical mastoid operation, but we are
surprised to note that Bodkin 1 finds that the antrum is infected in
93 per cent, of cases ahd that one or both antra are full of pus in
16 per cent.
Pharynx. —In 55 cases the condition of the pharynx Was not noted.
In the remaining 183 the conditions were as follows: Normal, 87 ;
slight adenoids, 21; enlarged tonsils, 25; enlarged tonsils and
adenoids, 47 (24 of these had tonsils and adenoids operated upon before
the radical mastoid operation). Three patients showed pharyngitis
sicca.
Condition of Meatus and Membrane on Operated Side. —In 125 of
the 248 operated ears the condition of the membrane could not be seen
on account of the presence of a polypus^ ' In ten cases the meatus
was so full of cholesteatoma, and so narrow in eight others that the
membrane could not be inspected. One case showed hyperostosis of
the meatus with a perforation in the lower part of the drumhead.
Of the remaining 109 operated ears, 30 showed central or anterior
perforations ; 1 £ almost entire absence of the drumheads ; 35 posterior
perforations, and 22 attic perforations. Five cases showed more than
one perforation. In only 48 cases was cholesteatoma diagnosed before
operation, though at operation it was found in ,104. Twelve cases
showed mastoid swelling or abscess and three a sinus, over the mastoid.
Eight patients had previously had Schwartze operations performed on
the same side. Six patients had radical operations performed once :
one patient had the radical operation performed six times and two
others eight times on the same side before coming to the Royal
Infirmary.
Condition of Meatus and Membrane on Non-operated -Side. —Of
the 228 unoperated ears the condition of thirteen was not noted.
Normal, 52; evidence of Eustachian obstruction, 34 ; acute suppurative
otitis media, 2; chronic suppurative otitis media, 36 ; chronic suppu¬
rative otitis media with polypus or granulations, 12; attic perforations
with granulations, 2. In 70 cases the membrane showed results of
chronic suppurative otitis media ; six had previously had mastoid
operatipns performed on thiB side and one other case had also a
labyrinth operation performed on this side.
Hearing before Operation. —In testing the hearing before operation,
we have found that—speaking roughly—the conversation voice is heard
1 Joum. Laryngol ., 1918, xxxiii, p. 200.
Section of Otology
33
at about three times the distance at which the whisper is perceived.
Further, when the good ear is closed with the finger, a patient hears the
conversation voice at double the distance he hears it at when the noise
apparatus is placed in the good ear. In sixteen of the patients the
hearing was not tested—usually on account of the age of the patients;
three other patients were deaf-mutes. Of the remaining 219 cases the
hearing was bad in 68 (C.V. at 6 in. or less) ; moderate in 131 (C.V. at
6 in. to 6 ft.); good in 20 (C.V. at 6 ft. or over).
Vestibular Apparatus .—This was tested in 206 cases. In the others
it was omitted usually on account of the age of the patient. In cases
with a large polypus occluding the meatus, only the rotation test was as
a rule carried out. Twelve cases showed slight spontaneous nystagmus
and one of these swayed slightly on Romberg’s test. One patient
showed a spontaneous pointing error. Four patients showed a fistula
symptom, though in none of the four was a fistula found at operation.
Normal rotation or caloric nystagmus was present in 140 cases. In 58
cases the reaction to the cold caloric test was delayed (in 10 of these
cholesteatoma was present and in 28 the external meatus was blocked
by a polypus). In four cases, one of them a deaf mute, there was no
reaction to either test (none of these are included in the section on
labyrinthitis).
Indications for Operation .—In several of the cases operated upon,
one of the former clinical assistants, Dr. Andrew Campbell, had carried
out intratympanic syringing according to the method employed by
Siebenmann, of Basle, and Nager, of Zurich. It was found that as
long as this treatment was continued the discharge was slight or
absent, but soon recurred when syringing was stopped. In several
of these cases the subsequent radical operation showed that the
attic, aditus and antrum were lined by cholesteatoma. In many
cases more than one indication for operation was present. (a)
Chronic suppurative otitis media and * failure of conservative treat¬
ment, 33 cases. In this group 4 patients complained of giddiness
and 1 of sickness. ( b) Chronic suppurative otitis media with polypi or
granulations, 93 cases: 11 of these complained of giddiness, 3 of sick¬
ness, and 1 patient showed facial paralysis. We wish to ask whether,
granted that the labyrinth is healthy, it is ^yorth while to remove aural
polypi on one or several occasions before ‘ proceeding to the radical
mastoid operation? (c) Chronic suppurative otitis media with pain,
mastoid tenderness and polypi, 57 cases: 9 of these complained of
giddiness, 2 of sickness; 1 showed facial paralysis and 1 other showed
34
Fraser and Garretson: Mastoid Operations
stricture of the canal. ( d ) Chronic suppurative otitis media, acute
exacerbation and subperiosteal abscess, 10 cases: in this group 1 patient
complained of giddiness, (e) Chronic suppurative otitis media, posterior
perforation, with or without cholesteatoma, 10 cases: 1 of these com¬
plained of giddiness and 1 showed facial paralysis. (/) Chronic
suppurative otitis media, attic perforation, with or without choleste¬
atoma, 24 cases: in this group 6 patients complained of giddiness, (g)
Chronic suppurative otitis media with a sinus over the mastoid,
4 cases. (/*) Failure of previous mastoid operation, 17 cases. In
group (h) 2 patients complained of giddiness and 1 other of sickness.
Operation.
Technique .—Since the publication of his paper on the technique
of the radical operation in the Journal of Laryngology three years
ago the operator has entirely given up the method of skin-grafting
there described and has adopted Mr. Marriage’s method. In order to
focus discussion on the question of technique, we invite the opinion of
the members on the following questions :—
(1) The value of preliminary radiograms of the mastoid processes.
During the War it has not been possible to have radiograms taken of
our mastoid cases owing to the absence on military service of the late
Major Porter and Captain Gardiner, who were in charge of this branch
of Dr. Logan Turner’s department.
(2) The line of incision—retro-auricular groove or hair margin ?
(3) Is it advisable to excise a crescentic piece of skin in order to
brace the auricle up and back ?
(4) Haemostasis. Is it advisable to adopt any method of local
anaesthesia—e.g., Neumann’s, in addition to general anaesthesia? Some
* American writers advocate the use of adrenalin during the course of the
operation.
(5) Method of removal of bone by gouges, curettes or burrs, or by a
combination of these three. Some American writers have muc£ to say
about necrotic bone found at the radical mastoid operation. In our
experience real necrosis is very rare. In the walls of the cavity inflamed
and softened bone is often met with, but actual necrosis and sequestrum
formation almost never. Byne is very “ recoverable ” tissue.
(6) Methods of meatal plastic. At what period of the operation
should the plastic be performed ?
(7) Curettage of tympanic cavity. Use of forceps to remove granu¬
lations. Difficulty in dealing with granulations in the region of the oval
Section of Otology
35
window and sinus tympani. The operator has found Milligan’s laby¬
rinth spoon of service in turning small polypi out of the latter
region.
(8) Removal of floor of bony meatus. Richards 1 and Bowers 2 recom¬
mend that this removal be so complete that the hypotympanic cavity is
entirely exposed to view through the enlarged external meatus.
(9) Removal of convexity on anterior wall of bony meatus. Bowers
apparently exposes the capsule of the temporo-maxillary joint in some
cases in removing this convexity, in order to expose the Eustachian tube
for after treatment.
(10) Method of dealing with the Eustachian tube. Richards recom¬
mends removal of the processus cochleariformis and the tensor tympani
so as to convert the muscular and tubal canals into one. Different types
of curettes for the Eustachian tube. Is it possible to remove all mucous
membrane from this region which, in many cases, includes numerous
air cells ? Bowers insists strongly on this point, though he admits
that the internal carotid artery may be exposed. The jugular bulb also
might be opened (J. S. F.). Yankauer claims that 83 per cent, of tubes
cap be closed by curettage with his instruments through the meatus
without radical operation, and that in 50 per cent, of cases chronic sup¬
puration is cured by this means. Longee, however, finds that only 8 per
cent, are cured. Unless we succeed in closing the tube at the radical
operation we have got a muco-cutaneous fistula, and any attack of naso¬
pharyngeal catarrh is liable to be followed by otorrhcea.
(11) Skin-grafting. Before application of the graft the operation
cavity is syringed out with warm sterile saline solution. Method of
application— (a) on gauze or worsted packing, or ( b ) by filling the
cavity with lotion and pipetting all the fluid from below the graft. Is
it advisable to cut a small hole in the graft so as to leave the window
regions exposed ? We believe that, in the presence of a normal laby¬
rinth, the hearing power after operation depends on the integrity of the
window niches and the mobility of the structures closing the windows.
It would appear possible that the skin-graft might impair this mobility
and also to some extent interfere with free access of air vibrations.
Contra-indications to skin-grafting.
1 Annals of Otology, 1918, xxvii, p. 374.
2 Laryngoscope , 1918, xxviii, p. 794.
36 Fraser and Garretson : Mastoid Operations
Findings at Operation (248 Operated Ears).
Superficial Tissues. —Normal, 207; oedema, 2 ; glandular abscess,
2 ; subperiosteal abscess, 13 ; fistula, 10 ; scar, 14.
Mastoid Cortex. —Normal, 208; deep hollow ovejr site of antrum, 6 ;
cortex eroded, 5 ; eroded with granulations, 6 ; fistula, 10 ; old operation
cavity, 13.
Mastoid Process. —Sclerotic, 174; sclero-diploetic, 31; diploetic, 12;
cellular, 8; contained fibrous tissue, 15; fistula through posterior
meatal wall, 1; entirely hollowed out by cholesteatoma, 5; Bezold’s
abscess, 2.
Mastoid Antrum. —Practically healthy, 50; contained only watery,
brownish or blackish fluid, 14 ; mucus or muco-pus with swollen
mucosa, 61; pus and polypoid mucosa and granulations, 57 ; contained
cholesteatoma, 66.
Sigmoid Sinus. —In 202 cases the sinus was not exposed at opera¬
tion. In 36 cases it was far forward (exposed by gouge) and found
normal; in 2 cases it was exposed by gouge and appeared thickened; in
6 cases it was exposed by disease.
Aditus. —In 32 cases the aditus contained cholesteatoma; in 9 it
contained granulations or polypi; in 7 the mucosa of the aditus was
swollen and congested; and in 3 there was some growth of new
bone.
Lateral Semicircular Canal. —The bony wall appeared thin and
eroded, but showed no actual fistula in 8 cases; 1 of these cases showed
the fistula symptom; 1 case (previously operated upon) showed new
bone formation in the region of the lateral canal.
Ossicles ( Malleus and Incus). —Under the conditions in which the
radical mastoid operation is performed it is not possible to speak with
certainty as to the condition of the ossicles in every case. After the
bridge has been removed there is often so much bleeding that, even with
the most careful swabbing, it is not humanly possible to observe in every
case whether the incus and malleus are present. For this reason we
do not wish to be dogmatic as to our findings, but with this reservation
the following statement may be made: Both ossicles healthy, 74;
malleus healthy but incus diseased (usually long process of incus eroded
or absent), 74 ; malleus eroded and incus gone, 12 ; malleus and long
process of incus eroded, 1 ; head of malleus eroded or absent and incus
absent, 21; handle of malleus eroded and long process of incus gone, 2 ;
handle of malleus eroded, incus healthy, 3 : malleus and incus ankylosed,
6 ; ossicles absent or not found, 55.
Section of Otology 37
Attic. —In 7 cases the attic showed swollen or polypoid mucosa; in
5 it contained granulations ; in 53 cases there was cholesteatoma in the
attic; in 1 case the attic was partly.filled by new bone formation; in
1 case there was a small hole in the tegmen tympani; in 2 cases the
facial canal was eroded.
Tympanum.-^k note was made of the condition of the tympanum
in*156 cases as follows : Swollen or polypoid mucosa, 28 ; granulations
in tympanum, 44; polypus growing from promontory, 69; polypus from
attic, 3 ; cholesteatoma in tympanum, 11; oval window filled by new
bone formation, 1.
Tube .—In 246 of the 248 ears the tube was curetted ; in 2 cases
it was not curetted as it appeared to have been closed by a previous
operation ; in 9 cases the tube was curetted and touched with chromic
acid; in 24 it was curetted and cauterized with the electro-cautery :
5 of this latter group did not report after operation; of the remaining
19 the cavity was satisfactory in 12, though 6 of the 12 required
attention; in 2 the cavity was moist; in 5 the tube was open.
Flap. —With regard to the flap, the operator continues to-be
satisfied with the results of the Koerner flap, which has been used
in practically all cases.
Skin-graft .—Mr. Marriage’s method of skin-grafting was adopted
by the operator in June, 1916, and since that time 83 of the operations
recorded in this paper have have been performed. Of these, however,,
only 70 have been skin-grafted. The remaining 13 were not grafted
for the following reasons : (1) The presence of fistula symptom, 2 cases ;
in one of these the canal prominence proved .normal but the stapes was
probably loose; in the second case the bony wall of the canal looked
thin. (2) Canal eroded, 1 case. (3) Exposure of the dtlra mater of
the middle fossa, 4 cases. (4) Exposure of the middle fossa, giddiness
and abnormality of the canal prominence, 4 cases. (5) Sigmoid sinus
exposed by disease and lateral canal eroded, 2 cases.
Progress.— Of the 238 patients 163 made uneventful recoveries.
Seven cases had stitch abscesses. In 19 cases the posterior wound
suppurated. In 3 cases the graft came away. Eleven had slight
fever after operation, 13 had spontaneous nystagmus to the non-
operated side, 7 suffered from giddiness and nystagmus, 6 suffered
from* sickness and vomiting. Five patients after operation developed
scarlet fever. The operator is of opinion that this “ scarlatina ” is,
at any rate in some cases, a form of mild streptococcal septicaemia
resulting from *the operation—i.e., it is not caught from another case
38 Fraser and Garretson: Mastoid Operations
of scarlatina in the usual way. One case developed erysipelas. Two
cases showed slight swelling of* the auricle and three developed peri¬
chondritis. There was no case of post-operative facial paralysis (i.e.,
paralysis present on the day after operation), but five patients developed
facial paresis from five days to a week after operation : this trouble
soon cleared up. One of the two patients who showed facial paralysis
before operation was quite cured afterwards. Two patients developed
purulent labyrinthitis after the mastoid operation and had double
vestibulotomy performed. Both recovered. These two cases are dealt
dealt with in the section on labyrinthitis. The two fatalities were as
follows:—
(1) K. W., female, aged 44, suffered from chronic suppurative otitis media
and aural polypi, bilateral. Labyrinths healthy. First operation (radical
mastoid on left side) : Pus and granulations, with necrosis of ossicles, skin-
graft applied, aural polypus removed from right ear. Operated ear did well
but discharge from right ear continued. Later, radical operation on right ear
showed similar conditions to those on left side, sinus exposed with gouge but
appeared normal, skin-graft applied. Temperature rose continuously for three
days after operation and patient had a rigor. Stitches removed and also
skin-graft. Patient developed a cough and blood-stained expectoration ; blood
culture showed streptococcus. Intravenous injection of eusol given. Death.
Post-mortem : Old pleural adhesions, empyema of right side, large infarct in
lower lobe of right lung. Cerebral sinuses showed no thrombosis.
(2) E. S., male, aged 5, suffered from chronic suppurative otitis media,
with acute mastoid exacerbation, enlarged tonsils and adenoids. Radical
mastoid operation : Cholesteatoma present. Child fell out of bed on the
day following operation and afterwards became unconscious. Operation
wound opened up but nothing abnormal found. Lumbar puncture yielded
clear fluid under normal tension. Death on evening following operation.
Post-mortem refused. Cause of death uncertain—Status lymphaticus ?
Septicaemia ? Acidosis ?
Mortality. —Mr. Heath claims a mortality of 1 in 360 and Mr. Adair
Dighton of 1 in 54 for the modified radical operation/ Mr. Dighton 1
writes as follows : “ In the chronic cases the risk to life in a Heath’s
operation is practically nil, whereas the radical mastoid operation boasts
a death-rate of at least 16 per cent, in these cases (Report of Ear-
Department, Royal Infirmary, Edinburgh, March, 1912).” We hold
that this statement is calculated to give an entirely erroneous
impression. If Mr. Heath and his followers intend only to plead for
1 “ A Manual of Diseases of the Nasopharynx,” p. 126, London, 1912, Balliere, Tindall
and Cox. «
Section of Otology
39
early operation in cases of middle-ear suppuration, which do not
yield to more conservative measures, few will be found to disagree.
If, op the other hand, they wish to indicate that the modified radical
operation is safe, whereas the radical mastoid operation is dangerous,
we hold that .they are misleading the medical profession. They
must distinguish between the radical operation as performed in cases
of middle-ear suppuration alone and the same procedure when carried
out en route to the relief of labyrinthine and intracranial complications
already present when the patient is admitted. In the first case the
radical operation according to our statistics in this paper has a death
rate of 2 in 238 cases or, if the 52 cases previously reported be included,
of 2 in 290 cases. In the second case the mortality is admittedly severe
but the fatalities cannot in fairness be attributed to the radical opera¬
tion. If a patient with extrinsic cancer of the larynx has a preliminary
tracheotomy followed by excision of the larynx, we do not attribute his
death, should it occur, to the former procedure.
After-treatment .—It is almost superfluous to go back to the methods
of after-treatment adopted before the days of skin-grafting, according
to Mr. Marriage's method. The writers have no experience of the
Carrel-Dakin method, which seems to be associated with special difficulty
in the after-treatment of the radical mastoid operation. French writers
have recommended ambrine—a form of paraffin which is poured into
the cavity and in which a wick of gauze is implanted to facilitate
removal. This treatment is begun from the fifth to eighth day after
operation and is continued for fifteen or twenty days. Guisez recom¬
mends Vincent's powder (one part calcium hypochlorite to nine parts
of boric acid), but again we have no experience of this method. Our
own practice in cases which have been skin-grafted is to pack the cavity
with iodoform worsted at the time of operation and to leave the wound
alone for five days. At the end of this time the stitches are removed
including that retaining the rneatal flap. The iodbform worsted packing
is also removed and the cavity mopped out with sterile gauze. The
cavity is then repacked for a further period of two days with iodoform
worsted and the dressings reapplied. Thereafter no further packing is
employed and the case is treated by means of syringing until the super¬
ficial layers of the graft come away and a dry cavity has, if possible,
been obtained. The meatus is left open in the daytime but at
night a piece of iodoform gauze is inserted, though the cavity itself
is not packed.
The progress of the case after operation appears to depend to a
40
Fraser and Garretson : Mastoid Operations
considerable extent upon the general condition of the patient. The
operator has noticed that the cases dealt with at the Edinburgh War
Hospital, Bangour, have made better recoveries than those in the Hoyal
Infirmary, and attributes this fact to the better physique and general
health of the patients in the former institution.
Stay in Hospital .—The average duration of the stay in hospital after
operation was twenty-two days. We have often felt that it is rather a
waste of hospital space and of nursing skill to keep patients in hospital
for several weeks after the radical mastoid operation. If the patient
lives in town the question is easily settled, because he can come up once
or twiqe a day for treatment. If, on the other hand, he lives in the
country, the question is more difficult. If we send such a patient home
we have to entrust the after-treatment to a relation or friend who most
probably has had no experience of ear work. The patient's doctor, even
if he knows anything about after-treatment, cannot afford the necessary
time. We have often thought that it would be a good thing if, instead
of retaining these patients in hospital, some less elaborate and expensive
form of lodging could be provided for country cases which require
attention once or twice daily.
After-care of the Operated Ear .—Even after the case has apparently
made a satisfactory recovery and the cavity has been completely lined
with epithelium, some attention is necessary if things are to remain
satisfactory. It is our experience that unless the operation cavity is
treated at regular intervals by means of peroxide drops and syringing
with lukewarm soda solution, drying, and the installation of spirit and
boric acid drops, wax and epithelium accumulate so that in time the
cavity becomes filled with putty-like material in which there is some
pus. Printed instructions are now given to all “radical mastoid” patients
on leaving hospital, but it is the exception to find that these instruc¬
tions have been followed. As a rule the patients confess, when they
report for inspection, that nothing has been done to their ears since they
left the infirmary. In many cases the auricle and mastoid region are
not even washed with soap and water.
Results.
We have found that accounts given by patients concerning the
condition of their ears after operation are quite untrustworthy. When
they returned to report some patients stated that their ears were quite
dry and yet examination showed that discharge was still present. Others
told us that their ears were still discharging, though inspection proved
Section of Otology
41
that they were quite dry. We accordingly decided not to send out a
questionnaire and to depend only on personal examination of our
operated ears. Sixty-three per cent, of the cases reported when
written for. This is fairly satisfactory considering the difficulty and
expense of travel in recent times.
The main point brought out by the examination of the patients who
reported was that the persistence of Eustachian catarrh or suppuration
is the main source of failure after the radical mastoid operation. We
have not as yet found an efficient method of closing the Eustachian
tube. The radical operation does appear, however, to free the patient
from the danger of an intracranial complication. We know of no case
in which such a complication has arisen after the radical mastoid
operation has been performed. Dr. Logan Turner tells us that this is
also his experience.
Results in the Non-skin-grafted Cases (171) reported on by Dr .
Garretson .—Of 171 patients, 107 presented themselves for inspection
at periods of from three months to five years after operation. Three
of these 107 were patients who had had both ears operated upon, so
that 110 of the 178 operated ears were seen. Of these, 37 appeared
to be cured, while 10 others were very satisfactory except that they
showed want of care (an accumulation of wax and desquamated epi¬
thelium). This gives 43 per cent, of cures. In 24 cases the inner wall
of the cavity was moist, but there was no pus. There was still some
purulent discharge in 27 cases. In 1 case the cavity was filled with
cholesteatoma. In 3 cases a false membrane had formed, almost
shutting off the deeper part of the cavity. In 4 cases there were
granulations in the operation cavity. Three cases showed a permanent
opening behind the ear. One showed a keloid in the mastoid scar and
a large amount of d6bris in the cavity.
Hearing after Operation .—This was tested in 93 cases, as follows :
Hearing improved, 35; the same, 36 ; worse, 22.
Results in the Skin-grafted Cases (reported on by J. S. F.).—Of the
67 patients, 44 presented themselves for inspection at periods of from
three months to two and a half jears after operation. Two of these
were patients who had had both ears operated upon, so that 46 of the
70 operated ears were seen. Of these, 20 appeared to be cured, and
12 others were quite satisfactory except that they showed want of care
(70 per cent, cures). In 7 cases the inner wall was red and moist.
Four cases still had slight purulent discharge, and one other had foul¬
smelling profuse discharge. Two cases showed membrane formation
42 Fraser and Garretson: Mastoid Operations
with a narrow opening into it through which pus came when the
patient performed Valsalva’s experiment.
Heaiing after Operation .—This was tested in 42 cases, with the
following results : Improved, 12 ; as before operation, 16 ; worse, 6.
Bowers 1 reports on 107 cases, 84 of which presented themselves for
re-examination: 63 of these were dry (75 per cent, cures). The hearing
was improved in 60 per cent., remained the same in 34 per cent., and
was worse in 6 per cent. There were no deaths, but one partial facial
paralysis.
Stucky 2 * reports on 100 cases with 89 dry ears. In the remaining
11 the tube was open and there was recurrent mucoid discharge. The
hearing was improved in 19, remained the same in 60, and was worse
in 21 cases.
Morissette Smith* showed 10 consecutive cases with dry ears. The
hearing was improved in 7 and remained the same in 3.
Dench has recorded 734 cases, with no death. He would be ashamed
to show only 50 per cent, of cures. 4
Bichards, in discussing Dench's paper, also holds that 50 per cent,
of cures is a bad result- and is due to inefficient operating. Speaking
from memory, we believe that Dench and Bichards claim from 70 to
80, or even 85 per cent, of cures.
On the other hand, Harris* states that he has examined 24 cases
operated upon by other American otologists, and of these 48 per cent,
were dry and 52 per cent, were still discharging. The hearing was
improved in 8 per cent., remained the same in 20 per cent., and was
worse in 20 per cent.
In the previous paper published by the operator and Captain Milne
Dickie it was noted that 26 of the 52 “ radical ” cases reported. Of
these, 17 were dry—i.e., 65 per cent. The hearing was, tested in 22
cases, of which 15 were improved, 4 were the same, and 3 worse.
It is needless to point out the divergence between the results
claimed by Dench, Bichards, Smith, Bowers, and Stucky on the one
hand, and those reported by Harris on the other. The writers
are disposed to believe that the statements of Harris more nearly
represent the results obtained by the majority of operators than do
those reported by the group of otologists mentioned above.
1 Laryngoscope , 1918, xxviii, p. 803.
* Sotith. Med. Joum 1917, x, p. 511.
J Annals of Otol ., 1918, xxvii, p. 374.
4 Annals of Otol., 1917, xxvi, p. 202.
* Neiv York Stats Med. Journ., 1917, xvii, p. 17.
Section of Otology
43
We have attempted to associate the appearances present' on otoscopy
with the state of the hearing, conditions found at and the result obtained
by operation. The cases have b'een divided into the following groups:—
(1) Central perforations, 20 cases. Hearing before operation: Not
tested, 20 per cent.; good or moderate, 83 per cent.; bad, 17 per cent.
In 30 per cent, of these the antrum was almost healthy, in 35 per cent,
the antrum centained muco-pus or the mucosa was swollen, in 25 per
cent- it contained pus, in 10 per cent, the antrum contained cholestea¬
toma. It will thus be seen that in this group there was little disease in
the posterior part of the middle-ear cleft. With regard to result, in
35'5 per cent, cases the cavity was moist and in 21’3 per cent, the
result was poor. In 42’6 per cent, the result was good. Hearing
after operation: Improved, 42'6 per cent.; the same, 28'4 per cent.;
worse, 28'4 per cent.
(2) In the second group the external meatus was partially or
completely occluded by a polypus, but cholesteatoma was not present.
These cases numbered 84. Hearing before operation : Good, 4'16 per
cent.; moderate, 63‘2 per cent.; bad, 30‘2 per cent.; not tested,
1'4 per cent. In 33'7' per cent, there was little or no disease in the
antrum; in 30 per cent, the antrum contained muco-pus or the walls
were swollen and congested ; in 30 per cent, the antrum contained pus
or granulation tissue. With regard to result, in 38 per cent, the
cavity was moist and in 12 per cent, the result was poor. The result was
quite satisfactory in 50 per cent. Hearing after operation: Improved,
46 per cent.; the same, 38 per cent.; worse, 16 per cent.
(3) The third group* consists of those cases with polypus or
granulations in which cholesteatoma was either diagnosed before
operation or found at operation. It was not possible in these cases
to state with certainty the position of the perforation. This group
numbered 32 cases. Hearing before operation: Good or moderate,
47 per cent.; bad, 30 per cent.; not tested, 23 per cent. In 94 per
cent, there was cholesteatoma in ' the antrum and in the remaining
6 per cent, there was only cholesteatoma in the attic or aditus. In
this group 43 per cent, showed a satisfactory result, in 52 per cent,
the cavity was still moist, in 5 per cent, the result was poor.
Hearing after operation: Improved, 43 per cent.; the same, 43 per
cent.; worse, 14 per cent.
(4) The fourth group consists of those in which there was a
posterior marginal perforation. These cases numbered 33. Hearing
before operation: Good or moderate, 67 per cent.; bad, 27 per
44 Fraser and Garretson : Mastoid Operations
cent. ; not tested, (3 per cent. In 33 per cent, of the cases
the antrum was practically healthy, in 33 per cent, the antrum
contained muco-pus or the mucosa was swollen, in 15 per cent, it
contained pus, in 20 per cent, there was cholesteatoma in the antrum.
It will thus be seen that on the whole the antrum does not show
serious disease in these cases. On the other hapd there was chole¬
steatoma in the neighbourhood of the round window, extending up
towards the attic and aditus in six of the cases. The final result in
* these cases was good as a rule. In 64 per cent, the result was good,
in 33 per cent, the cavity was moist, in 3 per cent, the result was
poor. Hearing after operation: Improved, 53 per cent.; the same,
18 per cent.; worse, 29 per cent.
(5) The fifth group are those with attic perforations. This group
numbered 30 Cases. Hearing before operation: Good or moderate,
80 per cent.; bad, 20 per cent. In 96 per cent, cholesteatoma was
present in the attic, though in 30 per cent, the cholesteatoma did
not extend as far back as the antrum. In the remaining 4 per cent,
the antrum contained only muco-pus and no cholesteatoma was found.
With regard to result, 75 per cent, were satisfactory and 25 per cent,
still had moist cavities. Hearing after operation: Improved, 14 per¬
cent. ; the same, 36 per cent. ; worse, 50 per cent.
(6) In 19 cases there was more than one perforation or there was
total absence of the tympanic membrane and ossicles. Hearing before
operation: Moderate, 37 per cent.; bad, 47 . per cent.; not tested,
16 per cent. In 10 per cent, of the cases the antrum was healthy, in
10 per cent, it contained pus, and in 80 per cent, it contained cholestea-
tojna. In 42 per cent, the result was satisfactory, in 33 per cent, the
eavity was moist, in 25 per cent, the result was poor. Hearing after
operation : Improved, 55 per cent.; the same, 45 per cent.
Modified Radical Operations.
•
Sex .—Of the 17 cases, 10 were males and 7 were females.
Age (in decades).—1 to 9 years, 1; 10 to 19, 3; 20 to 29, 8;
30 to 39, 2; 40 to 49, 2; 50 to 59, 1. Average age, 26 years.
Residence .—Edinburgh and district, 11; country, 6.
Side, —Right, 10; left, 7.
Cause .—This was stated in 6 of the 17 cases, as follows: Scarlet
fever, 1; measles, 3; teething, 1; mill accident, 1.
Duration .—As in radical operations.
Section of Otology
45
Nose. —In five cases there was no note of the condition of the nose.
Of the other 12 cases 4 were normal, 3 showed deviation of the septum,
1 showed hypertrophic nasal catarrh, and 3 showed both deviation of
the septum and hypertrophic catarrh ; 1 case had nasal polypi.
Pharynx. —In 4 cases the condition of the pharynx was not noted.
Of the remaining 13 cases, 10 were normal and 3 had enlarged tonsils
and adenoids.
Condition of Meatus and Membrane on Operated Side.- —In two of
the 17 cases the condition of the membrane could not be seen on
account of the presence of a polypus. In 3 others the membrane could
not be seen; in 2, owing to sagging of the meatal wall and in the other
owing to meatal stenosis. Of the remaining 12 cases 1 showed central
perforation, 5 showed posterior perforations, and 5 showed attic
perforations; 1 showed a posterior and also an attio perforation.
Condition of Meatus and Membrane on Non-operated Side .—
Normal, 3 ; evidence of Eustachian obstruction, 7 ; chronic suppurative
otitis media, 1 ; results of chronic suppurative otitis media, 5 ; meatus
narrowed after an injury, 1.
Hearing before Operation. —Good, 10; moderate, 6; not tested, 1.
Vestibular Apparatus. —This was tested in 15 of the 17 cases ;
14 cases showed normal reaction to caloric or rotation tests; the
remaining case showed spontaneous nystagmus to the operated side
and a w r ell marked fistula symptom on the operated side.
Indications for Operation. —What are the indications for the
modified radical operation in cases of chronic middle-ear suppuration?
Kaufman 1 states that the operation is indicated in cases of disease
confined to the antrum and mastoid in which the ossicles are in place.
It is difficult to know, however, how he ascertains these data. It is
usually considered that Heath’s operation is indicated in cases with
good hearing. In our experience such cases belong to one of two
groups : (1) Cases with “ central ” perforation in the lower or anterior
portion of the drumhead and with a muco-purulent discharge. These
cases are really tubo-tympanic suppurations in which the upper and
posterior portions of the middle-ear cleft (attic, aditus and antrum)
are not seriously involved. We believe that it is useless to open the
mastoid antrum in such cases according to Mr. Heath’s method. Even
the radical operation itself with curettage of the Eustachian tube too
often fails to stop the discharge. We believe that the best treatment
a—10
Annals of Otology , 1917, xxvi, p. 543.
46
Fraser and Garretson: Mastoid Operations
for this group consists in (a) attention to the nose and nasopharynx,
especially the removal of a large “ posterior end,” operation for tonsils
and adenoids, &c. ( b ) Syringing' the Eustachian tube through the
Eustachian catheter, (c) Syringing the tube by means of an ordinary
metal ear syringe with an olivary end which tightly fits -the meatus.
The fluid passes down the tube and returns by the nose. Argyrol can
be applied to the tube by these two methods, (d) Vaccine therapy.
(2) The second group in which hearing is often good consists of
cases with attic perforations. In these cholesteatoma is almost invariably
present, and we understand that Mr. Heath at one time regarded
cholesteatoma as a contra-indication to his operation. If this is still so,
we cannot agree with Mr. Heath’s view for we have operated on several
cases of attic perforation with cholesteatoma in which a modified
operation yielded a perfectly dry ear with the retention of excellent
hearing. In these cases the external wall of the aditus and attic were
removed, but the lower portion of the drumhead along with the ossicles
were not touched.
(3) The only remaining group of chronic middle-ear suppuration is
that in which there is a perforation in the posterior portion of the
drumhead extending to the margin. In many of these an aural polypus
is also present. We have found that in the majority of these cases the
long process of the incus is absent so that the continuity of the ossicular
chain is broken. The hearing is often poor, but if it is good the
modified radical operation should be performed.
Our usual indication for the modified radical in preference to the
radical operation was the retention of (1) good hearing in the operated
ear, or (2) moderate hearing when the other ear was distinctly deaf.
Technique. —As in the radical operation up to the point at which
the inner end of the bridge remains. Koerner’s flap is then cut and any
polypus in the meatus removed with forceps. If an attic perforation
is present the inner end of the bridge with the outer attic wall is
removed. Special care is necessary to get away all bone chips.
Marriage’s skin-graft is applied to the antrum in the majority of cases.
Operation.
Superficial Tissues. —Normal, 13; scar from accident, 1 ; scar from
old operation, 1; subperiosteal abscess, .2.
Mastoid Cortex. —Normal, 14 ; eroded, 2 ; old operation cavity, I.
Mastoid Process. —Sclerotic, 11; cellular, 5 ; scar tissue, 1.
Mastoid Antrum. —Healthy, 3; contained only watery, brownish or
Section of Otology
47
blackish fluid, 2; mucus or inuco-pus with swollen mucosa, 6; pus and
polypoid mucosa and granulations, 3; contained cholesteatoma, 3.
Sigmoid Sinus .—In 5 cases the sinus was far forward (exposed by
gouge) and found normal. In no case was it exposed by disease.
Progress .—Of the 17 patients, 9 made uneventful recoveries. Two
cases had stitch abscesses. In two cases the posterior wounds sup¬
purated slightly. One patient had slight nystagmus to opposite side
and another had rotatory and lateral nystagmus to the affected side
on the day following operation. One patient had slight fever and
some swelling of the auricle, but no redness, and the condition soon
cleared up.
Results.
Twelve of the 17 patients reported after operation. Of these,
9 were quite satisfactory. In 3 cases the cavity was still moist.
Hearing after Operation .—This was tested in 12 cases as follows:
Improved, 10; as before operation, 1 ; worse, 1.
We have attempted to associate the appearances present on
otoscopy with the state of the hearing, the conditions found at and
the result obtained by operation. The cases have been divided into
the following groups :—
(1) There was a central perforation in 1 case, with moderate
hearing, and the antrum contained only mucus. The meatus was still
moist five months after operation.
(2) In 5 cases the perforation was in the posterior superior part,
and in 3 of these a polypus was also present. In 3 of the 5 the
hearing before operation was good and in 2 moderate. The antrum
was practically healthy in 1 case. In a second it contained only
brownish fluid. The third contained muco-pus. In the fourth there
was pus and polypoid mucosa, and in the fifth Cholesteatoma. The
result is known in 4 of the cases, and in all of these the ear was dry.
The hearing was improved in 2 and remained the same in 1 case.
(3) An attic perforation was present in 6 cases, in 2 of these
combined with the presence of polypus or granulations. The hearing
was good in 4 of the 6 cases and moderate in the remaining 2.
The antrum was healthy in 1 case but the attic contained cholesteatoma.
The antrum contained discoloured fluid in 1 case. In 2 the antrum
9
contained muco-pus and in 2 cholesteatoma. The result is not known
in 2 cases. The ear remained moist in 2 cases while in the remaining
2 the ear was dry. Of the 4 cases who reported, the hearing was
improved in 2 cases, remained the same in 1, and was worse in 1.
48
Fraser and Garretson: Mastoid Operations
(4) In 1 case the meatus was stenosed, so that the position of the
perforation was not ascertained. Hearing was moderate. The antrum
was healthy. The result as regards condition of the cavity was excellent
and the hearing improved.
(5) In 2 cases there was sagging of the posterior superior wall of
the meatjis, preventing inspection of the membrane. In 1 of these
hearing was good and in the other moderate. In both cases the antrum
contained pus and polypoid mucosa. One case did not report but in the
other the ear was dry and the hearing improved.
(6) In the 2 remaining cases the meatus was occluded by a polypus
and the position of the perforation not ascertained. In 1 of these the
hearing was good and in the other moderate. In both, the antrum
contained only muco-pus. One patient did not report but in the other
the result was good and the hearing improved.
Labyrinth Cases.
The labyrinth cases numbered 26, 16 of whom were males and 10
females. The age of the patients varied from 5 to 53 years, as a rule
between 20 and 30. It is notable that the average age (25) was con¬
siderably more than the average age (19) of the intracranial cases.
Eleven of the patients resided in Edinburgh or its neighbourhood and
15 came from the country. Cholesteatoma was present in 13 of the 26
cases; granulations and polypi in 21 cases. In 3 cases there was an
attic perforation and in 2 cases a posterior marginal perforation could
be seen. A subperiosteal abscess was present in 5 cases and facial
paralysis before operation in 3.
Symptoms .—Pain in the ear or head, 18 cases; fever in only 2
cases; giddiness, 16 cases; vomiting, 8 cases. Noises in the head
formed a marked symptom in 1 case and were so bad that the patient
insisted on operation.
Hearing .—Not tested in 2 cases owing to the age of the patients.
In none of the remaining 24 cases was the hearing good. Moderate
hearing (C.V. at from 6 in. to 6 ft.) was present in 7 (all of circum¬
scribed labyrinthitis), and bad hearing (C.Y. at less than 6 in.) in 5
cases. Total deafness in 12 cases.
Vestibular Symptoms .—Spontaneous nystagmus, 8 cases; pointing
error, 2 cases; fistula symptom present in only 2 instances, although
there were 12 cases of circumscribed labyrinthitis. Rotation nystagmus
was normal in only 3 of the cases, while it was reduced in 11. In the
Section of Otology
49
others it was not tested. Caloric nystagmus was not obtained in 13
cases in which it was examined for. Many of these, however, had
cholesteatoma and polypus. Caloric nystagmus was present in 9 cases
of circumscribed labyrinthitis.
Type of Labyrinthitis, Operation Performed, and Result.
(a) Of the 26 patients, 12 were cases of circumscribed labyrinthitis.
In 10 of these the radical mastoid operation only was performed, and
3 of them were skin-grafted. All of the patients recovered. In 4 of
the 10 the hearing was improved, in 3 the hearing remained the same,
in 3 the hearing was not tested after operation. In one of the remaining
cases double vestibulotomy was performed in addition to the radical
mastoid operation. The patient recovered but had no hearing on the
operated side. In the last case Neumann’s labyrinth operation was
performed in addition to the radical mastoid operation. This patient
recovered, but was also deaf on the operated side.
(b) Diffuse purulent labyrinthitis (manifest)—3 cases—following the
radical mastoid operation. In 2 of these a fistula was present in the
lateral canal at the time of the radical operation. In 1 case the
radical mastoid operation alone was performed. The patient recovered
with loss of hearing. In 2 cases double vestibulotomy was done when
the patients developed labyrinth suppuration. Both patients recovered,
with loss of hearing.
(c) Latent labyrinth suppuration, 8 cases; in 6 of the 8 cases the
radical mastoid operation and double vestibulotomy were performed. All
6 patients recovered, but with total loss of hearing. In 2 cases the
radical mastoid operation, plus Neumann’s operation, was performed.
One of these patients recovered and 1 died. This latter case was one
in which there was a fistula into the cochlea discovered at operation.
The semicircular canals, however, were filled uji by new bone formation.
Neumann’s operation was followed by meningitis. . Microscopic
examination of the ear showed that the posterior part of the laby¬
rinth had become a solid mass of bone, while the cochlea still showed
granulation tissue and abscess formation.
(d) Spontaneous cure of labyrinth suppuration, 2 cases. In both
of these the radical mastoid operation only was performed. Both
patients recovered.
The other fatal case was that of the patient already mentioned who
suffered from chronic middle-ear suppuration, with noises in the ear
50 Fraser and Garretson: Mastoid Operations
which were so intense that she stated she would go mad if operation
were not performed. No labyrinthine lesion was obvious at the time of
the radical operation, which was immediately followed by double vesti¬
bulotomy and removal of the cochlea. In this case it would certainly
have been better if the radical operation had been performed first of
all, so as to obtain, if possible, a dry ear, before proceeding to removal
of the cochlea. The operator’s hand, however, was forced by the
attitude of the patient in this case.
Intracranial Complications.
These cases numbered 25, of whom 17 were males and 8 were
females. The average age was 19 years. All the patients were under
30 years of age.
The Edinburgh Royal Infirmary draws from a very large area, in¬
cluding Fifeshire, the Lothians and the border counties. In fact the
majority of the patients dealt with in this report came from districts
outside Edinburgh and Leith. Fifteen of the 26 labyrinthine and 17
of the 25 intracranial cases came from the country. Many of the cases
with intracranial complications were not sent in for several days or
even for one or two weeks after grave symptoms had developed. For
this reason it is not surprising that there is a considerable mortality
associated with operations for the relief of intracranial lesions. Up till
comparatively recently the course on “ diseases of the nose, ear and
throat” has not been compulsory, and many general practitioners fail to
realize the serious nature of symptoms arising as a result of middle-ear
suppuration. The majority of practitioners have now learnt to send in
to hospital without delay cases of appendicitis, strangulated hernia or
ruptured gastric or duodenal ulceration, but they still retain cases jof
suppurative otitis media associated with headache, vomiting, giddiness,
rigors, &c., and treat them by means of sedative powders or counter
irritation.
In 8 of the intracranial cases there was delay in operation. As a rule
this was the fault of the patient or his friends, who refused operation,
but in one or two cases the intracranial complication occurred between
the time at which the patient was first seen (when no urgent symptoms
were present) and that at which there was a vacant bed ready in the
department. Such occurrences are almost bound to happen in the
presence of a long “ waiting list.” Four of these 8 cases ended
fatally. Cholesteatoma was present in 18 of the 25 cases. In most
instances more than one intracranial complication xoas present .
Section of Otology
51
(1) Extradural Abscess. —Seventeen cases, 8 recoveries and 9
deaths. A perisinus abscess was present in 15 cases, and an extradural
abscess in the middle fossa in 1 case. In 1 case both perisinus and
iniddle fossa abscesses were present.
(2) Labyrinthitis. —Seven cases associated with intracranial com¬
plications and not included in previous part, (a) Circumscribed laby¬
rinthitis, 3 cases, 1 recovery and 2 deaths. Of the 2 fatal cases 1 had
sinus thrombosis and the other had purulent meningitis. (b) Diffuse,
labyrinthitis, 1 case, recovery. ( c ) .Latent labyrinthitis, 3 cases, 1
recovery and 2 deaths. Of the 2 fatal cases 1 had sigmoid sinus
thrombosis and meningitis, and the other had cerebellar abscess.
(3) Sigmoid Sinus Thrombosis. —Twelve cases, 6 recoveries and 6
deaths. In 3 of the 6 fatal cases purulent leptomeningitis was already
present on admission to hospital and 1 other developed purulent lepto¬
meningitis after admission.
(4) Temporo-sphenoidal Abscess. —Four cases, 1 recovery and 3
deaths. In 2 of the 3 fatal cases rupture into the lateral ventricle had
occurred before the admission of the patient to hospital. In the re¬
maining case rupture occurred after admission.
(5) Cerebellar Abscess. —Three cases, 2 recoveries and 1 death.
The death occurred from septic oedema of the braiu, spreading from
the walls of the abscess.
(6) Leptomeningitis .—Thirteen cases. (a) Serous meningitis, 3
cases, all recovered, (b) Purulent meningitis, 10 cases, 1 recovery and
9 deaths. In all the fatal cases other complications were present, as
follows: Circumscribed labyrinthitis, 1 ; latent labyrinthitis, 1; sigmoid
sinus thrombosis, 4; temporo-sphenoidal abscess, 3.
Summary. —-Of the ,25 cases 13 recovered and 12 died. 1
DISCUSSION.
Mr. ARTHUR Cheatle : This paper opens up an enormous field for dis¬
cussion. I would like to draw special attention to the public health question
raised by the authors. There was the recommendation passed by the Otological
Section at the last International Congress, and of which no notice has been
taken, and the authors think that the actual conditions found by recruits and
soldiers during the War may egg the authorities to action. We are all aware
of the loss of man power and money owing to ear troubles during the War,
and pensions therefor will have to be paid for many years to come. It is not
as if the Government had not received a warning in this respect, for in 1902
1 This paper is to appear subsequently in the Journal of Laryngology , Rhinology and
Otology , with detaiis of all fatal cases and of all intracranial cases whether fatal or not.
52
Fraser and Garretson: Mastoid Operations
I presented a report on an examination of the ears, nose and throat of 1,000
poor school children to the Otological Society of the United Kingdom. Among
other things it was found that eighty-eight of the children were suffering from
chronic middle-ear suppuration. A committee was appointed to consider the
subject, and a report was sent to the Board of Education pointing out the large
amount of preventable and curable ear disease among the children of the
poorer classes, and how such disease “ tends to considerable loss of hearing,
health and life ; that it militates against a child’s education, and that later on
the subjects of it are seriously hampered in their life's work, and often
incapacitated for the services of the State.” 1 During the last two years I, with
others, have been examining candidates for commissions in the Royal Air
Force. We had 35,000 through our hands : 5,000 were rejected, of which about
5 per cent, had chronic middle-ear suppuration. What, I think, is now-
required, is that this Section should appoint a standing committee of, say, six
members, to watch the Ministry of Health Bill, and be ready to advise the
Government. As its chairman I would suggest Sir Robert Woods, whose work
we are conversant with, who is a man of affairs, whe has been President of the
Royal College of Surgeons in Ireland,* and is now a Member of the House of
Commons. With regard to indications for operation in chronic middle-ear
suppuration the following sign is useful: If a marginal perforation is present
in the postero-superior segment, and pus can be seen to be drawn out by ex¬
haustion with a Peter’s magnifying speculum after thorough cleaning and
drying by mopping, it demonstrates the implication of the attic and antrum.
The figures given of anatomical condition of the cortex bears out what
one has been insisting upon for many years, namely, that the acellular
type of bone is a very great factor in causjng an acute inflammation of the
middle-ear tract to result in a chronic discharge; always excluding cases of
tuberculosis of the bone, those cases in which an acute mastoid abscess has
burst or been inefficiently operated upon leaving a sinus behind the ear and
discharge from the meatus, and the cellular type of bone in which the cells
are surrounded by very dense bone. There is evidence, I think, to prove that
the antrum is not always infected in acute middle-ear inflammation; but
it is most frequently and quickly infected in virulent infection, such as in
scarlet fever, measles, and influenza, and if the acellular type is present, the
dense surrounding walls of the antrum preclude external perforation and a
chronic discharge from the antrum into the meatus is established. With
regard to the “ modified operation,” I submit that it is a bad and unscientific
one in acute or subacute cases of mastoid suppuration ; for the drainage into
the meatus is apt to be poor, and an unnecessary permanent opening, with sub¬
sequent disabilities, is left from the antrum and mastoid cells into a deformed
cartilaginous meatus ; while if the Schwartze operation is properly carried out
there result a healed membrane, normal meatus, good hearing, and a sound
scar behind the ear. In chronic middle-ear suppuration really requiring
operation, it is inefficient, and there are very few cases in which it is likely to
be efficient.
* Trans. Otol. Soc . U.K ., 1902, iii, pp. 106 and 107.
Section of Otology
53
Dr. Kerr Love : I direct attention to one point, not so much in connexion
with the paper, but in a general way—namely, the connexion between middle-
ear suppuration and chronic mastoiditis. Those two terms are not, and cannot
be held to be, synonymous. It will be seen from otological literature that at
the present time there is a tendency to operate on all cases of chronic middle-
ear suppuration. During the last six years I have been treating school children
under the Glasgow School Authority. I have always under my care 500 cases
of chronic middle-ear suppuration, and I can count on recovery without opera¬
tion in far more than one-half of those cases. The procedure adopted is, first,
curetting the nasopharynx and removing enlarged tonsils. Secondly, we submit
the external auditory canal and middle ear to careful treatment for a con¬
siderable period, and if discharge does not disappear or comes back, in spite of
those measures, we operate on the mastoid antrum. I plead for patience with
school children. If you treat them carefully in the first weeks, or months,
you will get cure without operation in quite half the cases. With regard to the
so-called modified mastoid operation, I have adopted it for school children more
readily in the cases in which both ears are involved. I prefer not to do the
radical mastoid operation when both ears are involved, unless there is very
strong evidence that the radical is the only operation for the case. I have
been struck by one of the points which the authors bring out—namely, that
the type of disease is much worse in the children of the poorer classes. From
some schools I find fifteen in twenty children brought up per day to be cases
of chronic middle-ear suppuration, whereas among the better classes only five
in twenty belong to that type. They are all cases of deafness. I find, also,
when I take the children into hospital, that in the case of the poorer children I
nearly always get findings in the mastoid process, whereas among children of
the better class I sometimes get none. I think the operation has been unneces¬
sarily done in many of those cases. There are fifty cases with normal antrum.
Had all these cases been treated as we now treat school children, and at an
early stage, most of them would have recovered-without operation.
Mr. Charles J. Heath : I was interested in hearing the last speaker say
that he does not perform the radical operation when both ears are involved. I
conclude, from that, that he considers it more likely that a reasonable amount
of hearing will be retained after doing the modified operation, or, as I prefer
to call it, the conservative operation. That is one of the most important
things we have to consider. With regard to the question of the enormous
number of men who are deaf, as Mr. Cheatle has already told us, from aural
suppuration, it is one which will have to be faced soon, as well as the question
of how we are to deal with it. No one wishes to do an operation on an ear if
the disease can be cured without an operation. I find people ready enough to
do an operation on the nose, or on the nasopharynx for far less serious con¬
ditions, while they hesitate in the case of the ear. On my recommendation,
the Metropolitan Asylums Board have set up a hospital in London where all
the children under their control who have running ears can be sent. If, after
a few months* treatment, their ears have not ceased discharging, we usually do the
54 Fraser and Garretson: Mastoid Operations
conservative operation. Last night the resident medical officer told me he had
sent out on the previous day six children who had been treated by the con¬
servative operation, and one by the radical operation. I am not pointing that
out as my handiwork, it is the work of those whom it has been my privilege
to train. One of the patients I showed this evening was a nurse at that hospital.
She had had pain for three days before I was informed of it. Within three
hours I incised the drum-head. There was a free discharge. Next day the
pain persisted in spite of the free discharge, and I said that she had an attic
dam obstructing the antral drainage. That afternoon I performed the con¬
servative mastoid operation and found pus in the antrum under pressure. You
saw no disfigurement behind her ear, such as is the rule after a Schwartze
operation. It is a better result than a Schwartze would have given, and she
needed no bandage after eight or nine days. [Mr. CHEATLE : I object to
that.] She is an example of the conservative operation performed in an
acute case. Mr. Cheatle said he thought the conservative operations are
undesirable in acute cases. The only drawback I can see to the conservative
or any mastoid operation is the time the patient takes to get well, for bone
heals but slowly. I cannot understand why people allow ears to continue
running and not run the risk of an operation which is practically devoid of
danger, and, if done fairly early in the case, is practically certain to arrest or
prevent deafness. With regard to the after-treatment following the conservative
mastoid operation : At the hospital I referred to just now, children, from 3
years of age, troop- in to have their ears dressed. There are no tears nor
complaints. The tube—which I instituted for this work—is taken out of the
meatus, then the two little plugs ; two more plugs are put in, the tube replaced,
and the dressing put on. I congratulate the writers of the paper immensely
on their industry, though the amount of hearing saved does not, I fear, entitle
me to give them praise.
Dr. William Hill : It is'impossible to traverse the whole field opened up
by even Mr. Heath's speech, but I think this meeting should lay down some
guidance on one point at least, and that is, that the old Schwartze operation is
not obsolete, but it is a good operation for acute and subacute cases. I am not
certain it is not ample for the cases which Mr. Heath and perhaps we ourselves
occasionally submit to the conservative operation. I have pointed out before
that this operation was done years ago, before the Stacke, and that it is the
Kiister operation revived. By that operation we do not interfere very much
with the ossicles and the attic. I think that in one-fourth of the cases the
antrum escapes any marked disease, but it is a route for getting to the
middle ear in a more direct way than we can approach it from the meatus.
The Schwartze operation will do that well. Moreover, the Schwartze is a
conservative operation. We make a hole in the bone, and it fills up with
granulation tissue, and then w T ith fibrous tissue. In a case which has been
dealt with by the so-called Heath’s method, you look in the meatus to find
the posterior wall gone, and you can see into the antral cavity. Sometimes
the hole fills up, but you have altered the whole balance of the ear: it must be
Section of Otology
55
an ear which is exposed to. various vicissitudes of climate, cold draughts and
water getting into the ear, and that is the operation we are asked to substitute
for our usual Schwartze. That there are cases in which one may hesitate to
do a complete radical operation, especially in young people who have good
hearing, I can understand, and I have been in that position often myself, and
sometimes I have had very good results from the modified operation. Still,
results in hospital depend very much on your clinical assistants. I think
Mr. Fraser has been indulging very 'liberally in this mitigated operation.
Although seventeen is not a big proportion of the cases given, it is a large
number to have submitted to this operation. I do not think there are many
otologists who would do even that proportion.
Mr. W. Stuart-Low : I have worked at this subject for twenty-five years,
and have now operated upon over 1,000 cases, so I can speak with authority on
this subject from practical experience of my own operations. From this point
of view certain remarks and statements that I have just heard in this paper
I can agree with and others not. I was very pleased to listen to Dr. Kerr
Love’s views. There is an appalling number of children with discharging ears
both in private and in the hospital clinics, and I have often asked myself why
this is so. , The chronic ear discharge in children undoubtedly originates in
acute otitis media: this has been proved to be very common indeed in young
children, and is, I am afraid, not sufficiently frequently correctly diagnosed,
and the only sterling remedy for it carried out—viz., paracentesis tympani.
This simple operation ought to be far more frequently done, as it is the one
preventive measure against the child being launched on that sea of trouble—
chronic suppuration of the middle ear. The urgent necessity for correct
diagnosis of, and for the performance of, paracentesis tympani for acute otitis
media should be impressed on the medical practitioner. Again, the preventive
treatment of acute otitis media is the efficient removal of enlarged tonsils and
adenoids, and when otitis has occurred and resulted in ear discharge, if every
trace of the enlarged tonsils and adenoids were removed, reinfection of the ear
from the throat would be arrested and the local treatment of the discharging
ear through the meatus would be much more likely to result in an early
successful issue in the drying up of the ear. It should also be more clearly
established that ear discharge in children should not be allowed to go on
indefinitely and that the next step in the treatment of it after local treatment
and removal of enlarged tonsils and adenoids have failed consists in the
performance of the cortical mastoid operation. I say most emphatically that
the radical mastoid operation in children should never be undertaken. I never
do so under 18 years of age, but would rather perform three cortical mastoid
operations in succession at intervals of two or three years, although this is a
very unlikely necessity, as the cortical mastoid, by thoroughly draining the
antrum and so preventing the constant irrigation of the middle ear with
purulent fluid usually results in a permanent cure. The reason for studiously
avoiding the radical operation in the young is the danger of loss of hearing,
whereas the even repeated performance of the cortical mastoid operation
56
Fraser and Garretson: Mastoid Operations
almost always ends in the hearing being perfectly restored. I never practise
Mr. Heath s operation, as I fail to see the necessity for it—all cases I divide
into two—those the cortical mastoid operation can cure, and those that it
cannot, and upon such the radical operation should be done. I cannot recognize
the need for any middle way. I do think however, that Mr. Heath, as the
first surgeon ever to have cut a flap and stitching up entirely the posterior
incision, to drain through the meatus, deserves credit for this, but the other
steps of his operation I cannot approve, such as tinkering with special
instruments through the aditus, &c. Mr. Heath and those who follow him
find their chief argument in favour of his modified conservative operation
in the assertion that the hearing after the radical mastoid operation is largely
lost. Let these operators speak for themselves, because I can truthfully aver
that my results as regards hearing have been exceedingly good. I have shown
a sample of many of my cases here to-day, in which after the ear discharge
had .gone on for thirty years the hearing after the radical mastoid operation is
25 per cent, better than before the operation, and this is only typical of most
of my results. What has given a handle to those who decry the radical
operation is that there are many badly performed operations to be met with,
and I am afraid some indifferent operators are in the field. To attain my
good results I lay stress on certain points, which are briefly as follows :
Efficient and careful preparation of the patient for operation, by the
removal of all carious teeth and cure of pyorrhoea alveolaris by the aid of
the dentist. The septic tonsils are also enucleated, adenoids removed, and the
nose made free and aseptic. The general health is carefully attended to, and
change of air advised. Locally the ear is cleared of discharge by the Eustachian
catheterization and the use of sprays and Siegle’s suction by the meatus, and
by an antiseptic vapour (kelvolin) being forcibly blown into the tympanic
cavity : these measures are carried out over an interval of a month previous to
the operation. The discharges are always carefully examined by a bacteri¬
ologist and vaccines used for some weeks. At the time of operation I take
particular care never to curette the inner wall of the tympanic cavity, so as to
avoid scar tissue resulting. I fill the ear cavity just before stitching up the
wound at the end of the operation by pouring into it 10 c.c. normal horse
serum, and insert one gauze plug only, which is removed next day, and no
more plugs are ever inserted nor any rubber tubes whatever. An aural shield
is placed over the ear and the gauze dressing put over it, and then the bandage
applied over all. This effectively prevents bandage pressure on the ear, and so
all narrowing of the meatus is avoided and drainage facilitated. My average
time for the patients to remain in hospital is eight to ten days as against
twenty-two days mentioned by Mr. Fraser in Edinburgh.
Dr. Dundas Grant : It is singular that Mr. Heath should have said that
the usual operations for acute suppuration in the middle ea^ performed on the
mastoid process are not conservative and are not carried out with the view of
preserving or restoring hearing. [Mr. Heath : I did not say it.] It is in
Mr. Heath’s book on “ Otitis Media * f (p. 20). The Schwartze operation
Section of Otology
57
is intended to preserve and restore the hearing, and I cannot think why one
should want to do anything further in the way of making a hole in the
posterior wall of the meatus. Not long ago, I saw a case which had been
treated in this way, and it was discharging still. [Mr. Heath : I have seen
discharge after a Schwartze, often, and there has been great disfigurement too.]
That may happen in the operation, but it is quite exceptional for the patient
not to get perfectly well after a Schwartze. I therefore think it unnecessary
to perform an operation which leaves a chronic fistula : if a fistula were left
behind the ear in a “ Schwartze ” you would call it a bad operation, and a
fistula in the meatus is much the same thing. I do not see the possibility
of substituting a conservative operation for the radical in many cases of
chronic suppuration. I cannot help thinking that Mr. Heath’s teaching has
been practised by some of the surgeons who have been operating upon soldiers,
for I have in a number seen this opening in the posterior wall of the meatus,
and masses of granulations still discharging, so that I have had to convert the
“ conservative ” into a true radical mastoid operation. I object to Mr. Heath’s
statement that the radical mastoid operation necessarily means “ deafness.’*
[Mr. Heath : Have, you ever seen perfect hearing after it? I never have.]
I have seen very good hearing after the radical mastoid operation. But is
diminution of hearing to be called deafness ? The person’s hearing organ has
been injured by disease. This use of the word “ deafness ” is misleading.
[Mr/HEATH: If you can do the radical operation and have no deafness I shall
be glad to see the case.] [The PRESIDENT : The conditions are totally
different. The radical mastoid in one case is done for disease which affects
the hearing very seriously, and from which it can never recover. The result,
naturally, is bad hearing. The modified mastoid operation is done for disease
which has not permanently affected the hearing, and equally naturally, there
ought to be good hearing.] At a recent meeting here I showed a gentleman on
whom I had done a radical mastoid operation fourteen years ago and he heard
a whisper at 16 ft. Certainly he was not deaf. Where ossicles have been
removed by the radical mastoid operation, surely the resources of otologists
are equal to providing an artificial drum. These charges against the radical
mastoid operation are unfairly stated. The question has also been raised as
to whether grafts interfere with the hearing power. My impression is that
they do not. There is some difference in Mr. Fraser’s statistics in regard
to that. A very convincing case under my care was that of a gentleman on
whom I operated on both sides. On one side I grafted, on the other I did not,
the hearing beforehand being very much the same in both. Afterwards, the
hearing in the grafted ear was much the better of the two. With regard
to the indications for the modified operation, there is one which is worth
considering : that is, when the anterior part of the tympanum is shut off from
the aditus and antrum. In such a case the modified operation is very strongly
indicated. .Having criticized Mr. Heath, I should like to say I admire the
result of his technique in those cases in which his operation is indicated.
58
Fraser and Garretson: Mastoid Operations
Mr. Somerville Hastings : The following is my experience with acute
and subacute cases in regard to the Schwartze and the modified operations:
For several years my practice was to perform the Schwartze operation.
Whether my technique was faulty I cannot say, but I found them slow
in healing, and a sinus was often left. Then I tried this modified operation.
And certainly my cases have healed much quicker after the modified than
after the Schwartze operation; also the dressing appeared to me to be much
more easy and satisfactory . I started otology much later than most of the
speakers, therefore I commenced with no prejudices in favour of the Schwartze
operation, yet I have largely given up doing the Schwartze for acute and
subacute cases, especially in children, and am doing the conservative operation
almost exclusively. For chronic cases, of course, I still always do the radical
operation.
Sir CHARLES Ballance : In the first place, I have never seen Mr. Heath
operate, but. I have seen some of his cases afterwards. Some of them are not
good results. It seems to me we have not been discussing what is really the
essential point, and that is, When should an operation on the bone be done ?
Among the cases of acute otitis media we have all seen fulminating cases in
which the mastoid process is rapidly involved, and in which, after three or
four days, the cells are full of pus. Those cases, of course, require operation:
wherever pus is, it must be let out. Personally, I think there is nothing better
than the Schwartze operation for such cases, that adequate and thorough
drainage is obtained by this method, and that not only, perfect hearing, but
complete healing takes place in a reasonable time. I am sure there are cases
in which the Schwartze operation would not be altogether desirable, and need
not be completely done. But then I would say that the surgeon should never
commence to do an operation by a name; he should adapt his operation to the
case according to what he finds, for during the progress of the operation he
learns things. It is so in all departments of surgery. Now with regard to the
acute cases which require operation. Take the London Fever Hospital. Dr.
Caiger told me years ago that the great majority of cases of otitis media acuta
heal up before the patient leaves the hospital, without loss of hearing. So
that the majority of the cases heal up without the necessity of any operation
at all. Still, there are a certain number of patients who do require opera¬
tion ; and Mr. Cheatle mentioned those cases in which the tympanum is
early and acutely involved, and in which the ossicles soon become carious.
I reply to Mr. Cheatle that in such a case an operation should have been
done, and that the ossicles should not have been allowed to become carious.
That kind of operation should be done which will give absolute and free
drainage to the tympanum. In the radical operation and in operations for
acute disease we should avoid, as far as possible, interfering with the
tympanum. There are many cases in which the mucous membrane of the
tympanum is practically healthy and in which one or more of the ossicles are
healthy. I believe success in the treatment of the chronic disease depends
on doing as little as possible to the tympanum—I mean success with regard
Section of Otology
59
to the amount of hearing left to the patient. The same is true of acute cases,
especially of those acute cases which fulminate into the mastoid process,
because the tympanum, then, is only a conduit for the escape of pus, and
if you open the mastoid you get drainage of the pus through the wound, and
the result is the tympanum heals and the case recovers with perfect hearing.
I think the differences expressed here to-day lie not so much in differences in
the methods of operating as in the decision as to the cases which should be
operated upon. It is impossible to lay down rules, because the exact condition
is not known. But some surgeons operate early, and others say an operation
should not be done. Without differences of opinion we cannot advance, and
I am rather inclined to think we shall advance in the future more on the lines
of earlier operating, so as to try to save the tympanum from damage. In what
direction the advance should take place, however, I cannot say.
Dr. Dan McKenzie (replying for the authors): We have been listening
largely to impressions—from Mr. Heath, from Dr. Grant, from Sir Charles
Ballance, and even from Mr. Cheatle. But the paper which has been placed
before you deals with facts. Mr. Heath has not given me figures: I have
asked him for them. Let us have members producing their facts and statistics,
as Mr. Fraser and his colleague have done. Then we shall be able to discuss
these questions with more knowledge than we can at present.
•
Mr. J. S. FRASER (prevented by illness from being present, sent the
following reply to the discussion) : I cordially approve of Mr. Arthur Cheatle's
suggestion that a standing committee should be appointed to watch the Public
Health Bill, and to see that the otological aspect of public health is not for¬
gotten. I agree with Mr. Cheatle that my findings at operation with regard
to the structure of the mastoid process bear out his views with regard to the
incidence of chronic middle-ear suppuration. Further, I believe that Mr.
Cheatle is right in saying that in cases of mastoiditis in acute otitis media one
usually finds the cellular type of bone. This is one of my great objections to
performing the modified radical operation in cases of acute or subacute otitis
media with mastoiditis. The tip of the mastoid process lies below the level of
the external meatus, and consequently the operation cavity cannot be
efficiently drained into the meatus. To put it in another way, I agree
with Mr. Cheatle and other speakers that in cases of mastoiditis following
acute middle-ear suppuration, the Schwartze operation is the most efficient.
Through the incision made down to and past the tip, the whole of the diseased
cellular structures in the mastoid process can be cleared out and efficient
drainage secured. Further, the ear is left in a better condition than after
the conservative mastoid. The only acute cases in which the conservative
operation might be suitable would be those with a sclerotic mastoid process,
in which there are no tip cells, and even here I think that the Schwartze
procedure would be better. On the other, hand, in cases of chronic suppuration
the hearing is usually so poor that it is of little use to the patient, granted that
the other ear is normal or almost normal. With poor hearing in the ear to
60
Fraser and Garretson: Mastoid Operations
be operated on,it is not worthwhile to perform the modified or “conservative”
operation unless the hearing of the other ear is bad. I agree with Mr. Cheatle
that cholesteatoma in the attic, aditus and antrum, with healthy ossicles and
good hearing, is an indication for the modified radical operation. Such cases,
however, are rare. With regard to Mr. Heath’s case of recurrent suppura¬
tion cured by the modified operation, I can only say that, as the case was
one of recurrent suppuration, it was not Surprising. The patient might have
had a dry ear at the present time even if no operation had been performed.
One would like to know, however, whether Mr. Heath holds that there is no
possibility of suppuration recurring next time the patient gets a cold in "his
head. I agree with Dr. Kerr Love that about 50 per cent, of chronic cases
are curable by conservative treatment without operation at all. It is neces¬
sary, however, for this treatment to be carried out by skilled nurses. It is
quite useless to tell the patient’s mother to pub in peroxide drops and to
syringe the ear, &c. Even a nurse new to ear work takes two or three weeks
before she is able efficiently to carry out conservative treatment. Until Mr.
Heath publishes a paper somewhat similar to the present one (or to that
published by Dr. Dickie and myself in 1912), I do not think that we will get
very much further forward in this controversy. Until this time arrives we
have only the report of Plumer and Mosher regarding the end results of Mr.
Heath’s conservative operation. It is useless for Mr. Heath and his fol¬
lowers to say that the radical mastoid operation is dangerous, and that it
destroys the hearing, whereas the “ conservative ” operation is free from danger
and preserves or restores the hearing. They are not comparing like with like.
I understand that Mr. Heath performs his operation in many cases of acute and
subacute otitis media with mastoid involvement. I have not in this paper dealt
with cases of acute otitis media at all, though I am quite willing to publish the
results of my Schwartze operations. Again, as Mr. Heath has himself acknow¬
ledged, cases coming to the Eoyal Infirmary are very largely drawn from
country districts, and are often sent in only when an intracranial complication
is already present. I have drawn attention to Mr. Adair Dighton’s remarks
comparing the results of the radical and modified radical operation, and I
should like to have heard from Mr. Heath either a justification of, or an
apology for, these remarks. When I was working at Golden Square, in 1904,
my recollection is that Mr. Charles Heath was doing a sort of Stacke operation
for chronic middle-ear suppuration, attacking the antrum from the posterior
wall of the bony meatus, removing the outer wall of the aditus and attic along
with the drumhead, malleus and incus, cutting a meatal flap, inserting a rubber
drainage-tube into the meatus and closing the posterior wound. At that time
he also talked a good deal about conserving the hearing. A little later I was
surprised to find that Mr. Heath was doing quite a different operation, the
Kiister or so-called “conservative” mastoid. In this he leaves what he
formerly took away and takes away what he formerly left. It seems to me
that Mr. Heath first of all rediscovered the Stacke operation, and later the
Kiister operation. It only remains for him to rediscover the radical mastoid
Section of Otology
61
procedure. With regard to the question of conserving the hearing, or improving
the hearing, we all wish to do this. On the other hand, we want if possible to
cure the suppuration. The question is : What amount of hearing is really of
use to the patient ? If a patient has normal or almost normal hearing in one
ear, while in the other (ear to be operated on) he hears the conversation voice
at anything up to 4 or 5 ft., he will not use the bad ear but will depend
entirely on the hearing in the good ear. Thus, unless the hearing in the ear
to be operated upon is better than “ conversation voice at 4 ft.,” it is not worth
while to do the modified radical operation, granted that the good ear is normal
or nearly normal. On the other hand, if the hearing in the “ non-operation ”
ear is bad, then it is well worth while to do the modified operation even though
there is less likelihood of obtaining a dry ear. One can always perform the
radical operation later if necessary. Mr. Heath is wrong when he says that
only seventeen modified operations were done as compared with 280 radicals.
The number 280 includes fifty-two radical mastoid operations performed previous
to 1911, and published in the previous paper. If Mr. Heath takes this number
(280) he must also include the modified radicals published at that time; these
numbered eleven, so that the total of modified radical operations is twenty-
eight—i.e., 10 per cent. My findings at operation show that Mr. Heath's
pathology is wrong, and that the antrum is not the source of the pus in all
cases of discharge from the middle ear. Mr. Hill and Dr. Dundas Grant are
quite right when they state that the opening from the antrum into the meatus
left by the Heath operation is a possible source of danger, at least in cases in
which the aditus also remains open. Some years ago Sir William Milligan
pointed out that, if there was a perforation in one drum-head, even though a
dry one, that ear was much more liable to infection in cases of “ cold in the
head.” He drew an analogy between this condition and that where a man
tries to blow smoke into a bottle. If the bottom of the bottle is whole it is
not easy to blow smoke into it, but if the bottle has a hole in the bottom then
it is quite easy to blow smoke into and through the bottle. I take it that a
permanent perforation of the drum-head, or a fistula through from the aditus
and antrum to the meatus, corresponds to the hole in the bottom of the bottle.
I cannot show a patient after the radical operation with as good hearing as Dr.
Dundas Grant’s case—i.e., whisper at 16 ft./ but I have one case where the
patient can hear the whisper at 6 ft. In this I notice that both window
niches are freely open, one can see the footplate of the stapes (the crura being
absent) and the niche leading to the round window. I would suggest that next
year the Council of the Section should consider the question of having a
meeting to discuss “ the operative treatment of mastoid complications in cases
of acute and subacute otitis media.” Mr. Heath would no doubt champion the
“ conservative ” operation, and I am sure some otologist could be got to give
his results regarding the Schwartze operation.
A— 11
62
Tod: Septic Infection of the Lateral Sinus
Septic Infection of the Lateral Sinus accidentally injured
during the Operation of Mastoidectomy . 1
By Hunter Tod, F.R.C.S.
In this short paper I include only those cases in which the mastoid
operation was performed for chronic suppurative disease of the middle-
ear cleft and mastoid cells, and in which, at the time of the operation,
the sinus was apparently healthy. Theoretically such injuries should
not occur, and strictly speaking may be considered the result of careless
or faulty technique ; but nevertheless I feel sure that the majority of
those who have performed a large number of mastoid operations have
injured the sinus wall on more than one occasion. Fortunately subse¬
quent septic infection of the sinus, as the result of being injured,
rarely takes place, if we can judge from the few cases recorded in
literature, although perhaps this is no criterion on which*an opinion
can be based. Such injuries to the sinus may be divided into two
groups:—
(1) A clean cut through the wall of the sinus with profuse
haemorrhage, necessitating obliteration of the lumen of the sinus at
the point of injury in order to arrest the bleeding. In these cases I
have never observed subsequent infection of the sinus.
(2) Grazing of the outer layer or puncturing of the sinus wall with
no bleeding, or with only slight oozing of blood for a moment or two,
the injury sometimes being so slight as to escape notice unless a
careful examination be made, at the end of the operation; and even
then only a slight tear or scratch may be observed in the dura mater,
exposing a tiny area of a reddish-blue colour, the inner coats of the
sinus wall.
Before discussing my cases let me draw your attention for a
moment to the anatomy of the mastoid region (fig. 1), from the
operative point of view in connexion with injury to the sinus. Two
types may be considered :—
(1) The easy type ; usually in dolichocephalic skulls having roomy
At a meeting of the Section, held February 21, 1919.
See Him of Otology 63
mastoid cells with the sigmoid sinus placed far back. Id such .eases
the sinus can rarely he injured.
(2) The difficult type, most freipieul: ia brachiocephalic .skulls
in which the structures are compressed ifigeiher, gjvmg little room
for the exposure of the antruth. The nurstoid, process i« composed
of compact, hard bone. The sigmoid sinus is. usually superficial
and protrudes over; the tniier wall ol ihe- antrtmi, which may be very
small.' and situated high tip, almost.' 'under cover of the. middle fossa-
of the skoli-/s’. • - •• '. ■"
I have notes of six cases in which the lateral sinus was infected
after injury during the mastoid operation, all of which were of this
anatomical .ty'pey and htWli"Jt/"-if,^-wsciri'bej: : Theprhaury
operation was performed by myself in four of these cases (representing
less than | per cent, of the total number of cases operated on), by my
house surgeon in the other two cases.
Ccnc L —K L, female, aged .10. deration J 1*07 (by Umido surgeon 1 .
Chrome: ^rrli'ce-H'; of f*bo 'Wt mt. T&# ' eavi|y filled *vi£h
fcb^e was rdiiit>Bb doo)piete destruction of the
tympanic teemhro,ne-with .ayttatuk leading inio the attic region.:- There was
pouic tenderness over the 'm&eiidid . proses*,. Temperature i OO F , pulse l it),
Complete ojxn-atm# p©WaT'mad\ The was small ifie. hope
eroded, ’ .The sigmoid sums, over a. small area/ Tin. v/ouml was
closed by sptutm Although the pa&eat fait well after opemtiop;
freedom from bimdaebea, she had an kTOgrjlar temperature, MraO^ally to
noreniU oh the. seventh day after the oberatioiv. On the eighth • 4i|iy : ' ; -lihoi^ was
sudden pyrexia of 104 P. wifch sottiQ resfctej?nesft and a r.endeocyvto dco^ine^s.
Pyresda was maintained till the tenth day, when n. rigor oecmreil. 1 then re>
ojiened fcbo wound, exposing the sinus freely to tip of mastoid.- The lower part
Tod: Septic Infection of the Lateral Sinus
oi .this sinus ’was ihickenod and white; the upper ..part appeared norm*). The
•internal jug-alar wus then exposed in the neck V it was found collapsed above
the cowman facial vein. The common facia] vein vr&s ligated anil separated
from the jugular vein, tbe upper portion of the jugular- vein being dissected up
and brought into the neck v ‘The lateral sinus vj as freely incised and a ifcege:
septic clot removed from the lower part of the sinus as far as the bulb. Them
was free bleeding from the posterior portion of the sinus after tbo gauze was
•removed, this was arrested by re-plugging. An attempt made to ayyinge
through the towtfr .part -of the sinus ink) the neck failed* Twenty-four hours
hpetatioft temperature became; normal > tb#re was then varying pyrexia
ha a few days, afterwards the fcchipemture. became and remained norma]..
Uninfcmupiod reom^y.
*
& this case' the second .operation should not have been delayed so
long. The occurrence of sudden pyrexia a week after the operation
should have suggested infection of the lateral sinus.
GjURt 1 (Case l)
Cane IL —T. P r , male, aged -33. Operation- iiKiff. He had suffered from
tjhle-supphmtion with kitenuittepb attacks ol headaches ok the
^ffeoted side for several years. There was marked.middle-ear deafness, mxl
the tympanic cavity was filled with granulations. The complete mastoid
"operation 1 .wa$ performed. The mastoid process was hard and sclerosed. The
sinus wall was grazed at the ” knee r ’ by the chisel. Them was no bleeding.
The 'porfte'rita: wound *vaA closed by sutures and the meatus lightly packed. The
wound waMlreS«ed on the third day. On the fifth day after the operation there
was sudden pyrexia with rise of' temperature to : 102*6' V ' F. The wound was
redressed, and Apparently healthy The pyrexia subsided, texnper^tur^
Section of Otology
65
becoming normal on the ninth day. The stitches were then removed, as the
posterior wound was completely healed. There was a rigor on the morning of
the tenth day, with pyrexia of 103° F. The mastoid wound was re-opened, and
the lateral sinus freely exposed. There were yellow granulations over the site
of the injury. The sinus was obliterated above and below by pledgets of gauze
inserted between the bone and sinus wall. The intervening portion was slit
open and the clot removed. As the clot extended towards the bulb, the internal
jugular and common facial veins were ligated and severed between ligatures,
the upper portion of the jugular vein being dissected up and brought into the
neck. The patient made a complete recovery.
In this case I consider the treatment was correct, as the pyrexia
on the fifth day subsided after the wound was dressed, and the wound
appeared healthy.
Chart II (Case II).
Case III .—M. H., female, aged 19. Operation 1909 (by house surgeon).
She had had chronic otorrhoea since childhood. Complete mastoid operation
was performed. The sinus was exposed over small area and found to be
healthy. The temperature was normal for eight days after the operation, when
there was pyrexia of 103° F. with rigor. On the ninth day I operated again.
As the patient seemed very ill and to be suffering from definite septic
absorption, I first ligated the internal jugular vein, bringing the upper part
into the neck wound. After freely exposing the lateral sinus a perforation
of its wall was found where it had originally been exposed at the first
operation. A large septic clot was removed. The superior petrosal sinus also
seemed thrombosed as no bleeding took place at this point after plugging the
sinus above and below. Septic symptoms continued with rigors. Three days
later there was oedema of the right eyelid with exophthalmos, the left eye
66 Tod: Septic Infection of the Lateral Sinus
being similarly affected the next day. Death from pyaemia took place four
days later. The autopsy showed septic thrombosis of the circular and both
cavernous sinuses, extending into both ophthalmic veins.
Infection of the superior petrosal sinus fortunately is a very rare
occurrence, but almost certainly fatal.
Case IV. —F. J. G., male, age 24. Operation 1912. He had had chronic
otorrhcea of the right ear since infancy. Six years previously ossiculectomy
had been performed by another aurist, and after that otorrhoea ceased for four
years. There was no pain, but nearly complete deafness. The tympanic
cavity was filled with granulations. The complete mastoid operation was
performed. The bone was very sclerosed. The sinus was very far forward and
was exposed at the first blow of the chisel, the outer wall being punctured,
with slight oozing of blood which was stopped by temporary compression. The
posterior wound was closed. The patient did well till the eighth day, when
there was pyrexia of 100° F. with headaches. On the ninth day there was
pyrexia of 102°F. On the house surgeon removing the gauze packing from
the meatus there was brisk haemorrhage. An anaesthetic was immediately
given by another house surgeon who was present in the ward. The posterior
wound was opened tip; the haemorrhage was found to be coming from the
lateral sinus at the point exposed at the previous operation. The haemorrhage
was arrested by firmly packing with gauze. Next day (the tenth) there was
pyrexia of 103*6° F., with pulse-rate of 128. Under a general anaesthetic I
re-opened the wound and freely exposed the sinus, obliterating it by inserting
gauze plugs between the bone and sinus wall above and below the area
Section of Otology
67
originally plugged. The sinus was found to be thrombosed, the central
portion of the clot being already purulent. The gauze plug was removed and
the clot curetted out until brisk haemorrhage occurred at both points, fresh
plugging then being inserted. Next day the temperature was subnormal, but
the following evening there were several rigors with temperature of 103*6° F.
The patient looked ill but made no complaint of pain. The next morning
(the third day after the previous operation) a general anaesthetic was given
again and the jugular vein ligated, the upper portion being brought out into
the neck wound. The lateral sinus was again examined. On removing the
posterior plug there was brisk haemorrhage, which was arrested by re-plugging.
The superior petrosal sinus also bled freely until the haemorrhage was arrested
by plugging. A firm clot was scraped out of the jugular bulb. For some days
after the operation there was slight irregular pyrexia, the mastoid wound
being very foul, and the wound in the neck breaking down. Eventually there
was complete recovery. Blood cultures taken from a vein in the arm at the
time of the second operation grew streptococci in twenty-four hours. Vaccines
prepared from these cultures were given by subcutaneous injection on the
third, sixth, thirteenth, twentieth and twenty-seventh days after the operation.
In this case the sinus should have been freely exposed and obliterated
over the affected area at the time the haemorrhage was arrested. As
this was not done I should have tied the jugular vein when I operated
on the following day.
FEB. 1912. MAR;
Case F—-J. H., male, aged 35. Operation 1914. He had suffered from
chronic otorrhoea of the right ear for fourteen years, which became worse
during the three months preceding the operation, and was accompanied by
frequent headaches. Deafness was marked. On examination the ear was
68
Tod: Septic Infection of the Lateral Sinus
found to be filled with granulations. There was no swelling nor oedema, but
tenderness on pressure over the mastoid region. The complete mastoid
operation was performed. The bone was sclerosed, and the antrum filled with
inspissated pus and epithelial debris. The sinus was very superficial and was
exposed over a small area at the “ knee.” The outer wall of the sinus was
grazed; there was no bleeding. The cavity was irrigated with hydrogen
peroxide solution before packing, and the wound closed with two stitches.
The patient did well till the eighth day, when there was pyrexia of 102° F.
with increasing pulse-irate. On seeing the patient on the morning of the eighth
day after operation, as he complained of headache and general malaise, and as
there was increasing pyrexia, I decided to explore the sinus that evening. A
few hours later he had a rigor. On operating the same evening I found a
definite parietal thrombus at the eite of injury. After obliterating the sinus
behind and below this region, I excised the affected part and sent it for
microscopic examination, a section of which is now shown, together with a
drawing made from the specimen in which chains of streptococci can be seen.
This patient made an excellent recovery.
The interesting points of this case are: (1) The diagnosis of septic
infection of the lateral sinus from the occurrence of the sudden pyrexia
nine days after the operation. (2) The limited‘extent of the infected
area in the sinus wall.
MAY 1914
Case VI. —D. T., female, aged 22. Operation 1917. The complete mastoid
operation was performed for chronic middle-ear suppuration associated with
intermittent attacks of headaches. The middle ear was found to be filled with
granulations. The mastoid was sclerosed. The sigmoid sinus was punctured,
with slight oozing of blood as it lay superficial to the antrum. Within two
Section of Otology
69
days after the operation there was irregular pyrexia, varying from 99 F. to
102° F. On the ninth day after the operation, whilst the house surgeon was
dressing the wound, there was considerable haemorrhage, which was arrested
by packing through the meatal wall. There were Ho rigors. Next day the
wound was re-opened. On removing the packing there was profuse bleeding
from the lateral sinus. More bone was removed in order to expose the sinus
wall freely on each side. A gauze plug was then inserted as far back as
possible and also down towards the jugular bulb between the bone and the
sinus wall, the original median plug being then removed. As the pyrexia
continued, an anaesthetic was given again four days later (the fourteenth day
after the first operation). A purulent clot was found in the lower part of the
lateral sinus beyond the lower plug of gauze. The jugular vein was then
ligated, and its upper portion brought out into the neck wound. The pos¬
terior plug behind the affected area was then removed, the sinus wall being
slit up still further, and the clot removed until free bleeding took place. A
fresh plug was then inserted. Three days later pyrexia recurred, denoting a
septicaemia of a severe type with acute synovitis of several joints and pyaemic
abscesses of the buttocks and one shoulder. The patient eventually recovered,
after a prolonged illness.
JAN. 1917.
As in Case IV, haemorrhage from the sinus on the ninth day should
have been a sufficient indication for the free exposure of the sinus and
for a more thorough operation. As this was not done, when I opened
up the wound next day I should have ligated the jugular vein in addition
to removing the clot from the sinus.
70
Tod: Septic Infection of the Lateral Sinus
The following case, although it cannot be grouped amongst those
already mentioned, demonstrates how easy it is for the lateral sinus
to become infected :—
Case VII .—F. S., male, aged 8. Operation 1907. The complete mastoid
operation of the right ear was performed for chronic middle-ear suppuration.
When the mastoid cavity, which was filled with cholesteatomatous masses, was
curetted out the sigmoid sinus was found to be already exposed over a small
area. The posterior wound was only closed in its upper and lower angles, and
the cavity lightly packed with gauze. On the third day there was a rigor with
temperature of 106° F. When the house surgeon dressed the wound there
was slight bleeding, which was arrested by plugging. The temperature
remained irregular, from 99° F. to 101° F. until the eighth day, when there was
a further rigor. The next day there was pain in the right hip on movement.
On the following day (the tenth after operation) I again saw the boy and
diagnosed lateral sinus thrombosis. The sinus was freely exposed, obliterated
JUNE 1907. JULY
above and below, and incised. No definite thrombus was found, but localized
thickening of the wall at the “ knee ” of the sinus. The temperature remained
normal with an occasional rise to 100° F. for about four weeks and then it
became normal. Eleven days after the second operation there was facial
paralysis, and some oedema of the right optic disk. Two w T eeks later the
facial paralysis had become less marked. About this date there were attacks
of vomiting, there was marked wasting, and a tendency to fretfulness. A week
later there was paresis of the sixth nerve on the left side which gradually
became complete, followed by paresis of the sixth nerve on the right side with
slight optic neuritis. Eventually the patient made a good recovery.
Section- of Otology 71 .
The diagnosis seemed to bt? » fion-^nppnrative basic meningitis, the
actual cause of Dibich vtae tiukriovvn, but presujhAfcly: 'tlis? res^nlt of
infection of the latetal,sinus, it! thjfi cpu*# also !,b<? fcm«K should have
been eel y sjfr^osydon theiluviTday after' the oectjrs^flce of the vigor
am? hiemorvhage; ami pbiiteratod well bevonii the infec-ted area.
•
jfiastly* &no£fa&* type 1 x>£i$$se in 'wJbiqfe .tse&rmcl:;
to bo evidence that the lateml sinus injured ni the time of
operation, bu t the patient recovered in ; spite the sin a* not bmnn
suh^equently opened
On*. Vi/L—G. Hi, t'oimtks ugml StL Operation TJ07. The complete
iDastoicj oration Was performed for chronic middle-oar suppuration associated
with marked middie-ear deafness. The sinus was exposed over a small aim
during the operation and found to be apparently healt hy and uninjured. The
CruBt VIIJ (Case VI]I).
wound was closed by sutures and healed well. On the eleventh day after the
Operation there was pyrexia of 300* F* next day rising to 103 F. ; then there
ms irregul&r hypet'pyre^ of a septic type for sortie day* following Ttyere -
were m rigors. The patient complained of no definite pain, but of general
malaise. There was no vomiting, ho optic. ; oeuritisynor/^lrei' them #ny other
symptoms Suggesting an intracranial lesion. Ay the sin ns appealed healthy at
the first operation it did not seem possible that this could be fclte.'catt&s of thp
fever, but to make certsm the wound was reopened on the twentieth day alter
the first operation. More bone was removed and the sinus teely exposed
Its walls were found to he healthy except for a small area covered -with
granulations at the site where the sinus was originally exposed, and i t was
tw.«h, compressible. For these reasons, nothing was done, and the wound
' was partially closed. Healing again took place !*mt the hvpevpyimia eontimmd.
the .patient becoming worse. Three days later there were septic pnemnuum
and pleurbry, followed late) on hy cystitis* luematmda, synovitis of both
72 Tod: Septic Infection of the Lateral Sinus
knee-joints and one ankle-joint, and subsequently abscesses of the buttocks—
an obvious case of septicaemia. Cultures of the blood showed the presence of
streptococci, and vaccines were prepared. The first dose was given on the
twenty-eighth day after the first operation and subsequently they were given
at intervals of five or six days, and they appeared to have a beneficial effect.
Ultimately the condition improved, the patient being practically free from the
septicaemic symptoms, and the temperature again became normal about the
ninth week after the original operation.
I have no doubt that the cause of the septicaemia was infection of
the sinus wall at the time of the original operation and that if I had
opened up the sinus as soon as the hyperpyrexia occurred—that is on
the twelfth day after the operation—the onset of septicaemia would
have been prevented. It is interesting to note that throughout all this
long period no rigors took place.
Certain points become evident from a general consideration of these
cases:—
(1) Whenever the lateral sinus is exposed during the mastoid
operation careful inspection should be made at the end of the operation
to see if it has been injured in the slightest degree.
(2) If the sinus wall has been injured the wisest procedure is to
expose it freely on each side and obliterate its lumen completely by
means of gauze packing well beyond the affected area. This procedure
is indeed suggested by the fact that septic infection of the lateral sinus
does not occur in cases in which the sinus wall has been cut clean
through and its lumen at once obliterated by pressure in order to arrest
the haemorrhage. #
(3) There may be no evidence of infection of the lateral sinus until
about the tenth day after the mastoid operation has been performed,
when a sudden rigor may be the first symptom. As a rule for one or
two days previous to this there is pyrexia with increased pulse-rate.
These symptoms should be looked upon as danger signals, and if there
be no other cause for them the mastoid wound should be re-opened
and the sinus wall explored, and if necessary incised.
(4) If haemorrhage occurs from the mastoid wound a few days after
the operation it is not sufficient to arrest the haemorrhage by applying
pressure to the bleeding spot. The bone should be removed from the
sinus wall above and below the affected area, and gauze plugging
inserted between the bone and the outer wall of the sinus, the sinus
Section of Otology
73
then being slit up and explored, farther surgical treatment depending
on what is found. Haemorrhage from the sinus after the mastoid
operation means that the wall has been injured or that it was already
infected at the time of the operation. Haemorrhage associated with
pyrexia or a rigor always means septic infection of the lateral sinus
and indicates an immediate and thorough operation.
' (5)‘ The internal jugular vein should always be lighted in cases of
septic infection of the sinus in which haemorrhage has occurred, as in
these cases the thrombus is probably diffuse, ftnd the walls of the
sinus already infected even to a greater extent than is evident to the
naked eye.
(6) Intermittent pyrexia of a septic type without rigors, beginning
after an interval of about ten days after the mastoid operation, should
always suggest blood infection through the lateral sinus, and warrants
exposure of the sinus and probably its obliteration after exploration.
This condition must not be confused with the intermittent pyrexia
which may occur for some days after an operation for acute inflam¬
mation of the mastoid, the result of scarlet fever or streptococcal
infection, which is probably due to toxic absorption from the affected
wound surface itself, and which usually subsides without further surgical
interference.
DISCUSSION.
Dr. Dan McKenzie : I heard Mr. Tod’s original remarks on this subject in
1914,’ and since then I have had three cases of lateral sinus thrombosis occurring
on the tenth day following exposure of it at operation : I have seen the bleeding,
and had practically the same experience as his. In one case the opening in the
sinus wall through the bone was very small and yet bleeding took place, and
'I am certain the sinus was not injured. I expect the pulsation of the sinus
wall led to it being frayed against the sharp bony edge of the opening, and
there were bursts of blood when the dressing was being changed. One case
which I lost had both lateral sinuses involved, and I did not know which
one to go for when there was bleeding: I decided to go for the ear which
was most acutely involved, but I was wrong. I then went to the other side,
but the bleeding was so tremendous that it was impossible for me to control
it and explore the sinus. The other cases we had we brought round. I re¬
member another curious instance in which, in a cortical mastoid operation,
I had made a transverse incision in addition to the post-aural incision, and in
doing so cut through a large mastoid emissary vein. There was free bleeding,
1 Discussion on Mr. Hugh Jones’s paper on “ Septic Invasion of Lateral Sinuses ” (Clinical
Congress of Surgeons of North America), Brit. Med. Joum., 1914, ii, pp. 403, 408.
74
Tod: Septic Infection of the Lateral Sinus
and I had to pack the emissary vein. Ten days, later there were signs of
lateral sinus thrombosis, and I re-opened, exposing the sinus and its tributary
vein and took out a coagulum from the latter. The patient promptly re¬
covered. I agree with operating early, and, where you know that exposure
of the lateral sinus is likely to lead to thrombosis, if there is a rise of tem¬
perature you should open it up and inspect it without delaying more than
forty-eight hours.
Dr. H. J. Banks-Davis : Considering the frequency with which the lateral
sinus is exposed at operations, it is extraordinary how rarely it gets infected :
in fact it would seem to be difficult to injure it even if one wanted to. I once
snipped a piece .of the sinus out with fine bone forceps when operating on an
extensive cerebral abscess where the sinus was adherent to the bone which was
being removed. The haemorrhage was tremendous, but I was able to plug it
and to continue. I gave instructions not to take the plug out under three days,
but it was removed in forty-eight hours, and the haemorrhage recurred. As
long as it was plugged the patient remained safe. It was left in four days, next,
but on removal there was again haemorrhage. The patient lived a couple of
months afterwards, and then died of basal 'meningitis. I think the plugs put
in between bone and lateral sinus are liable to become septic unless frequently
changed. How long does Mr. Tod retain his plugs ?
• »
Mr. Stuart-Low : In the course of numerous operations, I have certainly
encountered many cases such as Mr. Tod enumerates, but I have not found
that wounding the lateral sinus has added to the dangers of the operation,
especially if my asepsis has been efficient. If one is dealing with a virulent
infection to start with, such as a streptococcic infection, and has fortified the
patient by having used a vaccine before operation and the aseptic measures at
the time of operation are sound, no great risk is run in wounding the sinus,
and this shows the importance of knowing the infective organisms before
operating. If the sinus has been wounded, and it bleeds freely, this is
advantageous, as it washes away the bacilli. It is well, therefore, to let the
bleeding go on freely for a few seconds with this object in view. I avoid
plugging the sinus in such cases, simply laying the gauze plug on the injured
vessel, wait and apply pressure, and then proceed wfth the operation with this
gauze held in position; this is left there as part of the dressing afterwards.
Should but little or no bleeding occur on wounding the sinus, more serious
consequences may follow, and it is best in such a case to slit up the sinus,
freely scoop out any clot discovered, let free bleeding go on for a few seconds,
and plug firmly both ends of the open sinus.
Mr. W. M. Mollison : Mr. Tod’s cases are very interesting, and that
kind of case is rare. He does not refer to cases of bleeding from the sinus in
acute conditions, but to a sequel to damage during straightforward radical
Section of Otology
75
mastoid operations. They are not to. be classed with those cases that Mr.
Stuart-Low has mentioned. I have met with only one case, and that came
on in the same way as Mr. Tod has told .us, ten days after the operation. The
patient left the hospital apparently well, and within twenty-four hours she
returned with typical symptoms of lateral sinus thrombosis, and in spite of
the fact that operation was at once performed and the jugular vein ligatured^
she died.
Mr. Charles Heath : I have had only one such case. It was an acute
one. I was removing the mastoid bone with a gouge and mallet when a large
piece of softened bone broke away and the rough edge of it damaged the sinus:
The haemorrhage was pretty severe, but I, plugged in the way mentioned by
Mr. Tod (that is, I made the two sides of the sinus come together), and left
the plug in for two or three days. Then I removed it; there was no haemorrhage,
and I inserted another. The case did well on removing the second plug.
The President : I suppose I must have wounded the surface of the
lateral sinus many times. One sees the sinus frequently of course, but only
three times have I seen bleeding from the sinus as the result of an accident
during the operation. None of those cases became septic. On the other hand,
in one case, during the curetting of the floor of the tympanum in the course of
the radical mastoid operation, removal of the granulations resulted in septic
thrombosis of the bulb of the jugular vein, though there was no excessive
bleeding. The characteristic symptoms set in about the ninth or tenth day :
the patient was up and about, and was shortly to be made an out-patient.
Fortunately, recognizing that the septic thrombus was in the bulb, I tied the
vein at the first operation and the patient recovered. As Mr. Mollison has
said, injury to the lateral sinus seems seldom to result in sepsis—presumably
because the sinus is freely exposed and the drainage is good. The last
case of wounding which happened in my practice was acute influenzal
apical abscess. There was a tremendous gush of blood, and I put a gauze
plug covered with B.I.P. over the bleeding spot, but not into the sinus.
A week afterwards the plug came out easily, without any haemorrhage. There
had been no rise of temperature nor other symptom of thrombosis.
Mr. HUNTER Tod (in reply) : I agree with those who say this is a
rare accident, but I thought it worth while to give my clinical experience ;
especially to emphasize the point that infection of the lateral sinus after
the radical mastoid operation may give rise to no symptoms for about ten
days, and that this fact should be recognized in order that on the occur¬
rence of such symptoms further operation should at once be undertaken.
As I have already stated, I have only had four such cases during a period
of eighteen years on the staff of the London Hospital, a proportion of less
than one in two hundred cases operated on. With regard to Mr. Stuart-Low’s
remark as to sepsis, I am of opinion that the sinus is infected at the time
76
Tod: Septic Infection of the Lateral Sinus
of the primary operation when the field of operation—a septic cavity—is
swarming with micro-organisms. The ten-day interval corresponds approxi¬
mately with the period of time at which embolism occurs after child-birth or
after an operation on the appendix, or even on the knee-joint, perhaps with an
immediate fatal result. This interval apparently is the time taken for the clot
to become septic and to disintegrate, although I have never seen the fact
stated. In my opinion all such cases are the result of septic infection of a
vein. In answer to Dr. Banks-Davis, I inserted a gauze plug between the
wall of the sinus and the bone so as to obliterate the sinus. I leave the plug
in three days and then take it out. If bleeding occurs I insert another plug of
gauze and leave it a further three days, and repeat until there is no further
haemorrhage on removal of the gauze—in some cases a matter of two weeks
or longer. During the changing of the gauze plug the patient should keep as
quiet as possible and fivoid coughing.
Section of ©toloflp.
President — Mr. Hugh E. Jones.
Particulars of a Case of Vertigo; Labyrinthotomy; Oblitera¬
tion of the Semicircular Canals and Part of Cochlea
by Bone . 1
By Richard Lake, F.R.C.S.
A. B., sailor, aged 23. This patient was shown at the conjoint
meeting of the Sections of Ophthalmology, Neurology, and Otology, in
order to show how in some cases one was absolutely unable to demon¬
strate nystagmus. He was admitted under me at the Seamen’s
Hospital on account of his severe vertigo. He was absolutely deaf
on the right side and extremely hard of hearing on the left. His
giddy attacks were very frequent and very pronounced, in fact, he
had fallen overboard four times. .
This patient was operated upon with a view to opening up and
destroying the posterior half of his labyrinth” on the right side. I
was absolutely unable to find the external canal, and cut backwards
trying to find the posterior, which also I failed to find, but after
a considerable amount of trouble was able to locate the vestibule
as quite an insignificant cavity much .smaller than usual. As the
patient suffered very severely from tinnitus, I attempted then to clear
out the cochlea, but was quite unable to remove the front wall, the
whole cochlea being apparently one solid mass of bone, so much so that
all I did after having cut away for some lehgth of time at the cochlea
was to drive the whole mass into the internal auditory meatus, setting
up a free flow of cerebro-spinal fluid. The patient was apparently very
JU —16
1 At a meeting of the Section, held March 21, 1919.
78 Stuart-Low: Epithelioma of Left Auricle after Operation
much benefited as far as his vertigo was concerned, but the case is
reported as an example of the obliteration of the semicircular canals,
and at any rate part of the cochlea by bone.
This case was withdrawn at the time that I had it down for dis¬
cussion (May 15, 1914), as the patient had suddenly become very ill.
Unfortunately, the case terminated fatally. I had intended bringing it
forward with a complete pathological report. The war so upset every¬
thing, however, practically everybody connected with the hospital
leaving, that I have been unable to find the temporal bones, which
1 know were saved. 1 have at last given up all hope of finding
them, and am therefore bringing forward the case without any patho¬
logical report. As far as I can make out, the patient died purely
from neglect of antiseptic precautions. I must say I do not think that
I can exculpate myself from a considerable amount of responsibility,
as I was unable to get down to the hospital as often as I should have
done to look after the case.
Epithelioma of the Left Auricle after Operation (Specimen
of Ear removed shown).
By W. Stuart-Low, F.R.C.S.
J. B., A man, aged 45, a warehouseman by trade, was shown at the
November meeting, 1918, the case being recognized as a very rare con¬
dition—viz., malignant disease supervening on a surface affected for
many years with lupus erythematosus.
Radical removal of the ear, including the entire cartilaginous and
membranous auditory meatus, was performed on November 25 last.
The method of operation was as follows : A long incision was carried
down the length of the retro-auricular groove and extended upwards
over the temporal region for 3 in., and downwards over the parotid
region for the same distance. Another incision, almost at right angles,
but sloping downwards somewhat, was carried backwards for 3 in. from
the middle of the first incision. Two flaps of skin were now raised
and turned upwards and downwards, and the glandular structures under¬
neath thoroughly cleared out above, behind, and below the ear, the
exposed surfaces being thep thoroughly scraped with a sharp spoon and
a solution of 40 gr. to the ounce of chloride of zinc, well rubbed over
the exposed tissues and bone. This very effectively checked the free
Section of Otology
79
bleeding which took place, and was also used with the object of destroy¬
ing stray cancer dells, and setting up a healthy inflammatory action.
The entire meatus—cartilaginous and membranous—was then forcibly
evulsed, and the walls of the meatus scraped, and the solution of zinc
applied. The skin in front of the ear was then reflected by an incision
from the attachment of the auricle above to that of the lobule below.
This anterior flap of skin being raised the pre-auricular glands were
removed, and the surface scraped, and the same solution applied. The
flaps were stitched in position, a thick rubber tube being fixed in the
meatus. The parts have healed perfectly, and it is interesting to notice
that the scaliness of the skin is now much less, as perhaps the lotion
so freely and frequently used in the after-treatment—viz., liq. hydrarg.
perchlor. 1-2,000—has helped to restrain it and improve the tone of the
tissues by lessening the latent tuberculous infection. The blending of
two dyscrasi®, tuberculosis and cancer, in the same situation, is hot the
least interesting point of this case.
9
A Female with Fibroma of the Auricle at the Entrance of
the Meatus.
By W. Stuart-Low, F.R.C.S.
Present for years—very slow growth, and only recently given
trouble.
Vertigo: (?) Labyrinthine or Cerebellar.
By John F. O’Malley, F.R.C.S.
Lance-Corporal W. R., aged 35. Knocked down by a bicycle
in December, 1914. “ Fracture of the skull ” was then diagnosed.
He was seven days unconscious and five weeks ^confined to bed. He
complains of the following symptoms since:—
(1) Noises in the left ear, by day and night (like steam escaping).
(2) Giddiness. More unsteady in the dark than by daylight, in the
morning and the evening than other parts of the day. When walking,
he tends to go to the left and “ bumps ” into anybody who is on this
side of him. He also falls off the kerbstone to the left.
Examination. —(1) Membranes intact, with good lustre, and no lesion
seen.
80 Wrightson and Keith: New Theory of Hearing
(2) Nystagmus : on looking to the extreme left half a dozen flickers
can be elicited.
(3) Equilibrium, (a) Romberg’s test. Standing erect, eyes shut,
unsteady, but no tendency to fall in any definite direction. ( b) Babinski-
Weil test.
February 20,1919: He went very definitely to right and progressed
in this direction each time he crossed the room. Treated for fourteen
days with 3-minim doses of liq. strychnini hydrochlor. and 10-minim
doses of acid, hydrobrom. dil., thrice daily. This was discontinued, as he
complained that it made his heart palpitate.
March 6, 1919 : Gait unsteady, swaying to left, but did not move
round from direct line between two points.
(4) Caloric test: Cold, at tap temperature ; four pints, reservoir 2 ft.
above ear. (a) Nystagmus: no perceptible alteration. ( b ) Romberg :
same, (c) Babinski-Weil: slightly more unsteady ; sways to right and
left, but decidedly more to the left; says he feels more unsteady.
(5) Hearing: Has made no complaint of deafness. Right ear, good ;
left ear, hears forced whisper at 10 to 12 ft.
(6) X-ray report: “ Small fracture, above and behind left mastoid
air cells, about half an inch long.” It cannot be seen extending into
petrous portion of temporal bone.
Are the present symptoms labyrinthine or cerebellar ?
Exhibitor will be grateful for suggestions as to treatment.
Demonstration on a New Theory of Hearing.
By Sir Thomas Wrightson, Bt., and Professor Arthur Keith,
M.D., F.R.S.
Professor Arthur Keith, M.D., F.R.S.
The theory is Sir Thomas Wrightson’s; I am merely responsible for
the application of the theory to the anatomical details of the inner ear.
The new theory was outlined by Sir Thomas Wrightscfn in a presidential
address given to the Cleveland Institution of Engineers in 1876, but it
was quite over-shadowed by the glamour attached to the theory and
name of Helmholtz. According to the Helmholtzian theory the internal
ear is a sort of microscopic piano, furnished with resonating strings,
almost ultra-microscopic in size, and some 16,000 in number. Each
Section of Otology
81
string or set of strings is supposed to pass into a state of vibration when
its sympathetic note enters the ear. Each .string or set of strings is
supposed to have a corresponding nerve-fibre, and we must suppose
that these nerve-fibres lead ultimately to a central nerve-cell station
or exchange, where 16,000 nerve-cells receive messages from their
corresponding ear strings. However satisfactory from the point of
view of a physicist, Helmholtz’s theory of the ear from the point of
view of a psychologist, physiologist, or an anatomist, is an impossibility.
The strings are there but they are so placed and so conditioned that the
one thing they cannot do is to vibrate; Nature has taken the utmost
care to render individual vibration an impossibility. In Sir Thomas
Wrightson’s theory the ear acts as a single machine; it is the most
minute and most delicately adjusted spring balance ever evolved or
invented—one designed not only to weigh the simplest and slightest
sound wave but also the most complex and voluminous. The ear not
only weighs every fluctuation in pressure but automatically registers and
records the minutest variation, and through the hair-cells or semaphores
which form an intrinsic part of the machine the system of messages or
semaphoric signals transmitted from the ear may be compared to the
dot and dash system of the Morse code ; the whole of the organ of
Corti is involved in the production of this code of signals ; all the fibres
of the auditory nerve are concerned in its transmission from the ear to
the brain. It is a legitimate inference to suppose that the time signals
carried on this code can be deciphered and be sorted out at nerve
synapses in the central nervous system. Thus Sir Thomas Wrightson’s
theory brings hearing into line with smell, taste, sight and touch,
whereas Helmholtz’s theory, by presupposing that each fibre in the
auditory nerve has its special function, breaks the most elementary law
we know regarding the nature of nerve constitution.
Recent advances in our knowledge of the evolution of the internal
ear throw a most definite light on the mechanism of the cochlea and
organ of Corti. The ear has been evolved from the balancing apparatus
of the primitive labyrinth ; the principle which has been adopted by
Nature in working out the organ of hearing is merely an extension of
the principle used in the primitive labyrinth. In the lowest fishes a
closed vesicle on each side of the head, filled with fluid, serves as the
central part of the labyrinth; on its floor is a nest or island of hair-
cells. On the hairs is balanced an otolith; nerve fibrils commence in
or round the hair-cells. So long as -a fish swims on an even keel the
ciliary semaphoric system is at rest; but if it heels over, ever so slightly.
82 Wrightson and Keith : New Theory oj Hearing
then gravity comes into play ; the otolith as it answers to gravity bends
the hairlets right or left, as. the case may be, and on bending the hairlets
sets up certain tensions or changes in the living cells to which they are
attached, and these changes are transmitted as signals or impulses along
the attached nerves. In this simple semaphoric apparatus there are
four elements : (1) the otolith or titillator ; (2) the hairlet or lever on
which the titillator acts; (3) the sense-cell on which the lever acts;
(4) the nerve-fibres which are acted upon or stimulated by the sense-
cells. In the sense organs or signal stations of the semicircular canals
which have been evolved for the registration of body-movements we
find the same four elements. The *cupola represents the titillator,
but it is no longer acted upon by gravity but by mass move¬
ments of fluid set up in the canals during movements of the head.
Barany was the first to show that movement of the fluid in one
direction gave one set of signals; movement in the reverse direction
another and reverse set of signals. With the evolution of the cochlea
and the organ of hearing the same four elements were used. The
titillator is the tectorial membrane; the hairlets or levers, the sense-
cells and nerves are as before, save that the sense-cells are now set in
an elastic scaffolding of fine elastic rods and fibres. But one novel
change has been introduced; in the balancing apparatus of the vestibule
the sense cells are fixed; the titillator is movable. In the cochlea Nature
has. reversed the arrangement and set the sense-cells on a movable
membrane—the basilar membrane, which responds to every displace¬
ment of fluid set up by waves of sound impinging on the inner ear.
On the other hand, the titillator is no longer free but is tethered to the
containing wall. Thus in the utricular system the hairlets or levers
are worked by gravity; in the canalicular system, mass displacements of
fluid set up by movements of the head bend the levers and give rise to
signals ; in the cochlea the force employed in working the lever system
is the minute displacements set up by sound waves, and the levers are
bent by the field of hair cells working against the titillator or tectorial
membrane.
The essential modifications required to make the otic vesicle into an
organ of hearing are (1) a closed vesicle, filled with fluid and every¬
where surrounded by bone of a peculiarly dense nature—all except at
one area—where a minute window—the fenestra rotunda—is established.
That window is essential, without it there can be no mass displacement
of the fluid and no hearing as sound waves sweep through the bony
walls of the vesicle. In the passage leading to that window is placed
83
Section of Otology
the organ of Corti—the apparatus . for recording the displacements of
fluid set up by the bone-conducted sound waves. To make the ear a
more sensitive machine another window is established in the bony wall
of the vesicle—the fenestra ovalis, into which is fixed a movable piston,
the stapes. By a bent lever, formed by the ossicles of the ear, this
piston is yoked to.the membrana tympani, and thus the ear is rendered
infinitely more sensitive to sound impulses carried by the air. Closure
of the fenestra ovalis, by fixation of the stapes, renders the ear more
sensitive to bone-conducted waves; closure of the fenestra rotunda
produces complete, deafness; these facts cannot be explained on the
hypothesis put forward by Helmholtz, but find a complete answer
from the theory put forward by Sir Thomas Wrightson.
Four phases are to be recognized in the completed movement of the
lever or hairlet of a sense-cell. Its upright or vertical position may be
regarded as one of rest—its zero position. In the first phase of a
complete movement the hairlet bends towards one side—towards the
right we shall suppose; in the second it returns to its upright or zero
position; in the third it bends towards the left; in the fourth it again
returns to its starting or zero point. It is clear that different con¬
ditions of tensions and pressures will be set up within the hair cell
in each of these four phases, and each phase we may postulate gives
rise to a nerve impulse or signal; the signals set up will vary with
the duration and force of each hairlet movement. In each sound wave
Sir Thomas Wrightson recognizes four corresponding phases: two of
these lie in the part of the wave where the air particles are being con¬
densed—the part in which there is a plus pressure; two of them lie
in the part where the air particles are being rarefied—where there is a
minus pressure. In phase I the plus pressure is rising; in phase II
the plus pressure is falling; in phase III the minus pressure is
increasing; in phase IV the minus pressure is decreasing.
Sir Thomas Wrightson’s original discovery, announced in 1876,
was the recognition of the fact that, if it could be supposed that each
phase of a sound wave did give rise to an effective stimulus in the ear,
then th§ brain was supplied, through the ear, with a sufficiency of data
to give a complete analysis of the most complex sound. Helmholtz had
supposed that sush an analysis could be accomplished only on the
principle of resonance; Sir Thomas Wrightson showed that there was
an alternative method.
That each phase of a sound wave is effective in producing a dis¬
tinctive movement of the luditory hairlets was a later discovery, but
84 Wrightson and Keith: New Theory of Hearing
formed a very essential part of Sir Thomas Wrightson’s theory. It
was a sequel to a neglected discovery of Sir William Bowman’s, made
somewhere about the year 1846, that the basilar membrane is made
up of two parts—a striate zone and a hyaline zone; the hyaline zone
resembles the capsule of the lens in structure and in staining reaction,
and must be regarded as elastic in nature. Sir Thomas Wrightson
has demonstrated that the displacements which sound waves set up
in the fluids within the ear act against the elastic resistance of the
basilar membrane, and that thus, each of the four phases of a sound
wave, which he had originally postulated on theoretical grounds, do
thereby become effective in producing a separate and distinctive move¬
ment of the hairlets. In my opinion the various parts of the cochlea,
of the organ of Corti and the conformation of the various liquid passages
of the ear, which were left unaccounted for on Helmholtz’s theory,
now receive a satisfactory explanation. I have no doubt that when
physiologists, psychologists, and aural surgeons have mastered the
details of the new theory they will find themselves provided with clues
to phenomena which were formerly inexplicable.
Sir Thomas Wrightson, Bt.
From Professor Keith’s remarks no idea can be gathered how much
is owing to him in the presentation of this theory of hearing. As a
distinguished anatomist who understands every detail of the parts
involved he grasped the idea that if a machine was required to transmit
the varying pressures of a sound wave to the nerve terminations that
transmission must be of a dead beat character. In the cochlea this
transmission, according to the theory, is conveyed from the compara¬
tively large area of the outer drum on which the air-pressures act
through the bent levers of the ossicular chain to the smaller area of the
stapes. The stapes is about one-fifteenth the area of the drum, so that
according to a principle well known to hydraulic engineers the unit-
pressure is increased in the proportion of 1 to 15 in the cochlea, and a
further increase is effected by the leverages of the ossicles.. These
increases jn pressure imply a corresponding decrease in displacement of
the stapes.
By the laws of equilibrium in fluids, demonstrated two hundred
years ago by Pascal, we are bound to admit that every momentary
change of unit-pressure in the air-wave would be thus multiplied
considerably in the liquid of the cochlea between the stapes and the
Section of Otology
85
basilar membrane. And these varying unit-pressures are instan¬
taneously carried throughout the whole of the cochlea above the basilar
membrane. If two separate pistons are placed in a cylinder with liquid
entirely filling the space between them, pressure on the left piston will
be transmitted right through the intervening fluid and move the second
piston exactly as though a solid connexion existed between the pistons;
and this is also true, however the area of the passage between the two
pistons may vary, so long as the total space between the two pistons is
entirely occupied by fluid. We shall see that the transmission of
pressure through the cochlea is sometimes by displacement of fluid
and sometimes by the action of levers, but the effective units of work
impinging on the drum membrane are all to be accounted for in the
bending of the hairlets or nerve termination, so that a dead-beat trans¬
mission of power exists from drum to hairlet.
The basilar membrane is tapered in breadth from nil at the fenestral
end to a maximum at the helicotremal end. One-fourth of its breadth
throughout its length of 35 mm. is highly elastic while the remainder
is inelastic and rigid. The inelastic part is hinged along one of the
sloping sides of the tapered opening which forms the frame of the
whole membrane, and the elastic or subarcuate zone is hinged on the
opposite sloping side. When, therefore, the pressure comes upon the
whole surface of the membrane a triangular prism of liquid is displaced
which at each moment is exactly equal to the displacement of the
stapes. To the inner edge of the pectinate or rigid zone are attached
the inner legs of the Corti arches, and as the outer legs rest as a hinge
or pivot upon the sloping edge of the tapered aperture to which the
elastic zone is also attached the up and down motion of the membrane
causes the apex of the Corti arch to move transversely to and fro. As
the pressure and therefore the motion is nil at the fenestral end no
motion is transmitted at that point, but as the arches approach nearer
the helicotremal end of the basilar membrane, the pressure and dis¬
placement, and therefore the transverse motion of the apices of the
arches, increase to a maximum at the helicotrema. The whole of the
up and down motion of the basilar membrane is carried into the bent
levers of the Corti arches where it is once more carried through rigid
levers.
From the apex of the Corti arches the pressures pass into the
reticular membrane which carries the hairlets. The upper ends of the
hairlets penetrate the surface of the tectorius, and the to-and-fro trans¬
verse motion of the reticular membrane causes a bending of the hairlets
86 Wrightson and Keith: New Theory of Hearing
and such bending will be in proportion to the reactionary pressure at
the tip of the hairlet resting in the tectorius.
The basilar membrane being thirteen times the area of the stapes
the total pressure will, at each moment of time, be thirteen times that
on the stapes, according to Pascal’s law, but this pressure and displace¬
ment divides itself, as explained, from nil to a maximum over the whole
length of the basilar membrane, and the bending of each elastic hairlet
is the measure of the pressure between its end and its contact with the
tectorius according to its position in the whole length of the basilar
membrane. The resistance of the elastic portion of the subarcuate
zone and of the deflecting hairlets and other portions of bending solids
in the cochlea act in accordance with the laws of elastic solids as
demonstrated about two hundred years ago by Robert Hooke.
The difference between the pressure of the sine wavfe and that of
the combined Hooke resistances causes a change in the residual curves
and introduces indications of fresh impulses in the four phases of the
sine curve.
Diagrams are shown of the resultant curves of pressure in the liquid
of the cochlea and in these the time positions of the impulses are seen
to coincide not only with the well known time positions of the simple
sine wave forms but of compounded tones where the time positions of
the differential tones, the summational tones, the octaves and other
harmonies are revealed, all being confirmatory of the theory.
The residual time-pressure represented by the final liquid curve
has to reach the brain by some process. I suggest that this may be
explained if we assume a nerve current always passing through the
point where the hairlets and tectorius meet.
Professor Hughes’ great discovery of the action of the microphone
shows that where an electric current is passing through a circuit in
which a slender point of contact is subjected to the varying pressures
of a sound wave, the sound wave is transformed into an electric wave,
which after passing through a telephone wire to a receiving telephone
can then be reconverted into a sound wave. Such a condition is
perhaps worthy of the consideration of physiologists as a means of
carrying the wave form to the brain.
Section of Otology
87
DISCUSSION.
The President : One point which occurred to me is the question of bone
conduction: I am not quite clear on that point. The fact of the stapes being
absolutely fixed, and possibly the foramen rotundum also being closed, would,
I presume, convert the canal into a rigid, inelastic body, and it is difficult for
me to understand exactly how the mechanism described acts when the only
means of the conduction of the sound waves is through the bone. Are all the
waves arriving by bone conduction synchronous and do they not cause mutual
interference ?
Sir Robert Woods : I have studied the Helmholtz theory, and while one
could not help acknowleging the great weight due to so accomplished a physicist,
I confess I never had a really intelligent grasp of his theory, perhaps because,
as I think now, the theory is wrong. But it is quite otherwise with the theory
which Sir Thomas Wrightson and Professor Keith have now laid before us.
The way in which Professor Keith co-ordinated the relations between the
stimuli which are received by the auditory nerve as static stimuli, and auditory
stimuli, was very elegant. We need have no difficulty in accepting the same
kind of stimulus, that is, a purely mechanical stimulus, producing two entirely
different effects, because the question of why one is translated as a sensation
of movement, and the other as sound, is a matter for the psychologist to study.
Whether he will ever arrive at a reasonable theory on the subject is another
matter. I am not quite certain if I correctly followed Sir Thomas Wrightson
in his statement with regard to movements owing to different pressures on the
basilar membrane: I was not sure whether I was not mixing them up with
tensions, that is, reserving the word “ pressure ” strictly for what goes on in
the fluid, and “ tension ” for what goes on in the membrane. If we use those
terms indiscriminately, it leads to confusion. [Sir Thomas Wrightson :
I referred to total pressure.] With regard to bone conduction, I do not think
that need present much difficulty. I presume the President referred to those
cases of otosclerosis in which the stapes was fixed, and so forth. But if you
have got bones in a state of vibration, it must shake up the internal nervous
mechanism of the ear by agitating the intracochlear fluids, and then there
must result a sort of movement between the hair-cells of the organ of Corti
and the titillator.
Professor Keith : With regard to bone conduction, I think we obtain
therefrom a strong support for the theory of Sir Thomas Wrightson. I can
best show it to you by a diagrammatic section across the ear. In demonstrating
the evolution of the ear, I have shown you that the only opening which is
necessary for hearing is the fenestra rotunda: the fenestra ovalis is not
necessary.' In certain conditions in which the stapes gets fixed, or where there
is disease of the middle ear and the drum is perforated, pressure on the stapes
to keep it firm improves hearing. Under the Helmholtz theory you cannot get
88 Wrightson and Keith: New Theory of Hearing
an explanation of that fact, but Wrightson’s theory gives you exactly what you
want, and in this way. Supposing you have no drum, but sound waves are
passing through the petrous bone, you will have compression and rarefaction
of its contained cavity as the sound waves pass through. During compression,
the fluid displaced will find relief at the fenestra ovalis and hence never act
on the basilar membrane at all. But if you fix the stapes, all the displacement
must go towards the fenestra rotunda and must thus act on the basilar
membrane organ of Corti. If, on the other hand, the fenestra rotunda is
blocked there will be no hearing. I do not think anyone has come across
a patient who could hear with both fenestras blocked. On Helmholtz’s theory
ought we not still to be able to hear even if both ovalis and rotunda are
blocked ? I do not see why a cord should not vibrate inside a closed cavity.
Professor Albert Gray: It is common, in discussing most theories of
hearing, to speak of the labyrinth as a closed cavity, but in some animals
it is far from being such, the aqueduct of the cochlea being a wider opening
into the labyrinth than either the oval window or round window. Another
difficulty I have in accepting this theory is from the point of view of the
physiologist. Helmholtz’s theory, we know, cannot be right, but the theory
can be modified. Professor Keith objects to the difficulty of single fibres,
or one or two fibres, vibrating independently of the membrane. The whole
membrane can vibrate so long as there are maximum points of vibration.
But my difficulty with the theory is chiefly on physiological groupds, and
it is a difficulty which many have felt. The more we think of it, the more
difficult it becomes. I refer to the transmission of nerve impulses. By
Sir Thomas Wrightson’s theory, and Rutherford’s telephone theory, we are
asked to believe that nerve-fibres can transmit these sound vibrations, varying
in rate up to 30,000 or 4t),000 per second up to the brain without fusion,
at any rate in the middle parts of the scale. These vibrations have not only
to succeed one another without fusion, but they have to pass through the
ganglion spirale and through the ganglia in the medulla, then to pass on to
the cortex cerebri, where the brain cells have to analyse them. That is taking
only a simple harmonic tone. What, then, must we think of it when we come
to the analysis of two or a number of these simple tones compounded together ?
We have to have a nerve-fibre conveying these without fusion, and also
conveying impulses of which no two in succession are alike, with absolutely
exact correspondence to the sound impulses which produce them. These
impulses must pass through the cells of the ganglion, through the fourth
ventricle unchanged, and up to the cells of the cerebral cortex. And we are
not done with it even there. The impulses, when they get to the cerebral
cortex, are still compound, and they have to be resolved by the brain cells into
stimuli corresponding to simple harmonic sounds. We have no evidence that
such phenomena can occur in nerve tissue, and all the evidence that we have
points in the opposite direction. Thus, physiological experiment has shown
that the minimum time for a nerve-impulse to pass from an afferent fibre into
Section of Otology
89
a nerve-cell and out again by the efferent fibre is 0'003 second. That is to say,
that the maximum number of nerve-impulses which can pass into and out of
a ganglion cell (bipolar) is 333 per second. It may be that more recent
investigations have proved these experiments to be fallacious, but I do not
know of such. And if they are correct, then it is difficult to see how one can
accept any theory of. hearing that depends upon tone analysis in the brain.
Sir Thomas Wrightson has made his theory appeal to us by the clearness
of his explanation, but I do not think any theory we have at present will prove
quite correct, though I believe some modification of some of them will.
We do not yet know enough about the physiology of nerve conduction.
As far as the transmission of sound impulses to the tectorial membrane is
concerned, I might agree with him ; but where I should join issue, with him
would be as to the place where the analysis takes place. My inclination is to
the view that it takes place in the cochlea, not in the brain.
Mr. Waggett : The simple cochlea in the bird was a difficulty under the
Helmholtz theory. Has Sir Thomas Wrightson examined it in connexion
with his theory ?
Professor Keith : I have devoted considerable attention to the question
of the bird, and the bird’s ear gives the strongest support to Sir Thomas
Wrightson's theory : it answers all the postulates. I should like to refer also
to one or two of the important matters raised by Dr. Gray concerning the rate
of conduction of nerve stimuli. Professor Bayliss has already discussed the
matter. It astonishes me to suppose that those of us who are so accustomed
to listening over the telephone and getting all the modulations of the speaker’s
voice accurately brought through, can think that Nature could not do what
man has done successfully. What reason have we to suppose that messages
cannot come and be received by the hundred thousand ? Even on Helmholtz's
theory, where each vibration knocks the cilia against the tectorial membrane,
we must presume that 16,000 messages can pass per second along the same
fibre. If you sound a note with a vibration frequency of 15,000 per second,
you must have 15,000 impulses on the resonance theory.
Mr. Sydney Scott : It is a great pleasure to hear Sir Thomas Wrightson
and Dr. Keith on their hypothesis, but aural surgeons meet with many con¬
ditions which seem to present stumbling blocks to the acceptance of this
theory even in its present form. Supposing we accept the conception of the
four phases of the sound wave which Sir Thomas Wrightson has clearly
described, and of course admit that the wave is transmitted by air in the
external auditory canal to the intact tympanic membrane, thence by the ossi¬
cular chain to the footplate of the stapes and the perilymph. What is hap¬
pening to the membrana secundaria ? Sir Thomas Wrightson and Dr. Keith
believe that the membrana secundaria moves outwards in response to the first
compression phase which causes the stapes to move inwards and conversely
when the stapes moves out in the second and third phases that the membrana
no
Wrightson and Keith : Neiv Theory of Hearing
secundaria moves inwards. Are we then to consider that the tympanic
membrane throws a sound-shadow in the tympanic chamber ? C*n we accept
the view that although the drum-head moves too and fro, there is no wave
imparted to the air in the tympanum? Personally I cannot abandon the
belief that the sound wave is transmitted simultaneously to ossicular chain
and tympanic air, and so that it acts through both fenestras of the labyrinth ;
thus there would be a double compression through the perilymph of the scala
tympani and scala vestibuli and across the endolymph to the essential structures
for the reception of the sound stimulus. I think Mr. Jenkins will agree that our
knowledge of the structure of the membrana tectoria was greatly advanced by
Hardesty’s researches. The relationship of this important structure to the
cilia of Corti’s cells is most suggestive that the essential mechanism is repre¬
sented by changes in the contact tension between these two structures, a view
which has been upheld on previous occasions. 1 But before we can accept any
new theory we really require new data. For instance, to mention one anomaly,
we know that fixation of the stapes alone will cause defective hearing but does
not prevent the essential sound stimulus when transmitted by sound waves of
sufficient energy by air and bone conduction. The whole gamut can be trans¬
mitted by bone conduction, as the monochord has shown. Moreover, I have
observed two patients who presented well-marked classical signs supposed
to be characteristic of unilateral fixation of the stapes, in whom I found the
whole ossicular chain and drum absolutely normal, in the course of an opera¬
tion in each case designed for the relief of intolerable tinnitus, an operation
which we abandoned some years ago. The stapedes were mobile, and free
from microscopic abnormality. Yet the hearing tests gave the same results as
those met with in cases of immobile stapes. I think we must give more
attention to the fenestra rotunda.
[Mr. Scott showed a photograph of a radial section of Corti’s cells,
in the human subject, which was previously illustrated in the Proceedings.*]
Sir Thomas Wrightson : The fenestra rotunda goes out with exactly
the same displacement as the other membrane goes in. In a hydraulic engine
the liquid exhaust of the engine has exactly the same cubic displacement as
the high-pressure liquid which does the work; but, the work being done, the
exhaust goes out at the reduced pressure, reduced in equivalence to the work
done. The cochlea is in fact a minute hydraulic engine, which transfers the
units of work from the air waves which fall upon the outer drum to the hairlets
at the nerve terminations.
Mr. RICHARD Lake : In all these theories I have wondered why no one
has considered the ossicular chain as an accommodating mechanism in the
conveyance of sound. We can get on well without any of the ossicular chain.
1 Arris and Gale lecture, Royal College of Surgeons, 1910.
* “Discussion on the Value and Significance of Hearing Tests,” Proceedings , 1911-12, v
(Sect. Otol.), p. 107.
Section of Otology
91
When Botey first removed the stapes from animals he found they could hear
well without it; the stapes was removed in a large number of cases by Jack,
in America, and hearing was often improved. Still, one cannot help feeling
that the ossicles are there for some purpose. If we are prepared for a sudden
sound, its occurrence causes us much less inconvenience. In listening intently
for fine distant or delicate sounds one can undoubtedly hear more distinctly;
and I believe the function of the ossicular chain is also partly for protection,
as well as partly as an accommodating mechanism. The head of the stapes is
practically hollow, with a central pin, and such arrangements are for the pre¬
vention of shock arriving at the vestibule. The drum itself is of no importance
in hearing, it is to keep the whole middle ear moist so that sound waves can
pass well through it. The stapes may be fixed in scar tissue, so that it is all
one mass, yet if one makes an artificial drum, with a little cotton wool to
which vaseline has been applied, the improvement in hearing is enormous.
Until we settle how sound waves get into the middle ear we shall not make
very much progress in the physics of hearing as applied to the cochlea.
Dr. W. Hill : Are we to understand that that very complicated apparatus,
the auditory portion of the labyrinth, is of no use as an analysing organ ? As
tar as I can understand from what Professor Keith said, what he means is,
that the labyrinth, as such, may be set aside, as taking no large part in the
function of hearing. We should be told plainly if that is what the openers
of this discussion mean. Surely the complicated cochlea is as much a
functioning apparatus in this new theory as in the Helmholtz theory ? It
seems that we might as well have had the open auditory apparatus of the
crustacean, a cavity furnished with hairs and filled with sea-water containing a
few grains of sand. I do not think there is anything inherently improbable in
the alternate condensation and rarefaction idea, but surely that does not
dispense with the complicated analysing apparatus. That is to say, I agree
with Professor Gray, that probably the elaborate mechanism in hearing such
as goes on in a highly musical person, must depend on the labyrinth. In spite
of its delicacy, it is the last part of the ear to suffer from disease. It is only
in mumps, syphilis, and a few diseases like that, that we find serious disorder
of this complicated, organ of Corti. I have long held the view expressed by
Mr. Lake, that part of the hearing function is not only conduction through
the ossicles, but aerial conduction across the tympanum to the membrana
secundaria. That seems to offer difficulties in the acceptance of any theory
advanced up to the present.
Dr. DUNDAS GRANT : I do not known whether Sir Thomas Wrightsons
theory carries us the whole length that we might wish, but his exposition of
the mechanics of the cochlea seems absolutely convincing. I do not think
there had ever b6en such a clear exposition of it until he published his views.
Something similar was published by ter Kuile in 1900, but Sir Thomas
Wrightson appears to have antedated that. How does he explain differences
92
Wrightson and Keith: New Theory of Hearing
in pitch. 1 Ter Kuile thought it depended on the distance up the cochlea to
which the waves ran. I think that is doubtful: it is difficult to understand.
And one of the difficulties one has felt in regard to Helmholtz's theory has
been that one has tried to imagine the waves running up the scala vestibuli,
round the helicotrema, and down the scala tympani: whereas a movement
must take place at the base of the cochlea long before that, with a displacement
of the membrana basilaris, which is communicated to the fluid beneath it,
there being a safety valve in the membrane of the fenestra rotunda.
Sir Thomas has explained very well the significance of the comparative areas,
of the membrana basilaris and the fenestra ovalis, and it is a most ingenious
idea that the pressure is equalized all the way up, by the basilar membrane
being wider at the part where naturally the pressure of the fluid has become
almost extinguished, namely, at the apex. I think that is a basis of truth
which will stand firm in all theories. Mr. Scott has suggested that considerable
air-pressure is exercised on the fenestra rotunda from the tympanic cavity
which should neutralize pressure from the inside of the cochlea, but I think
that pressure conveyed through such a compressible medium as air is not
comparable to that through such an incompressible medium as water.
Pressure through the fluid medium must be infinitely greater than that
through a gaseous one. Mr. Lake has spoken of splendid hearing being
retained without tympanic membrane and ossicles. If those parts are not in
excellent functioning condition, hearing is far Abetter without them, though not
so good as when they are in good condition, as probably Mr. Lake will agree.
Zimmerman pointed out how hearing is conveyed through bones, and Mr. Lake
has referred to the great value of the artificial drum. But I am convinced
that when the artificial drum is placed on the stapes a better effect is produced
than when it is placed on any other part of the labyrinthine wall, unless indeed
the round window. What its exact function is, it is difficult to say. I think
that if the plate of the stapes is mobile it takes up the vibrations and conveys
them to the stapes, but in any case the hearing is best when the artificial
drum is on the stapes. We are very much indebted to Sir Thomas Wrightson
for the light the theory sheds on hearing, so far as it goes, but, as he himself
says in his book, there is still a vast hiatus in our knowledge of the conveyance
of sound through the cochlea to the brain.
*
Mr. JENKINS .* I should like a definite statement as to whether this theory
is based upon a mass movement of the fluid in the cochlea, or not. I think
we should have that decided, because everything depends on it. I found so
much difficulty in fitting in any mass-movement theory of hearing that in 1913
I decided it was a molecular movement in the labyrinth which would form the
basis of a theory of hearing. Mr. Lake and Mr. Scott have already voiced
two or three of my objections to the present theory. One was that when the
1 1 omitted to ask Professor Keith and Sir Thomas Wrightson how we are to explain the
selective areas of degeneration in the cochlea produced in guinea-pigs by exposure to sounds
of various pitch.
Section of Otology 93
stapes is removed and there is only a thin membrane in its place, there may be
good hearing.
Mr. Stuaet-Low : One of the most important factors in the transmission
of sound waves across the conducting apparatus to the inner ear is maintenance
of a condition of plus pressure in the tympanic cavity—normally the pressure
is always plus, and this keeps the tympanic membrane taut, a most essential
thing for its aptness for appreciating the variations of pitch. When the
pressure becomes minus the drum is pressed in and retracted on the ossicles,
and middle-ear deafness begins with all its baneful consequences, such as
tinnitus, &c. This paramount plus pressure depends almost entirely on the
health of the Eustachian tube, and this largely on the mucous lining of
the tube being normal. Should the mucous lining, which is specially thick
at the lower part, become impaired and desiccated the efficient closure of
the tube becomes impossible, and under such circumstances plus pressure in
the middle ear disappears, with the result that the back door of the tympanic
cavity, so to speak, is permanently ajar, the ossicles become fixed and
motionless, and their powers of transmission lost. I believe that this impair¬
ment of these functions of the great ventilating shaft of the middle ear, which
often commences so very insidiously, is very largely the cause of that bugbear
of otology—middle-ear catarrh. Theories of hearing are very interesting, but
for practical otologists the middle ear is the battle-field where the contest
against deafness has to be fought and success won, if won' at all. Once the
inner ear is functionless nothing can be accomplished, and therefore for us its
consideration is mostly scientific and technical rather than therapeutic.
The President : My difficulty is still very much the same, and I hope to
have it explained now. This matter of the fixing of both foramen rotundum
and foramen ovale : it does not satisfy me to say, as Sir Robert Woods said
that “ vibrations of a sort ” reach the membrana basilaris : the theory demands
a very regular and orderly movement of these delicate structures (the mem¬
brana basilaris and the organ of Corti) ; the wave lengths are transmitted, as
Professor Keith said, in a sort of Morse code from this mechanism to the
brain, very much, I suppose, as the wave lengths of light set going by the
semaphore or heliograph are transmitted by the excitation of corresponding
nerve stimuli through the retina to the brain. At the same time, I always
feel that there is much more room in the brain for analysis of sound than is
possessed by the much smaller and probably less highly organized nerve
elements of the organ of Corti and ganglion spirale.
Sir TlfOMAS WRIGHTSON (in reply): One of the questions raised concerned
the pressure of the air in tfce middle ear. The middle ear is connected with
the external air through the Eustachian tube. When the drum of the ear
moves inwards, the transmission of the wave form here (model) is through bony
levers articulated together. You will see by this mechanism that the liquid
unit pressure is increased in the cochlea due to the decreased displacement on
JU —16a
94 Wright son and Keith : New Theory of Hearing
the same principle as the Bramah press. With regard to bone conduction,
this is derived from the air compressions and rarefactions acting on the
exterior of the head, causing bone vibrations which are conducted to the walls
of the cochlea. Whatever displacement of liquid is effected here must pass
the basilar membrane, therefore the hairlets work through the action of that
displacement if even the stapes is fixed. One speaker said he did not think
nerves could pass along impulses of so many thousand vibrations per second
as required under the theory. In answer one would ask, What about the
telephone ? Every sound and gradation of sound which a person speaks at
one end is passed along the wire, so that every inflection and impulse of the
voice is heard by the receiving ear. If, then, waves at this rate can pass
through a copper wire, why cannot we conceive of a nerve taking the same
number? Yes, the theory is based on the mass movement of fluid.
Section of ^toloo?
President—Mr. Hugh E. Jones.
Case of Chronic Adhesive Otitis; Myringotomy and Partial
Ossiculectomy . 1
By P. Watson-Williams, M.D.
Miss S. E., aged 26, came under observation in May, 1916, with
deafness of several years’ duration. Mfembrana dry, slightly opaque and
thickened, only slight retraction, with dry adhesive catarrhal otitis
(malleus immobile) Rinne negative.
When I first saw her she could hear whispered words uttered
strongly (H.W.W.), right 28 in., left 20 in.; after Eustachian
catheterization (H.W.W.), right 54 in., left 36 in. The sphenoidal
sinus on the left side was found infected on exploration and was opened
and the tonsils enucleated. The Gell4 test proved positive, hence the
conclusion that the stapedio-vestibular joint was not ankylosed. On
September 20, 1916, crucial myringotomy was performed and later,
October 17, the left membrana was more freely excised and the lower
half of the handle of the malleus removed with the intention of
making the perforation permanent. The beneficial effect of the
operation as far as hearing was concerned was very distinct, H.W.W.
becoming 24 ft.
The patient was shown at the meeting of the Section on
November 17, 1916. At that time there was some middle-ear
suppuration and the opinion was expressed by some members that
the improvement in hearing was in part due to the suppuration and
would not persist, and it was recalled that similar operative measures
had often been tried in the past and abandoned as the improved
1 At a meeting of the Section, held May 16, 1919.
,vu—34
96
Watson-Williams : Chronic Adhesive Otitis
hearing did not persist. The exhibitor promised to show the case
after a year had elapsed.
It is now two and a half years since the operation was performed,
but the beneficial effect on the hearing remains. It is noteworthy that
it was the most deaf ear that was selected for operation. It was
contended by the exhibitor that the temporary middle-ear suppuration
was due to infection by the Eustachian tube from the infected
sphenoidal sinus and with the cure of the sphenoidal catarrh the ear
has remained dry and free from suppuration for over a year.
Now, H.W.W., right 5J ft., left 25 ft.
DISCUSSION.
Dr. H. J. Banks-Davis : Why has this operation fallen into abeyance, if
it can produce a result such as this? The point Dr. Watson-Williams raises
regarding sinus suppuration as a cause of a persistence of aural suppuration
after even “ well done ” mastoid operations, is one of the greatest practical
importance.
Dr. Dundas Grant.: I think these operations fell into disrepute because
they were too often practised in cases which were really instances of sclerosis
of the middle ear. In the present case there was no stapedio-vestibular
ankylosis, and Dr. Watson-Williams took a reasonable way of excluding that.
Although there are differences of opinion as to the value of Gell6’s test, it
should be used before operating. With regard to the influence of the disease
of the sinuses, I think it was very considerable, as in other forms of purulent
catarrh of the nasopharynx. Often, in the cases of radical mastoid operations
in which the discharge persists it is because disease remains in the nasopharynx,
not in the petrous cells. The patient “blows his nose” into his ear, and if
attention is given to the nasopharynx and astringents injected into the
Eustachian tube—I use collosol argentum, or a weak solution of chloride of
zinc—the condition often clears up. Another reason why the operation is not
now generally practised is that it has been found that when there is no
ankylosis of the stapes, considerable improvement will take place as the
result of inflations or injections, and of gymnastic massage of the ossicles.
This case is a very encouraging one.
Mr. Clayton Pox : What was the condition of the Eustachian tube in
this case ? Seeing there has been such a marked improvement, it is possible
the tympanic orifice to the Eustachian tube was occluded. After atresia of
the tube, and with distinct pressure on the stapedio-vestibular joint, immediate
improvement results if myringotomy be performed and a perforation be made.
I had such a case in which the patient was stone-deaf bilaterally : I removed
a piece from each membrane, and there was perfect hearing afterwards from
the moment he came off the operating table.
Section of Otology
97
Dr. P. WATSON-WlLLlAMS : I did not remove the incus or the malleus in
this case; I only removed the long process of the malleus, and that was done
solely tp secure a large persistent opening.
Mr. HUNTER Tod: Dr. Watson-Williams has hadagood result in this case,
but I hope it will not lead to this operation being performed without grave
consideration. After removal of the handle of the malleus, if fixed by adhesions
to the inner wall of the tympanic cavity, or after ossiculectomy, great improve¬
ment of hearing may be obtained, but this may be only for a short period.
The ultimate result depends on whether adhesions re-form or not, and
particularly whether the stapes remains movable or becomes fixed by subsequent
scar tissue. Some time ago I published particulars of fifty cases of ossiculec¬
tomy performed on account of chronic middle-ear suppuration. I originally
did this operation as a temporary measure in hospital cases because we had
not sufficient beds to admit all those patients apparently requiring the radical
mastoid operation. Some of those patients got excellent hearing ; and in only
three out of the fifty cases published was it ultimately necessary to perform
the mastoid operation. In the cases which did well I think it was simply due
to the fact that the stapes did not become fixed. I do not consider that it
makes much difference with regard to the hearing power whether you only
remove a piece of malleus or the malleus and incus : but by the latter method
you are less likely to get recurrence of adhesions. In some of the non¬
suppurative cases in which ossiculectomy was performed in the hope of
improving the hearing, the ultimate result showed further loss of hearing
power. With regard to the excellence of hearing which may be obtained
even after removal of all the ossicles, I showed a hospital case here some
years ago in which, as a result of ossiculectomy, the stapes came away
unexpectedly, and in spite of this the patient heard a whisper at a distance
of 20 ft. 1 I saw this patient again recently, and she could still hear 10 ft.
off. This shows that we do not yet fully understand the function of the
ossicles with regard to hearing.
Dr. KELSON : This is a brilliant but also a dangerous result. Some time
ago I did a similar operation on a couple of cases of marked chronic catarrhal
deafness, in which the patients were very anxious that something should be
done. But, after the usual temporary improvement, both became ill, in
fact worse than before, and this is the usual experience. Cases of the kind
are simply legion, and it would be disastrous if everybody were to start
doing this operation. Here is an ear which suppurated after operation:
how can anyone say that adhesions will not form after the suppuration ?
We can only suppose that in this case adhesions have not occurred, and
so the improvement has continued.
1 Joum. Laryng. y Rhin . and Oiol. } 1907, xxii, p. 33.
98
Watson-Williams : Chronic Adhesive Otitis
The President : The condition of the Eustachian tube seems to be of
vital importance in this case : I think that it is probably the cardinal point.
Assuming the Eustachian tube to be closed, I suppose the opening un the
membrane would make a difference to the hearing. But if the tube is
patent and the ossicles are all mobile as they are said to be, I do not see
the advantage of a hole in the membrane. I have had cases in which the
handle of the malleus was firmly adherent to the promontory, and I failed
by removal of the handle of the malleus to obtain any result worth recording.
The undoubted improvement of the hearing in Dr. Watson-Williams’s case is
difficult to explain.
Dr. P. Watson-Williams (in reply): The Eustachian tube in this patient
is patent. In my mastoid cases I see no objection to a patent Eustachian
tube after the operation, but when there is suppuration in the mastoid, and
the upper end of the Eustachian tube is open, I curette it, to get rid of the
infected granulations. In many of my cases the result is good and the ear is
dry although the Eustachian tube is patent. Many of the cases of chronic dry
adhesive catarrh, I believe, are due to a latent infective condition, and not
infrequently to a latent sinus infection in the nose, with slight persistent
infection and constant re-infection of the ear. In this case there was no
suppuration. You do not so often see a catarrhal condition in the ear after
nose suppuration in the latent cases of sinus infection, but there is not an
outpouring of leucocytes and polynuclears, and therefore when there is less
gross evidence of pus there is more likely to be a widespread infection. This
patient had a discharge and was deaf for three years before I saw her, and she
had some catarrh in the nose. There was no gross evidence of sinus infection:
there was only a little glairy fluid, and it was only by means of exploration
and getting a culture and film examination made that one learnt that the
sinuses were infected. I think that the failure in some of the cases where
this operation has been tried has been due to overlooking the co-existence of
latent sinus infection. The reason this patient’s improvement has persisted
is that the sphenoidal sinuses have cleared up. I always explore these sinuses
before doing the mastoid operation, because it only occupies two minutes, and
one sometimes gets a surprise in the shape of a sinus infection which, if
undiscovered, would have spoilt the success of the mastoid operation. In
answer to Dr. Kelson, I rarely do this operation, and I have not done it in
another case since this was done. I should be very sorry if it were concluded
from this one case that this is the sort of result one may generally expect in
chronic catarrhal deafness. But with the necessary care in selection this case
demonstrates that you can get a good result.
Section of Otology
99
Case of Circumscribed Labyrinthitis.
By J. F. O’Malley, F.R.C.S.
Sergeant S., aged 35, came under my care at the Royal Herbert
Hospital in August, 1918, with the following history: Partially deaf
since 4 years of age. Right ear discharged all his life, left ear
discharged for nine years.
Admitted to hospital August 10, 1918, for severe vertigo. He was
unable to stand and felt giddy when lying in bed. On the second day
after admission vomiting set in and all nourishment was rejected for
forty-eight hours. He had gross rotatory nystagmus to the left, but as
he was too ill, 1 did not test his equilibration. Both ears contained a
little pus. Temperature was normal.
He had a milder attack of this type one year previously, but no
vomiting, and a fortnight previous to August, 1918, was admitted
to another military hospital for giddiness and “ head symptoms,” which
were first suspected of being early cerebro-spinal meningitis.
As his temperature and pulse remained normal throughout the
attack, I refrained from any surgical interference. He improved
steadily and was able to get up and walk in ten days. He was then
anxious to know if I could cure him by an operation, but I discouraged
this on account of the recent inflammatory activity in the posterior
labyrinth.
He has reported at intervals since and a month ago he put the
following questions, on which I should like the opinion of the
members :—
(1) With his ear condition would it be safe for him to invest all his
earnings in a watchmaker’s business ? (He is a working watchmaker,
and if anything happened to him the business would be useless to
support his wife and family.)
(2) Would an operation make him safe, and would I recommend it ?
Present condition (left ear): Scarring of the tympanic membrane
with a mass of granulation tissue in the posterior part of the attic.
There is very little discharge. Hearing: He cannot distinguish
whispered words close to ear. Equilibration: No unsteadiness on
standing with eyes shut. Caloric test: Water at tap temperature:
There was a definite response after the use of 2£ pints. Rotatory
100
O’Malley: Circumscribed Labyrinthitis
vestibular nystagmus was induced. Fistula test: This was not elicited.
(As this is often masked in the presence of polypi or granulation tissue
I do not attach much importance to its being negative.)
DISCUSSION.
Mr. C. B. West: The evidence in Mr. O’Malley’s case points to the patient
having an irritated labyrinth, possibly a locally inflamed labyrinth. And prob¬
ably resolution of the labyrinth infection has taken place. I think it is a
typical case for the radical mastoid operation without further extension of the
procedure. If at the operation a fistula is found, I should be tempted to
curette away the granulations in the neighbourhood, and not to operate on the
labyrinth.
Mr. Sydney Scott : Is Mr. O’Malley justified in calling this a case of
labyrinthitis ? I do not find any evidence of labyrinthitis in his notes ; on the
contrary, he points out that caloric and rotation tests give normal reactions. If
we may presume that these tests were applied with the head upright they
would certainly indicate that the superior as well as the horizontal canal was
normal, which is against labyrinthitis. Vertigo and nystagmus even in the
presence of middle-ear suppuration, certainly do not necessarily indicate the
presence of any inflammatory intralabyrinthine process. We meet with such
symptoms even in non-suppurating cases, and can sometimes induce vertigo
and nystagmus by altering the tension in the normal middle ear. Becently I
described a case showing how vertigo and rotatory nystagmus and forced
movements of head and limbs were caused merely by suddenly altering the
tension in the middle ear. 1 Moreover, the direction of the nystagmus was
dependent upon whether the tension was increased or diminished. For these
reasons I would not regard Mr. O’Malley’s description as one of true laby¬
rinthitis. I should agree to limit operative treatment to the middle ear as
Mr. West suggests.
The PBESIDENT: On examining the man with the tuning fork I noticed
that his bone conduction was quite full, and this to some extent confirms what
Mr. Scott and Mr. West have said—viz., that the labyrinth was not seriously
involved. I also agree with what has been said about the radical mastoid
operation : there is no need to carry the procedure further than that.
Mr. O’Malley (in reply): I never at any time contemplated doing more
than a radical mastoid operation on the patient. But I thought it would be
useful if the meeting would discuss the questions I have put down. I feel he
had some inflammation in the posterior part of the labyrinth when I saw him,
because there was no greater reaction in his middle ear than there is now.
Vomiting persisted for forty-eight hours, and I do not see a cause for that
1 Joum. Laryng ., Rhin. and Otol., 1919, xxxiv, p. 51.
Section of Otology
101
unless the posterior*labyrinth was involved in an inflammatory attack, which
I called circumscribed. A radical mastoid operation was what I intend doing,
but I cannot guarantee it will make him absolutely safe, though it will remove
his focus of disease in the attic region.
Case of Labyrinthectomy.
By J. F. O’Malley, F.R.C.S.
Miss H., aged 27, came under my care at the Royal Ear Hospital,
in September, 1913, complaining of severe giddiness and inability to
carry on her employment as a clerk in the City. Right ear : There was
total loss of the membrane and malleus. The foramen rotundum,
promontory and process of incus attached to the stapes were easily
discernible. There was practically no inflammatory activity or pus
present. Hearing was almost extinct. Left ear: Membrane intact
and hearing good.
In November, 1913, I performed a radical mastoid operation and
found a fistula in the external semicircular canal. Her condition did
not improve, and in January, 1914, I did a labyrinthectomy. Her
improvement waB slow during the healing process, which lasted about
two months. She then went away for change of air for some weeks
and returned to business feeling quite able to carry on. The air raids
upset her eighteen months ago, but beyond this she has been quite well
since. As one rarely sees a case of this type at any of the meetings,
I thought it might interest members to see this patient.
DISCUSSION.
Mr. Lawson Whale : Will Mr. O’Malley explain the technique he
employed, as there are so many operations performed under the name of
labyrinthectomy ?
Mr. O’MALLEY (in reply): The patient was in a very wretched condition
when she came to me in the end of 1913, and was uncertain in her movements
when walking in the street, and consequently she had to stay away from
business. Her giddiness and spontaneous nystagmus were very manifest. After
trying palliative treatment for a time, I decided on a radical mastoid operation,
and then I found a fistula in the semicircular canal. I waited to see how
she went on, but as she became worse I decided to open the labyrinth. I did
102
O’Malley : Case of Labyrinthectomy
a double vestibulotomy, and also opened the cochlea. Aft6r a couple of months
her condition improved, and she has remained well since*
Mr. C. E. West : In connexion with what Mr. O’Malley said in regard to
complete destruction of nerve-endings in these operations on the vestibule, it
is my belief that the giddiness, after destroying operations on the labyrinth,
is not due to survival of the irritable nerve-endings, but to the destruction
of the nerve-endings ; that the giddiness is due simply to the sudden creation
of labyrinth asymmetry on the two sides, and is precisely similar, in type and
effect, to that of irritation of the opposite labyrinth. And I think the type
of the nystagmus conforms to that. In the treatment of these cases I used to
mop out the vestibule with formalin, but I have given that up now : I think one
is safer without it, especially in regard to the facial nerve. I have paralysed
one facial nerve with formalin. Patients do better by simple opening and
drainage of the vestibular cavity by double operation or the inferior operation
alone, which suffices in most cases. Why, too, did Mr. O’Malley go forward
in the cochlea, because risks of translation of infection through the internal
auditory meatus are greatly increased if the cochlea is opened ?
Mr. Sydney Scott : Was the operation performed on an active or defunct
labyrinth, as there is no mention of this? Was the patient giddier during the
first three or four days following the vestibulotomy, or was there no giddiness ?
The former would of course indicate that the labyrinth was active, while the
latter would show that it was already defunct.
Mr. J. F. O’Malley (in further reply) : The labyrinth was very active,
and responded to all the ordinary tests, so before I tried to ablate it that
labyrinth was active. I did not enter into detail on the points about which
Mr. West asked me, because I am familiar with the fact that when a labyrinth
is suddenly destroyed by gross disease or by operation, you get a definite set of
symptoms, which depend on the over-action of the opposite labyrinth. Such
symptoms were present in my case. But the long time she took to recover
her balance led me to conclude that perhaps I had not fully got rid of all the
nerve tissue. She had noises on that side, but no hearing. The cochlea wae
opened to get rid of the noises.
Section of Otology
103
Two Cases of Fracture of the Base followed by Otitis
Media, Meningitis and Death.
By J. S. Fraser, M.B.
(From the Ear and Throat Department , Royal Infirmary , Edinburgh, under
the charge of A. Logan Turner , M.D ., F.R.C.S.E ., F.R.S.E.)
On November 17, 1916, I demonstrated before this Section two
cases of fracture of the base of the skull involving the ear. Both of
these patients died very soon after the injury, from compression of the
brain. In the first case fracture of the base was accompanied by
bleeding from the ear but there was no flow of cerebro-spinal fluid
and microscopic examination showed that the fracture involved only
the middle ear while the labyrinth capsule was not injured. In the
second case there was a flow of blood mixed with cerebro-spinal fluid
from the external meatus, and here microscopic examination of the ear
demonstrated that the fracture involved the labyrinth capsule and
reached the internal auditory meatus.
I now bring before you two further cases (Nos. Ill and IY) of
fracture of the base associated with injury to the ear. In the first
of these the line of fracture passed through the internal meatus and
vestibule and the injury was followed by infection of the effused blood
with suppuration in the middle and inner ear, followed by meningitis.
The injury occurred on February 11, 1917, and death took place on
February 15. In the second case demonstrated to-day the patient—
a child aged 6—suffered from fracture of the base of the skull in
August, 1913, but at the time made a good recovery from this injury.
One year later the patient suffered from double suppurative otitis media
and the infection appears to have passed through the tympanic cavity
and to have given rise to purulent meningitis, from which patient died.
The labyrinth was not involved and it is reasonable to suppose that the
infection occurred through the preformed path made one year before
when the skull was fractured and, as post-mortem examination of the
ear showed, the incus was dislocated into the mastoid antrum and
the roof of this cavity fractured.
104
Fraser: Two Gases of Fracture of the Base
Case III. —Fracture of Base involving Right Middle and Inner
Ear: Purulent Otitis Media and Interna with Purulent
Leptomeningitis. ( See figs. 1, 2, 3, and 4.)
J. L., male, aged 44, labourer, was admitted on February 13, 1917.
Two days before admission, as he was going home under the influence
of alcohol, he slipped and fell on the pavement, striking the right side
of his head. He was not unconscious after the accident but there was
bleeding from the right ear and also from the mouth. The haemorrhage,
however, soon stopped. After the accident the patient suffered from
severe vertical headache and was not able to sleep. On admission he
felt as if he were rotating from left to right about a vertical axis.
The right ear has been quite deaf since the accident. He has felt sick
but has not vomited.
Examination. —Slight watery discharge from right ear. Right
tympanic membrane red and bulging but perforation not seen. Cochlear
apparatus: Complete deafness in the right ear with the noise box
in the left. Weber lateralized to good ear. Vestibular apparatus :
Spontaneous nystagmus to left (sound side) of second degree. Patient
tends to fall to the right and shows a pointing error to the right.
Anterior rhinoscopy normal. No blood seen at Eustachian orifice on
posterior rhinoscopy. Patient lies in bed on his left (sound) side.
No facial paralysis. On admission (February 13, 1917) : Temperature,
101° F.; pulse, 76; at 4 p.m. the temperature rose to 103° F.
Sterile cotton wool placed in external meatus; purgative given.
Kernig’s sign absent; plantar flexion on Babinski’s test; knee-jerks
normal ; superficial reflexes present. Fundus normal. Lumbar
puncture : Fluid blood-stained but not under pressure. (Films showed
marked increase in cells, with many polymorphs. Red blood corpuscles
present in large numbers. No organisms seen in films and on culture
only one or two colonies of staphylococcus developed—contamination ?)
Temperature, 102° F., and pulse 80, at 8 p.m. February 15, 1917 :
Patient very ill. Severe headache and backache. Temperature 105°
to 104° F., pulse only 72. Kernig’s sign present. Knee-jerks increased.
Slight facial paralysis on right side. Second lumbar puncture: Fluid
under great tension and still blood stained. Polymorphs greatly
increased. Cultures again show a Gram-positive staphylococcus (albus).
Patient died at 12.45 p.m.
Post-mortem. —Blood present over the vertex in subdural space and
also in the right temporal region. At the base of the brain purulent
Section of Otology 105
leptomeningitis was present over pons?; medulla and lower surface of
cerebellum. Laceration of left tern poro--!Sph enoidal lobe. The right
temporal bone- shewed a stellate fracture involving both petrous and
■stjuaifious portions. In the roof of the antrum a piece of bone was
loose. The fracture passed through to the roof of the external meatus.
Fib. i (Cut Hi).
J. U, aged U, 'Rfcf*nr frftotorc o i bjvse JtHohiiig right trtbMte ffnd inner
ear,'to!lo>*e£.$£pitvn \*t >t tobyrm&itte und mori\n^lh. Vertical twlivti No 1& l i.
* 6 diam, of tipper part o/ .Wa£ filled/ mfb.' ha ?mor .
exudate - t - % tipper of toctureT >be r^rVe rd mmpried/by, u&m £-
gitis ; 4 y iovftir er-4 OfLtiftuj ?•
tiifetf portion of ty ru panie eavity x : ? v < v ^
Microscopic Exa/tukation. of Unfh.t Middle and Inner Ear.
• {Vertical Section.*' /'mm h'tfom hade/card.)
External Auditory Mcntu .%— The external meatus contains desqua¬
mated epithefibth ami there is blood on th> floor.. Haemorrhage lias
Stripped off the epithelium at.the inner end of the external meatus m
the posterior superior part, where fchti fracture appears. The anterior
wall of the external aoditOrV meatus is also fractured.
106 Fraser,: ’Two Canes of Fracture of the Base
Tympanic Membrane .—The tympanic Jaembrane 1* thickened.
The mucous lining of the drumhead in the upper part li partially
stripped oHV. In the /'lower part of the drumhead the superficial
epithelium is separated into two layers and. between them there is
biodd Further'Sn r between rhe mucosa and fibrous tissue layer, there
ift blood-clot and fibrin, fomHition/ There is a rupture of the tympanic
nieniibrahe below aad behind the baridle of the malleus.
Fig. *2 (Case W).
Vertical sectipn--,No 260, x tt diam. 1, upper-Slid of. fnmiute; which passes
mio vefctibjate . 2, ii^morjhagio ptn*utofr.- fcx'tulfcte' ih " tubule'; •/£> fraoturtr
f-toftrogjt %ay spiral h\m\ aft ; 4 ? cxudfitA Jo sraia tympani'; 5, lower end of
/m'.vure ; G>‘"bbc*morrhngic bxutUfo in tympamc c^vitj ; perforation of
mvt&pt&ns ; &, fracture of external mfiattw.
EwtarJrinn- Tube .—The outer wall of the tube is fractured. Thf>
mucous membrane is practically healthy. The exudate in the tube
contains many pus cells but in the lower part of the tube inis mainly;
Wood.
Tympanic Cavity. —There is a fracture through the roof of the
tympanic cavity which runs into theprocessus -cochleanformis. Itt
the roof of ibe tympanum ' there -ih-' an containing hsemorrhage.
p
Ite ^-: ... <:
Section of Otology
Just above the head of the malleus: the roof is very thin and is shattered.
The fracture extends through the roof to the aditns and an train and
then through the outer wall of the attic into the external meatus.
There is blood in the cells above and internal to the labyrinth and also
m the cells in the floor of the tympanic.cavity in the anterior part.
Thhie is also a fracture of the floor of the tympanum—•ue.v of the roof
of the jugular bulb. The clot in the tympanic cavity has shrunk
against the walls leaving a clear space in the middle. The tympanic
Flo °. (*;«:«, nit.
V^?r^l agctioir Ns. : M4; k 4 •.#£:2 t of.
tympamp rpof; 8. t i^iparior vertical t*f r talar**/ ctwtftt
'fp; wmX; f,
ixt tytijpAftic anil 10. f^cfcuH of uxt6f»3&i ma&iiw ; j)» p^rforatipp oi
tytapapjc mciiiLr^ntx.'"a'.;,;.' 'V/.f s-'[y
mucosa is Bligbtly thickened and infiltrated. There ifc hjumorrhage in
the outer part of the attic and also in: the fold of uroeous membrane
joining the malted? to Tber^ is biorxl hud pns in the
sinus tympani. In the lower part of the .tympanum posteriorly the
■exuflate ig. purulent. • . ' :
Fraser i Tm> Gasm of Fracture of the Boat
QwrAes and' Muscles —The • stapes lias been crashed and shows at
least two fractures-. There is pus in the joint between the incus and
Stapes. The inallette and incus are hot fractnjred The tensor tympani
and stapedius are healthy.
Facial Nerve .—The facial nerve is healthy as it passes above the-
cochlea, but the fracture goes through the facia! canal above the oval
window. There is very little hemorrhage'in'the facial canal itself.
W, Pii'i. i (Cage III).
Verticil >:cr;tk»u No. 385, y. 6 1, of iniUfrtt*'; % upp^r tmd c?f
•fe-acture-t '& aditut? : two ejidft of iitercal bnrt\ti ; 5, *up(*r'»or :
C\ in nit coll, in torn a) to labyrinth.; 7, tw mids ofpONt,<mor wtUtU r
B, oxud&fco m sinus tympani; 9 and 12, frft&ttre of fintef io? wa)i of »moroAl
meatus; 10 V e*kr}ml finoafcut*; 11, perforatron &uunb<wid . 13./ icrtJg proven
of moiis* '■ . : • J s .-./'V- . V
Labyrinth- —There is some infiltration but no rupture; of
the an'nhjair'4|i»jiB0et:i’ This' passes through the upper margin'
of the oval window, There is also a fracture of the .region of the round
window. One can trace the continuity <4 the .exudate in the niche of
the round window with that in the scala tytnpani.
Section of Otology
109
Cochlea .—Except at the beginning of the basal coil (intra-vestibular
portion of cochlea) the bony capsule of the cochlea is not involved in the
fracture. There is haemorrhage in the spiral ligament, especially in
the basal coil. Corti’s organ is unrecognizable—just an amorphous mass
with cells lying in the basilar membrane. There is some organization
of the exudate in the scala media and in the upper part of the basal coil
in the scala vestibuli. The helicotrema shows haemorrhage and it is
doubtless through this that the blood in the scala tympani has got inta
the scala vestibuli. All three scalse contain exudate but the scala
tympani shows much more than the others. In the blood in the
scala tympani in the basal coil there is a peculiar concentric arrange¬
ment as if the blood had been poured out in layers. In the apical coil
of the cochlea Reissner’s membrane is ruptured. In the lower part of
the middle coil Reissner’s membrane lies almost in contact with the
basilar membrane. There is very little, if any, blood in the aqueduct of
the cochlea, though the fracture runs right through this region.
Vestibule .—The fracture runs into the roof of the vestibule and then
downwards through the bony spiral lamina and the region of the round
window into the tympanic cavity and finally passes through the floor of
the cavity. The aqueduct of the vestibule contains haemorrhage at the
vestibular end but further inwards the aqueduct is almost free from
blood. The vestibule itself is almost completely filled with haemorrhage.
Only traces are seen of the membranous structures in the vestibule,'
for the most part they have disappeared. Inside the vestibule the clot
has shrunk against the walls, leaving a clear space. Apparently the
infection has not passed to the meninges along the aqueduct of the
vestibule. The tip of the promontory is almost chipped off.
Canals .—There is no fracture of the labyrinth capsule in the region
of the canals. The lateral canal contains pus and blood. The' superior
canal contains very little haemorrhage. The crista of the superior canal
is fairly normal but the cupola is not present. The endolymphatic
space of the posterior canal is filled with cells. The non-ampullated
end of the posterior canal is almost healthy. The crus commune is
almost free from blood.
. Internal Meatus .—There is very little blood in the internal auditory
meatus though the fracture extends right through from the floor of the
middle fossa, through the bony roof and floor of the meatus, to the
region of the opening of the aqueduct of the cochlea. There appears to-
be a rupture of the dura in the roof of the internal meatus and there
is some haemorrhage between the dura and the bone. The fracture
110
Fraser: Two Gases of Fracture of the Base
extends down to the glosso-pharyngeal nerve. Some cellular exudate is
present in the fundus of the internal meatus, but there is apparently
no tear of the nerves.
Jugular Bulb. —The fracture extends through to the roof of the
jugular bulb, though the bulb itself is healthy.
Case IV.— Fracture of the Base with Fracture Dislocation of
Incus and Rupture of Roof of Right Mastoid Antrum,
August, 1913. One year later Double Acute Purulent
Otitis Media followed by Leptomeningitis and Death.
J. F., male, aged 6, admitted on August 31, 1914. The child
suffered from fracture of base of skull in August, 1913, with bleeding from
right ear. At this time he was admitted to the Royal Infirmary for
fifteen days. He remained well till August 30, 1914, when earache
{right ear) and headache came on. August 31,1914 : Vomiting. Uncon¬
sciousness at 10 p.m., jerkings of right arm. Right pupil larger than
left. Rigidity of neck. Kernig’s sign doubtful. Admitted to Ear and
Throat Department at midnight. August 31, 1914: Right meatus
contained wax. Temperature 101° F., pulse 110, respirations 24.
General twitchings of right side with rolling of eyes. Death at 7 a.m.,
September 1, 1914.
Post-mortem (five and a half hours after death).—Flattening of con¬
volutions. Cerebro-spinal fluid increased and turbid: exudate in
interpeduncular space. No obvious tubercles. Films from exudate
show mononuclear cells and some polymorphs. No organisms seen.
No tubercle bacilli. Cultures sterile after twenty-four hours. Sphe¬
noid and ethmoid healthy. Left middle ear contained turbid fluid.
Old fracture of roof of right mastoid antrum.
Microscopic Examination of Right Ear. (Vertical Sections from
before backward.) (See figs. 5, 6, 7, and 8.)
External Auditory Meatus and Mastoid. —The mastoid process is
cellular, the cells extending right up to the middle and posterior fossse.
Many of these cells are full of pus. There is a gap in the roof of the
mastoid antrum. The gap is filled with fibrous tissue, and there is a
piece of bone lying loose in the midst of this fibrous tissue, with pus
around it. This piece of bone proves to be the incus, which has become
dislocated backwards into the mastoid antrum. From the appearance
. Section of Otology 111
of the well formed fibrous tissue surrounding the iocu§ it is evident that
this is an bid dislocation. Whsfc appears to have, happened is that the
incus became dislocated backwards at the time of the fracture in laid,
retaining its attachment to the floor of the aditus, and at the sametime
there was a fracture of the roof the antrum. The patient recovered at
the time as so infection occurred, but one.year.later when be developed
an acute suppurative otitis media the infection passed, by way of
the tympanic cavity, the aditus and antrum, through the old gap,
FUU f. (Cftse IX).
J. F:, aged 6, old fracture of base oneyear before ’gugei ai acute j*iijj>tmrattvf>:
otihifi media ( bibvionil). The infection to have Spread to the
thttiugb iiW gap left by the obi. lecture io lhu root of the antrum Vertical
^ctiv-A through right middle and mner ear, -No, lyO { V *8 d/a&t: l, upper part
of hasn't u:«U ot cochlea normal ; % tensor tymp&ui; tiihal p^rtioii ot'tympanic-
cavity showing swollen iiifUtf^had mucous; ptizufynt iu. -air cells
ViobJw eoohieo.; &, purulent exudate pasBuigiQto sealA tymp&tu (A biisnA cod from
the internal racatvis ; 6, fundus of internal n>fcauis' with. 'bcauebafr tit eouhiear
.nerve surround^ hy mcurogitis-
which was apparently filled with fibrous tissue,, to the intracranial
structures, and the result wa* purulent leptonie-ningitie and death.
Tjpit'pa'i'df Meinbrane.—The mucous membrane layer is very thick.
There is no sign of rupture of the drumhead.
11 *J Fraser: Two Cases-of-'-Fraeture nf (tie Base
Eustachian Tuhr ■—The lining Membrane of the tube itself is very
vascular and swollen, and the snbnmoosa is infiltrated with pus cells--:
Tympanic' CavUy^1£h&iyta p'amc cavity is full of pus. There is
m> Sign of fracture of the roof of the/cavity.. There is pus in the
cells in the roof of the tympame cavity, but there is no sigrj of erosion
of the lateral can ah
.. Qsxides and Muscles --The : footplate of the stapes is quite normal.
The crura of the stapes are present and attached to the stapes. It is
Fig. 6 (Caa^ IV),
Vortical section, Ho. 390, x G M$#&< 1, nuhatcnata \yjth t?»gorg^<J
vezmh i % utTinte ; % Uciat uorw l, fenstw x 6. footplate of ;
0, Uaudfo vf malleus aUaebud to drumhead • 7, purulent exudate in tyutpafcuai ;
>;■ 6r«;d of Oifuai ) ?$0cxwf endQlympfcftfcicus; 10, Smooth
ifrtid of SUpeflor VOlUO;ti (jftUftt.
the long process of the incus which has been broken. The head of
the malleus is in very close contact with the roof of the tympanic
cavity, there .ia some filrcms tissue and blood dot external to it. The
head of the-malleus appears in be ankyiOged to the new bone which
Section of QtolofJi) 113
'
has been formed in the rpof of the* middle ear.. The tensor tympani
is healthy. i, V ,
Laiuynnth Whuloioi The mucosa nr the oval window k. not much
thickened.. The niche of the ,ro»md window contains -pas 1 and swollen,
inubosa, but there is no evidence of infection- passing through the round
window merhbi’atJfe. *- . . ' ;
Fte. ? (Ca-i IV).
Vtifrfexoal^^itpHv.;^;.? M0 f . lV posiuW which should be pcpU|ii&cl
by tucuh (compftfo %. 4< Ho, 13); 2y haad rA malleus; 3,exudate'.in ;
4, stapodturt ruu^Vy fylw* e^ds of ^ostefipr cauai j 6, two snds pi Utwal c&itel ;
V, eupi»f kn- uw$L :
Cpitfitt There ate.manywhite-celts in the seals tympani in the
basal coil. There is a layer, of pus cells in the scala .tympani' just on
the inner aspect; next to th.e modiolus. There is also a layer' of pus
cells in the puddle coil in the hoaia tympani. The ptis in the seals
tympani does not e.ttend as fat: as the helicotfema. It may have been
that the infection from the- meninges spread up to the scala tympani
114 Fraser: Two Case .v of Fracture of the Base
dong '..the cochlear aqueduct e?ea though the aqueduct itself is sot
crowded with pus. There is some infiltraticm of put. cells from
the internal \ meatus into the spiral ganglion of the basal coil,
forti’s organ ;; There is.: no sigp of any recent
.fracture m the cochlear part of. the specimen. Iteissner's inem-*
• brane" is slightly depressed in ail noils, as is usual io cases of
. meningitis. '. ' •- , : " : -V'
Fig. 8 (Case IV).
Veyfcicai section, Nix $85,' x f» itiam. l/cannsetiv* ia'-^p \*ti hy f\U$
?rat.tdJDC •< % Jong process of incus ; 8, articular siirfeco nf roeij* •; i t ottW? edge
at old inicWTti 6y.-'tip at : akoift proGoss of; msyis fWaiii.ed’ ta
fteot oradUtfa w|)i{e the i\M of iha booft feftiue *r*d bac&
iuu> tk(f* autrum ; 6, opydewnio bruit# or exWnjTil. injaAtua'-'^eofifi^ Vstfv
7, exudace hi air colls b^hmd Jabyriiitb,
YeslihtU and -.Canals .—The utricle and saccule are quite healthy,
also the corresponding nerves. There is pus in the narrow canal con¬
taining the nerve to the ampuhaof. the posterior canal, hut the
ampulla itself is healthy;
Section of Otology
115
Internal Meatus. —There are many white cells in the internal meatus
within the arachnoid sheath—i.e., there is definite meningitis in the
internal meatus.
The facial canal, the saccus endolymphaticus, and the jugular bulb
are all normal.
Otosclerosis associated with Otitis Media.
By J. S. Fraser, M.B.
[ Note. — On two previous occasions (May 19, 1916, and November 17, 1916), similar
cases of otosclerosis associated with otitis media have been demonstrated before this
Section.—J. S. F.]
Old Middle-ear Suppuration (Bilateral). On Right Side, Chronic
Adhesive Process with Obliteration op Tympanic Cavity and
Otosclerosis. On Left Side, Chronic Suppuration with
Cholesteatoma, Fistula in Lateral Canal, Labyrinthitis,
Cerebellar Abscess and Meningitis. Otosclerosis also
Present on the Left Side in usual situation.
W. F., male, aged 27, admitted December 1, 1915. Patient has
had chronic middle-ear suppuration on the left side for ten years. Some
years ago an incision was made behind the left ear, and since then there
has been discharge at times from the wound. Ten days before admission
the wound ceased to discharge, and three days later the patient began
to have occipital and frontal headache. Four days before admission
vomiting commenced and has continued. For one week there has been
facial paralysis on the left side. Of late the patient has complained of
giddiness on getting out of bed, and has tended to fall to the
left side.
Examination.—The right drumhead shows a large retracted scar.
The left external meatus contains foetid pus and granulations. Cochlear
apparatus : Schwabach lengthened ; Weber lateralized to right (better)
ear; Binne absolutely negative on left side. On the right side Rinne
is said to be positive ! (This test was not carried out by Dr. Turner or
the writer.) Patient cannot hear any of the tuning-forks by air con¬
duction on the left side. With the noise apparatus in the right ear
patient is quite deaf. Vestibular apparatus : On Romberg’s test patient
falls to the left, and the direction of the fall is not altered by changing
116 l^ser.i ^ with Oiiiis Media
the' position of the head. Slight spontaneous nystagmus to t he light
and slow coarse ratstton- nystagmus to the left; slight nystagmus.on
looking straight forward; pointing ettof to right with i)6t.h. hpper
extreirdtig?,.' ’ Sold, syringing of left ear produced no change in the
spontaneous'nystaginus; in one ami a half .-minutes. General condition
Temperature .8.8:48 jF'., pulse 88, respirations 20, Patient lies called
op in bed on the left side (diseased aide).. Complete facial paralysis on
left. side. Pupils equal and react to light* No ocular paralysis and no
Fig. 9.
W. F., a$*’d '27; old bilateral uskldlc^i' suppuration aasomted with
otosobyr-o^fi. V*n.icni' i&rytkm >fen%b tight*' Uary ifo»/.U5, v 6 diam* 1, upper
pari ci coil of. eokbte* ; 2 $ iSu^itebiak; tube %bwli commvmiediea dirr^fcly
witld‘l»Utpexterriai jmba&us; by cotm motive tissue;
4, Miwriind ot eovhteiv . # f iix tenuU oioatub kiho*tW£ meningitis within ^inichDiud
■ sbaatb. , ~ 7^ k \ ' '
: '
double vision. Patient is bright men tally, and answers questions ’well,:
though: l>» has had a-stammer since childhood. . Knee-jerks present and
equal. No ankle . clonus. Plexor response to Babinski.’s test. No
Kcrnig’s sign. “ Finger nose " test more accurately performed on eight
Section of Otology
117
side than on left side. Dysdiadokokinesia well marked on left side.
Grasp of both hands good. Tongue rather furred.
Operation on Evening of Admission. —Cicatrix on surface of left
mastoid. Mastoid process Bclerotic with a track of pus extending from
the surface to the antrum, which was full of cholesteatoma. Fistula
from antrum through posterior wall of meatus. Dense healthy bone
over sinus, and sinus wall normal. Fistula present in lateral canal.
Facial nerve lying uncovered by bone above oval window. Eoof of
tympanum and antrum healthy. Dense healthy bone present in tri¬
angular area and healthy dura mater exposed in this region. Posterior
canal opened up (Neumann’s operation); promontory also removed.
Dura of triangular area slit up. No excess of cerebro-spinal fluid. No
pus in subdural or subarachnoid space. Cerebellum explored with
negative result.
Progress. —December 2, 1915 : Temperature 99° F., pulse 64 to 76.
Vomiting present. December 3, 1915 : Temperature 96'2° F., pulse 60.
Patient became very restless this morning and had to get heroin.
Kernig’s sign present with meningitic cry. Lumbar puncture: Cerebro¬
spinal fluid alkaline. Albumin in excess. “ Fehling reducing sub¬
stance ” present. Microscopic examination shows many polymorphs but
no bacteria. Cultures negative. Wound dressed. Cerebellum again
explored with negative result. Later in the day patient became uncon¬
scious. December 4, 1915 : Death at 1 a.m.
Post-mortem. —Basal meningitis. Outer aspect of left lobe of cere¬
bellum lacerated opposite surgical opening in skull. On transverse
section of the cerebellum an abscess, the size of a walnut, is seen in
the anterior part of the left lobe further forward than the exploratory
opening (although this had been made in front of the sigmoid sinus).
The abscess contains greenish-yellow pus and its walls are sloughy.
The abscess abuts closely on the fourth ventricle, but no communi¬
cation is visible. The ventricles of the brain contain slightly turbid
fluid.
Microscopical Examination of Right Ear (Chronic Adhesive Process and
Otosclerosis). (Vertical Sections from before backward.) (See
figs. 9—14.)
Tympanic Membrane. —There is a large retracted scar in the drum¬
head adherent to the promontory. The scar is adherent to the long
process of the incus, and Shrapnell’s membrane is greatly retracted
and adherent to the neck and head of the malleus, so that Prussac’s
space is obliterated.
1.18 Fraser: Q/osderutis a-miciated wiih Oiili? Media
EtisUxchim, Tuba. —Th«e is a filrght. layer of mucus over tbe. epithe¬
lium of the. tube. The epithelium oil the' floor of the lobe is sijuktaotts
aad is peeling: off.
Ti/ri)j;miuc. Cavity .—'The upper part shown, very swollen mucosa,
practically no tympanic cavity remains. There is also great thickening
of the mucosa in the lower part. The attic is filled' with. delicate con¬
nective tissue. The lateral canal pmcimefice is normal on the inner
Fi&; m
W. F. SciotUm through right ear, No. '220, X B diam. ar(^ vf’oto-
ocUfcteie ] goniculato ganglion oi laotal necye ; 3; tetssor tyfcxpAm; 4, tympanic
oftrity obiitor^tef} ; 5* pToiAQftfcory fcoyotatT fey squainous optthalium; i\ hypo-
tympanic m*ity obliteraM by connective titemi 7 . niche of round window ;
8, bo$blmf ppornpg of perilymphatfe aqueduct ; 9, sottc-rior wall o/3fcecultts.
wall of the aditus—no osteitis vasculosa here. The aditus is obliterated
by new connective tissue. The antrum is not entirely obliterated
as there is a small space just abpve the prominence of the lateral
canal. v\r,.-= : . ‘ V' c; ” ; - ; •
Section of Otology
and ’Museha .—Tbs stapes is/preahnt, embedded in gi ; ann-
.to&tiir f-issph. The long process of the incus is embedded in. the thick
granulation tissue of the. oval window. The head of the malleus and
body of the incus are normal. The periosteum of the short process of
the' incus. ia-.'peatfyiithi.cfcendd. The stapes is not ankylosed. The
tensor tympani is healthy. The stapedius is norruali
Facial Nerve .—There is squamous epithelium on both sides of the
geniculate ganglion.
-Sc
>V Si
.
W. F. V*rti6ai saut/on of figbfc *&f, i>\x ,25A\ . :< § than*.. ivppar m&rghv
of ofcoaolarotie asm: % fooi&I ti*rve * ter&ae iviapam; 4, attic, obliterated by
connective Ussne■; 5 anti V, tipper &f*d .1c"\v$r margins oi aunuliis tyrapuckui^
between yviiioU the tympanic mcnatath? should stretch; & soar in dromhead
Mhoreftt to promontory ; H* uic$vpt winders ; 9 , footplate of stapes not
ankyiti&ed,
Oimf iViitdoof —An area of otosclerosis (osteitis vasculosa) is seeo
just nba?*' the- basal coil of the cochlea in the anterior margin of the
oval window. Some giant cells are present iu the large vascular spaces
v
T20 Fraser; QfyckiMir dswcfat##:. 'iviili Otitis Media
of tbeT'new bon* formation, The mpeous noemhraneof tbs niche of the
oval Window is very thick, infiltrated and vase-alar* and there are cystic
epstcefe in the subnnicosa. There is no area of osteitis vascnlosa in the
posterior margin of the oval window.
hHb
mmmm
.Fit, 12 .
W, F» . xeer j^/T x*fcbt mi , Sft, Wfr.-•'*.>■$5 il$xn.< Wgb&r ppyyxt
vii?** ot m rt of fi#, j). 1. uppu' iMig*; i n »-xt <.♦**. terc.iio i*tm ; % footplate of *U*x*tf<
not inkyJr*<?rt : :i- iutrsyest^buiar port.u>/t ot -oj.ia snwlfo; 4* loiter, soargirj v?
oto-Boldc«-H-ut S. wmierdivQ.ti&ue -.fiS i j ng niche of r>v4 wiMow.
Bound Wimhiir. — The ■ mucous oaembiane uf the niche of the
round Wihddw is a Utile aWoHieh, ; ahd there is blood pigment present
here.
Seefittw of- Qiotegii 121
Cochlea .—The basal coil is healthy. There i? a. little pws id the
■cranial end of the perilymph aqueduct; and some pus cells in the
aqueduct of the cochlea Coru’s organ is healthy, the hair cells are
visible m the. middle, and apical coils.. There is some blood pigment in
t he iuodiohift. ’There are practically no. pus cells in the cochlear opening
of the,aqueduct of the cochlea
Vestibule .—The otosclerosis; reached the endosteum of the vestibule
just;above the infcrMhsfcihular, part .of the cochlea, and hew vascular bone
Fig. 18'
\V< f*V Verikuvl ae«iten of right ear* Ho, 3Q0 f X S dlam. I* >far*. 'of :afco ; -
sstordsis.tnsm-;• 3 ? attic- obliterated by cooociotive tbsuo; 4, haodle
$| m&Ueus ; 5, adhe-Wa t>? tween «car in drumhefttl and iruior vyuii of tympanum;
K'. hpivcfcs in lower purl of tympanum , 7, ju^ulkr oulo ; $, atfipuBkry -«*ad
caofri’; of stapes not* atikjiosuad*'
bulges .i»to : the vestibule tendostosis). The utricle and saccate are coi*
lapsed owing to the presence of an air bell in the vestibule (artefact)
Camls .—The canals are healthy. The. 'posterior canal has been'
122 Fraser; Otosclerosis associated with Otitis Media
Interned Meatus .—There jb sortie meningitis in the internal meatue
within the arachnoid sheath. The cells of the vestibular ganglion ate
normal.
Nutii.—' This specimen shows that Lueae was right y/ben he said that
it was impossible to distinguish between a bhyonic' adhesive pro6es&
and otosclerosis—that the One condition ran into the other.
V ; V ; S ‘ Fla. U, >( * • , , ; * v.
. W. F. Vertical ^raion right No. ft tiinm, l t WJoHor whil;
^mxwjotnna Sissijfe tiding luliius: <| y ) i,Jf3^nd 6 $. rtialleueaiapedths*;
ft, cofciiectlve iiigguo ht portion of tyihjmmm; '*?„ sinw t/mpam admo^t
free from connfe&t it* tiiwimV two. mUti otthtii v *?;. ends ‘M
lateral eatia1,
Section of Otology 1^3
Ossicle *.—Ttys malleus arid Incus were absent or, were removed at the
mastoid operation. The stapes has evidently been displaced at the
labyrinth operation and the footfk$*te' & seen lying in the Vestibule,
- jfagictl Metm
•In the region of the gehiciilate. g^glion the facial
oervg: i6 ia contact with the granulation tissue which m Junltrating the
marrow spaces above the cochlea, Theie is marked erosion of the bone
of the tenial canal just internal to the gc©ich^e g*ogh<>n. Above the
oval whardow the facial canal is very large and is full of granulation
tissue, which appears to be compressing the nerve.
\V. Fv, Vertical section at hil ear, No. 160, x 6 d iani. Note that on tjns side
labyrinthitis was present, autd th$. l»Byrititk ojm.fouoti (double vestibitlotomy)
had j^irtamed nerve surrounded by .gronaUtinM tissue ;
;2,.g*;«mlfetkorj t^suo in tlooi of middle Jrwaa ttWve the Uibvrmtfi ; 3, area of
i^teoTuycUtJS ax tending chwn . int&mal ta. Mvymith find to dura ot
^..ost-nr/ifiyeji'tji*. fttwe find internal to vestibule; 6 r c-h*p
.of loose hone troni kbVtitifeb ogeraidou $■ b, pbrtifetti* ?, &cm oi oto-
•;olero2i^ witb etil>vr^ed vasmfat sgwatM due to foeedt iniluntmal ory attack.
Oioschrpm asmcmte/t with Otitis MeMm
Fraafir
Laliynnfh Capsule wd Surniutuiing jimtj 'Tissue. —The marrow
spaces surrounding, the cochlear capsule are very largo-and are filled by
.extremely vascular marrow, uloseiv resembling granulation, : tissue.
There is a layer .of granulation tissue in the floor of the middle
fossa above the cochlea coid vestibule, with marked erosion of the
surrounding bone. In front of the position of the oval window and
just interna! to the tensor ly rap&ni there is m area of deeply staining
bone (otosclerosis)
The spaces m . (be bone are very wide and are
Pw. 10.
W. $£&&& aetttlDti oi left JjSG*- X 35 di&m. Higher power
\ it:v; yt part oi fcg, 15;- i, purulent exudate m YeatiUute ;. -2, htftuoh
of vtislibrilaa*^ wkevs 1 ofcdbclerotie area \ 4* vascular of hto-
;.*infl^nsIna.tury in Oiftfttlao*,.
filled by. connective- ..tissue which ruainiy consists of small cells. . .It,
would appear that the otosclerotic area .on the- left aide has become
infiltrated With:•• inflammatory tissue, ..|<£oba,bl.y as a result of mixed
•infection. Bourn giant cells are seen m the excavated areas of the
otoselciroti:' bone next to the tynipanic cavitv. Internal to the vestibule
Section of Otology 126
Cochlea .—The cartilage bone capsule of the; cochlea is hpaltby. The
aguedaet of the cochlea towards; its cranial end contain?; pus cells. The
basal coil of the cochlea tfordams h^motrhagitt m ; all three'
sealap and t.hr rjgghout the. buch lea tlfe-scaia media iff Ml of blood The.
basal cbiMeai' the vesiibuie contains chips* of bone, resulting from the
labyrinth opera tw*
W. Jf\ Vertical 'section nt left fcM*. No. >: 6' duiau X,. facial o^tve
sunoundcd by jmffaxamatonr tissua; y£. : gTauulfctiotr tissue m i\oot of roirddfre
Jtmvi ’i >% footplate of disputed til to «5StiS\iJ© opera tiorr; 4, a tea Ot
oa^qtm oHtiv ia fecne iu4*strjfti to vestibule ; d r otep ot lpf>«e bone produced by
operatiicio6. aiosdfcrolio &tea with tvo&nb aeufcV iU&immMary ioliUmtioo;;
tensor tyxnpanu
at the iabj’rinth operation, but ccmtamg some pis. The saccule and
utricle have disappeared.
Garnikt .—The posterior part of the labyrinth, containing the canals.
Zf; '' • -
126 Fraser: Otosclerosis associated with Fragilitas Ossium , d-c.
has been so much destroyed during the performance of Neumann’s
operation that it is impossible to give any accurate account of its
condition.
Internal Meatus .—The nerves are infiltrated with pus.
Jugular bulb healthy.
It will thus be seen that there was an otosclerotic area in the usual
situation in both ears. On the left side the patch of osteitis vasculosa
showed very wide spaces, but this may possibly have been due to mixed
infection associated with the labyrinthitis, or even with the labyrinth
operation.
Otosclerosis associated with Fragilitas Ossium and Blue
Sclerotics, with a Clinical Report of Three Cases.
By J. S. Fraser, M.B.
In the Edinburgh Medical Journal, April, 1917, Dr. Edith Bronson
<U.S.A.) published an article on “ Fragilitas Ossium and its Association
with Blue Sclerotics and Otosclerosis.” The paper contained a very
full description of the condition and an exceedingly copious bibliography.
It is therefore unnecessary to enter at length into an account of this
“ tripod ” disease. I merely wish to call your attention to the asso¬
ciation of otosclerosis with blue sclerotics and fragility of the bones,
and to give a report of the clinical investigation of three cases.
Dr. Bronson’s article is mainly concerned with the Currie family.
The grandfather, William Currie, broke his thigh at the age of 16, and
during the next few years had many other fractures. His sclerotics
were deep blue in colour and the frontal and occipital regions unduly
prominent. He suffered from deafness.
William Currie had six children, all girls. Three of these suffer
from the same conditions as their father, and one of these was examined
by me (Case I). One other daughter has fragilitas ossium and blue
sclerotics, but is not deaf, while the two remaining daughters have
white sclerotics, normal hearing, and no history of fractures.
The third generation of the family consisted of twenty-four children
born alive. Two of these have been examined (Cases II and III), both
of whom were the daughters of the eldest child of William Currie.
Twenty members of the third generation of the Currie family are
Section of Otology
127
still alive; of these, six show blue sclerotics and fragilitas ossium,
though only three are stated to suffer from deafness.
The fourth generation of the Currie family are still in childhood,
and, apparently, no deafness has as yet developed, but many of them
show blue sclerotics. The condition of affairs in the Currie family is
well shown in the accompanying chart, for the use of which I am
indebted to Dr. Bronson and the editors of the Edinburgh Medical
Journal :—
CHART l.-THE CURRIE FAMILY.
x -
t|-
£? -
Died in early infancy. 0 ■» Died while family was under observation.
History of blue sclerotics. u «b History of fractures and blue sclerotics.
Cross line indicates case was examined by the writer.
Colonr of sclerotics or presence of fractures not known.
55 individuals in this family. 35 of these examined by the writer 21 of the 55 have blue sclerotics. Of
these 21, 13 had fractures, 6 died in infancy without fractures, 1 is at present an infant, and one is a healthy
boy of 6 years with no fractures.
Deafness present in Cases 1, 3, 3, 7, 12, 14, and 22. Only Cases 6, 12, and 14 were examined.
Case I. —Mrs. S., aged 49, has had over forty fractures of various
bones and has distinctly blue sclerotics. Deafness started eight years
ago after a cold. Patient stated that she was nnable to hear for one
week at this time, and was very miserable about it. When the cold
went away the hearing in the left ear improved to some extent. She
has never had any-otorrhoea. She now complains of noises in the
ears like “machinery,” and states that she hears better in a noise.
She speaks in a low well-modulated voice. Examination: The
tympanic membranes show slight loss of gloss but no retraction.
Marked redness of the promontory can be seen through the drumhead
on both sides. Functional examination showed distinctly lengthened
Schwabach, Weber lateralized to the left; Binne negative on both
au—36
128 Fraser: Otosclerosis associated with Fragilitas Ossium, <£c.
sides. (C^ used for. these tests.) not heard by either ear by air
conduction; heard by left ear but not by right; C 128 beard by
both. C 255 up to beard by both ears by air conduction—better
by left ear than by right. Longitudinal vibrations of monochord
not heard at all. Watch not beard by bone or by air conduction.
The slightly raised voice is heard at 4 in. by the right ear when the
left ear is closed by the finger. With the noise apparatus in the
left ear the patient hears just as well or better than when the left
ear is closed with the finger. • The conversation voice is heard by
the left ear at 18 in.
Case II. —Mrs. B., aged 39 (niece of Mrs. S., Case I), has suffered
from deafness for twenty years. Patient noticed that her deafness got
rapidly worse during her pregnancies. She states that she hears
better in a noisy place, and that she hears worse on a dull day.
She complains of a “ whistling ” sound in her ears. Examination :
The tympanic membranes are almost normal, perhaps slightly indrawn
and lustreless, but one can see the flamingo tinge of the hypersemic
promontory through the membranes. Functional examination with
showed a lengthened Schwabach, negative. Rinne, and Weber’s
test lateralized to the right (worse ear). C 16 , C. H and C M were not
heard by either ear.
Case III. —E. A., female, aged 35, has distinctly blue sclerotics and
has had both “ ankles ” broken, but no other fractures. A sister, who
comes with her, has had no fractures and is not deaf, though her
sclerotics have a slightly blue tinge. This sister can hear C S2 . The
patient herself has been deaf since the age. of 16 and the deafness
has gradually increased. She has never had any otorrhoea. She states
that the noises in her ears used to be very severe “ like a big wheel
crank going round.” Patient is a mill worker and says that she can
hear best in the mill. For the last year she has suffered from attacks
of dizziness which are relieved by lying down. At these times she is
very sick if she lifts her head up. The dizzy attack comes on with her
monthly periods. Examination: The left drumhead shows a slight loss
of gloss and retraction. There is, however, a suspicion of hypersemia of
the promontory. The right drumhead shows a distinct scar below the
umbo, which points to an old attack of perforated otitis media and
makes one very doubtful of the patient’s statement that she has never
had otorrhoea. Functional examination with the C 258 fork shows a
distinctly lengthened Schwabach, Weber lateralized to the fight (better
ear), and a negative Rinne in both sides. When the sounding fork
Section of Otology
129
is placed on the left mastoid the patient refers it to the right ear.
C 32 and are not heard by either ear by air conduction. C ]2 8 heard by
left ear not by right. and C 612 heard by both. C 1024 heard by both
ears, better by right. C^g heard by right ear only. The longitudinal
vibrations of the monochord are not heard at all by air conduction by
either ear, but by bone conduction she hears the monochord up to
9,000 D.Y.S. There is no spontaneous nystagmus and no Bombergism,
but the patient would not submit to the rotation or caloric tests.
Dr. Bronson states that the term “ foetal rickets ” was formerly used
to include a group of conditions including osteogenesis imperfecta,
achondroplasia, and cretinism. Osteomalacia is also allied to this
group of diseases, though it does not appear so early in life.
Osteogenesis imperfecta or fragilitas ossium occurs in two forms:
(1) congenital and (2) late. These, however, cannot be very definitely
separated.
Clinical Picture. —(1) In osteogenesis imperfecta of prenatal onset,
the child is undersized, frequently premature, and is either stillborn or
dies soon after birth. The head is a crepitant bag with only a mosaic
of small plates for a bony covering. In infants which survive birth the
ultimate shape of the head will depend upon the pressure to which it is
subjected. There is often distinct bilateral enlargement which causes
the ears to bend outward and downward. The frontal and occipital
regions may also be prominent. (2) In the late form of the disease
the stature of the patient is affected According to the age of onset.
As a rule patients are of small stature. In certain instances of post¬
natal onset of fractures—so-called “ idiopathic fragilitas ossium ”—the
shape of the head is similar to that in the congenital form, so that it is
reasonable to suppose that in these cases also there has been imperfect
prenatal osteogenesis. Ossification of the skull may be nearly normal,
yet the extremities show many fractures, and vice vers4. The length
of the long bones may or may not be affected, but the earlier the
onset of signs of osteogenetic defect, the greater the shortening is
likely to be. Hypotonicity of joints with dislocations may occur.
The number of fractures, generally speaking, corresponds with the
earliness of the onset. Spurway in 1896 and Eddowes in 1900 called
attention to the association of blue sclerotics with a hereditary tendency
to fractures. Congenital heart affections, cleft palate, haemophilia,
rickets, and early arteriosclerosis are frequently met with in such
families.
Yoorhoeve attributes all these conditions to hereditary inferiority
130 Fraser: Otosclerosis associated with Fragilitas Ossium, <&c.
of the mesenchyme, from which the skeleton, the sclerotics, the heart
and blood-vessels, the lymph glands and vessels, the fibrous tissues and
involuntary muscles are formed. In January, 1916, van der Hoeve and
de Kleyb described deafness due to otosclerosis as an accompaniment of
brittle bones and blue sclerotics. (The labyrinth capsule is of course
a mesenchyme structure.) Burger, Adair Dighton and others have
described cases in which nerve deafness was associated with fragility of
the bones and blue sclerotics. Burger suggests that the stria vascularis
—a mesenchyme structure—may be at fault. Burger, of course, wants
to bring the deafness into line with the other mesenchymatous defects.
It seems possible, however, that the patients may have been suffering
from advanced otosclerosis with secondary nerve deafness and that the
true nature of the ear lesion may have been overlooked. It is note¬
worthy that in Adair Dighton’s case—a female aged only 23, an age at
which nerve deafness is extremely rare—the deafness came on three
months after child-birth.
Otosclerosis .—I have heard Dr. A. A. Gray state that in his opinion
one person in every two hundred suffers from otosclerosis and I am
quite willing to accept this estimate. Even if the disease is not so
appallingly common as Gray thinks, every otologist must be aware that
it is one of the most frequent and hopeless conditions with which he
has to deal. For these reasons any line of investigation which may
shed even a little light on the subject is well worth following up.
The association of otosclerosis- with defects of the mesenchymatous
structures appears to be of great importance but I do not think that
everything is thereby explained. Just as the fragile bone requires
the application of some force before it breaks, so, in my opinion,
the defective labyrinth capsule requires some infective agent before
otosclerosis develops. There is much too great a tendency to attribute
otosclerosis to one single cause alone—e.g., heredity, disorders of the
endocrine gland system, toxin absorption, otitis media, or to a weakening
of nerve influence. It seems quite likely that several or all of these
causes may be combined. No one can deny that heredity plays an
extremely important r61e. But on the other hand there are undoubtedly
many cases in which no family history of deafness can be obtained.
Our knowledge of the endocrine glands and of pathological chemistry is
at present too vague for us to be able to dogmatize on these subjects,
but apparently the hypophysis does seem to have some influence on
the development and growth of bone. Gray holds that toxaemia plays
an important part in the production of otosclerosis. Loss of nerve
131
Section of Otology
influence has been put forward by some as a most important factor in
the production of the disease and Gray’s recent book tends to emphasize
this point. It is of interest to note that the female sex is specially
affected by such conditions as osteomalacia, fragilitas ossium, and
otosclerosis, and that pregnancy and the puerperium have a very
prejudicial effect on the last of these conditions. The question of the
importance of otitis media is much disputed. I hold that an attack
of otitis media may be compared to “ the match which fires the
magazine.” The hereditary tendency corresponds to “ the powder.”
The loss of nerve influence and disorders of the ductless glands, which
preside over the processes of bone formation and repair, may be com¬
pared to “ a want of water with which to extinguish the flames.”
BIBLIOGRAPHY.
Burger. Zentralbl. f. Gyn., 1903, xxvii, p. 374.
Dighton, Adair. The Ophthalmoscope , 1912, p. 188.
Eddowbs, A. Brit. Med . Journ ., 1900, ii, p. 222.
Spurway, J. Brit. Med. Journ ., 1896, ii, p. 844.
Van der Hoeve and de Kleyb. Nederl. Tijdschr. v. Geneesk ., 1917, i, p. 1003.
Voorhoeye. Nederl. Tijdschr . v. Geneesk ., June, 1917.
DISCUSSION.
Dr. Albert Gray : Mr. Fraser asked whether what he indicated on the
picture of one of the sections was an area of otosclerosis. It struck me that
that was otosclerotic bone, but some parts appeared to be much more deeply
stained than others, though sometimes one gets that in otosclerosis. I think
otosclerosis was present in both temporal bones. The disease is nearly always
bilateral. With regard to the question of heredity, and the association in the
same person of blue sclerotics and fragilitas ossium, the question there in point
is whether there is a single factor producing both those conditions, or whether
they show variations in the individual independent of each other. These are
liable to be transmitted, though they may be independent of each other.
There is no connexion between blue irides and otosclerosis, for example, but
these qualities like all others are liable to transmission. It may be that in the
members of those families these conditions are a peculiarity. In the family of
a medical man in Glasgow otosclerosis is one variation, and another variation
in it is hammer-toe. Otosclerosis and hammer-toe have been handed down
through threer or four generations, but there is no necessary connexion between
the two. With regard to Mr. Fraser’s suggestion as to the possibility of a
compromise in view, what I have felt all along is that in otosclerosis we
have a tendency in the individual, but, as he says, one of various things may
132 Fraser: Otosclerosis associated with Fragilitas Ossium , dc.
be the “ match ” which sets light to the magazine. In my book I quote a
case in which hereditary otosclerosis has gone through many generations in an
historic family. In the member of the family I saw—a female—there was
acute middle-ear inflammation on one side at 18 years of age, and instead of
the condition improving .otosclerosis and noises in that particular ear progres¬
sively developed forthwith. But the other ear did not become affected until
sixteen years later. In both ears there was typical otosclerosis. That
illustrates what Mr. Fraser said: there is the powder, and given the match
the disease is liable to be started.
Mr. SYDNEY Scott : In considering the question of heredity and ear
disease, it may be that an important factor in the causation of familial deaf¬
ness is some structural departure from the normal, not merely in the ear itself
but in the nose or nasopharynx. For example, among certain families prone
to post-nasal catarrh and subsequent deafness, I have met with precisely the
same deformity of the nasal septum which produced decided nasal obstruc¬
tion in father and son and was associated with the catarrh which led to
subsequent deafness. In his studies of familial otosclerosis, has Dr. Gray
noticed any similar structural peculiarities, which may have favoured local
infections at certain periods of life, and led to the deafness and changes in
the ear such as Mr. Fraser has demonstrated ?
Mr. Fraser (in reply): I disclaim any idea of being a Mendelian expert
but I do not think that the connexion between the fragility of the bones and
blue sclerotics on the one hand, and otosclerosis on the other, is merely a
matter of accident. I would like to refeY Dr. Gray to the reference I gave to
the Dutch family in which these three conditions were associated. He will
then see that Dr. Bronson’s cases are not the only cases on record. Further,
there are other cases in which blue sclerotics and fragility of the bones have
been associated with deafness—said to be nerve deafness. I should like very
much to examine these patients to ascertain whether they are really cases of
nerve deafness. I think it probable that they are advanced cases of oto¬
sclerosis with secondary nerve deafness. Dr. Kerr Love has shown that in
congenital deafness (congenital deaf-mutism) the epiblastic structures are at
fault, and that mental deficiency, epilepsy, albinism and defects of the nervous
structures of the eye are frequently associated with this form of deafness. In
these cases, then, we have a congenital weakness of epiblastic structures. On
the other hand, there seems some reason to suppose.that in otosclerosis we
have to deal with a congenital weakness of the mesenchymatous tissues, and
the case records which I have brought before the meeting to-day appear to be
excellent examples of this. With regard to the simile of the “ match kindling
the magazine ” Dr. Gray wants me to say that anything may constitute the
41 match.** I cannot do this for I believe that it is otitis media which cor¬
responds to the match. I have shown to-day, and on previous occasions,
what I take to be the inflammatory condition of the bone in the anterior
margin of the oval window in cases of otosclerosis, and I want to renew the
Section of Otology
133
challenge which I formerly made. I propose that Dr. Gray, Mr. Jenkins and
I should submit our specimens of otosclerosis to pathologists and ask their
opinion as to the nature of the bone disease present. I myself do not see how
that bony overgrowth with the big vascular spaces can be anything but
inflammatory. I do not understand how “ idiopathic nerve weakness " can
give rise to an area of new bone formation in front of the oval window. I
* believe that we have to deal with an inflammatory condition—the result of
former attacks of catarrhal or suppurative otitis media. I have now shown
before this Section three cases of otosclerosis in which middle-ear suppuration
was present and I must remind Dr. Gray that in three of the four cases
mentioned in his book there was otitis media present at the time of death. I
do not claim that the middle ear is always in a state of catarrh or suppuration^
In many cases the inflammatory process in the tympanic cavity apparently
passes off entirely but it leaves behind a chronic infection of the deep layer of
the mucoperiosteum in the anterior margin of the oval window, which results
in the bony changes we know as “ otosclerosis." In people with no hereditary
tendency to otosclerosis, otitis media in the great majority of cases clears up
entirely or at most leaves a little thickening or opacity of the drumhead. In
people with the hereditary otosclerotic tendency, and even in some without
such an hereditary tendency, the effects of otitis media do not entirely pass
away but leave behind a small focus of disease which gradually extends.
Section of pathology
OFFICERS FOR THE SESSION 1918-19.
President— -
W. Bulloch, M.D., F.R.S.
Vice-Presidents —
W. S. Lazabus-Barlow, M.D.
J. C. G. Ledingham, M.B.
lion. Secretaries —
Gordon W. Goodhart, M.B.
J. A. Murray, M.D.
Other Members of Council —
F. W. Andrewes, M.D., F.R.S.
F. A. Bainbridge, M.D.
C. H. Browning, M.D.
H. H. Dale, M.D., F.R.S.
H. R. Dean, M.D.
J. F. Gaskell, M.D.
M. H. Gordon, C.M.G., M.D.
R. T. Hewlett, M.D.
P. P. Laidlaw, M.B.
J. Henderson Smith, M.B.
B. H. Spilsbury, M.B.
H. M. Turnbull, M.D.
Representative on Library Committee —
W. Bulloch, M.D., F.R.S.
Representative on Editorial Committee —
S. G. Shattock, F.R.C.S., F.R.S.
SECTION OF PATHOLOGY.
CONTENTS.
April 15, 1919.
E. H. Kettle, M.D., B.S. page
On Polymorphism of the Malignant Epithelial Cell ... ... ... 1
J. Burton Cleland, M.D.
The Conveyance of the Virus of a Human Acute Infective Polioencephalo-
myelitis occurring in Australia to Monkeys, Sheep, a Calf and
a Foal ... ... ... ... ... ... ... 3£
C. Da Fano, M.D.(Univ. Pavia), and H. Ingleby, M.B.
Demonstration of Preparations from Cases of Encephalitis Lethargica ... 42
February 4, 1919.
C. A. R. Nitch and S. G. Shattock, F.R.S.
Diffuse Emphysema of the Intestinal Wall (two cases), with Remarks
upon Pneumatoses.. ... ... ... ... ... 4(V
IV
Contents
SECTIONS OF MEDICINE, PATHOLOGY, AND
EPIDEMIOLOGY AND STATE MEDICINE.
(COMBINED MEETING.)
October 22, 1918.
DISCUSSION ON EPIDEMIC ENCEPHALITIS.
Dr. F. W. Mott, F.R.S. (p. i) ; Dr. P. N. Panton (p. iii) ; Dr. F. G. Crookshank
(p. iv) ; Dr. J. A. Murray (p. v) ; Dr. C. Da Fano (p. v) ; Dr. Helen
Ingleby (p. v) ; Dr. W. H. Hamer (p. v) ; Lieutenant-Colonel S. P. James,
I.M.S. (p. viii) ; Dr. F. G. Crookshank (p. xii) ; Sir Arthur Newsholme
(p. xiii); Dr. P. N. Panton (p. xiii) ; Dr. John Robertson (p. xiv); Dr. F. G.
Crookshank (p. xiv) ; Dr. Farquhar Buzzard (p. xv) ; Dr. A. J. Hall
( p. xv) ; Dr. A. Salusbury MacNalty'(p < xvii) ; Dr. F. G. Crookshank
(p. xxi) ; Dr. A. Salusbury MacNalty (p. xxiii).
The Society does not hold itself in any way responsible for the statements made or
the views put forward in the various papers.
John 13ai.k, Sons & Danikikhon, Ltd., 83-01, Great TitchlieM Street, London. W.l.
Section of patbologg.
President—Dr. W. Bulloch, F.R.S.
On Polymorphism of the Malignant Epithelial Cell . 1
By E. H. Kettle, M.D., B.S.
{From the Pathological Department , St. Mary's Hospital.)
The adoption of modern experimental methods has so revolutionized
the study of malignant disease that it is now possible to carry out
extensive investigations without paying more than the most superficial
attention to the microscopic structure of tumours. Nevertheless, all
cancer research must ultimately rest on a histological basis. In the
clinical laboratory, where the available material can scarcely be sub¬
mitted to experimental conditions, the fundamental importance of
histology is unchallenged. The pathologist must depend mainly upon
the microscope to distinguish between innocency and malignancy, and
should he desire to pursue broader aims than the purely utilitarian his
work is still practically restricted to histology. This line of research,
however, is far from being exhausted. In classification alone, much
remains to be done in the way of separating the true neoplasms
from those blastomatoid conditions which so much resemble them,
and give rise to so much confusion in our conceptions of tumour
formation. Again, by a careful consideratiqn of their microscopic
structure, it is possible to discover a great deal about the biological
properties of tumours, and the influences’ they exercise upon the
healthy tissues in which they grow. Finally, it is of the greatest
importance to correlate with human pathology the results of experi¬
mental research. But for any work along these lines to be fruitful,
1 At a meeting of the Section, held April 15, 1919.
ju—17
2 Kettle: Polymorphism of tlie Malignant Epithelial Cell
it is essential that it should rest upon a sure foundation of wide
and accurate histological knowledge.
The subject would be less difficult, and less interesting, were the
growth of the malignant cell invariably regular, but this is far from
being the case. The majority of adenocarcinomata may exhibit much
the same structure, but examples are met with- from time to time in
which the tumour cells possess a varying degree of polymorphism which
may even be so extreme as to make the correct classification of the
growth a matter of the greatest difficulty.
That the malignant epithelial cell is capable of polymorphism is
perfectly well recognized. The interchangeability of the acinous and
the solid structure in adenocarcinomata is familiar to every one, and the
origin of a squamous-celled carcinoma from columnar epithelium has
been reported on several occasions [1] [2]X Greater variations than
these, however, are not as a rule considered .possible. It is true
Krompecher [3] holds that under certain conditions of growth and
environment epithelial cells may assume a spindle /oral and may
actually be converted into connective tissue elements, but his views
have not fdund general acceptance, and the doctrine of the specific
nature of cell growth is not seriously questioned.
Without going so far as to claim that the adult epithelial cell can
actually become changed into a connective tissue cell, I am convinced
that some carcinomata may possess such extreme powers of polymorphic
growth that their cells, losing all trace of their epithelial origin, 'may
become indistinguishable from connective tissue elements. This has
been observed in the -propagation of certain carcinomata in the mouse
[4], and though the limits imposed upon the study of human tumotirs
makes the proof of a similar process in them much more difficult, it cs<n
be demonstrated, as I shall hope to show, with a considerable degree of
certainty.
The recognition of this power of polymorphic growth is particularly
important in the study of those cases in which multiple malignant
tumours occur simultaneously in the same individual. Examples of
this condition are not very rare [5] [6], but in most of them th<3
different growths are widely separated anatomically, and, biologically,
appear to be equally independent.
Of more interest are those instances of multiple tumours occurring
in the same organ when the growths are in actual contact with one
another, since there is always the possibility that the presence of one of
them may have been the factor in determining the genesis of the other.
Section of Pathology
3
This would seem to be the more likely from the demonstration by
Ehrlich and Apolant [7], Haaland [8], Bussell [9], and others, that
during the course of propagation of certain carcinomata of the mouse
the stroma may assume sarcomatous properties. Taylor and Teacher
[10], in a report of seven cases of multiple tumours in the human
being which had come under their notice, believed it justifiable to
assume a causal relation between the neoplasms in, at any rate, some
of them. Their tumours, however, and others reported of a similar
nature, would appear to be open to the criticism that in each case the
neoplasms seem to arise as separate entities, whereas in the development
of sarcomata during the propagation of carcinomata the change in the
stroma has taken place in the centre of the carcinoma, so that the two
growths are intimately mixed. It is true that Stahr [11], in a Case
studied by him, found sarcoma development taking place at the periphery
of a carcinoma, but this is exceptional, and the fact remains that the
human tumours differ from the experimental in that their constituents
are in juxtaposition rather than in combination.
Very rarely, however, double tumours occur to which this criticism
cannot apply, for the carcinomatous and sarcomatous elements are so
closely blended that it is impossible to separate them. These neoplasms
usually known as “ carcinoma-sarcomatodes,” Or “mixed tumours,’'
have, of course, nothing in common with the complex embryomata
which arise, for example, in the testicle. They are essentially carcino¬
mata in which the stroma has sarcomatous properties, and bear a close
resemblance to the mixed tumours which develop in the course of
propagation of carcinomata in mice.
In man, true mixed tumours are extremely rare. Herxheimer [12]
published a case where one occurred in the oesophagus and collected
reports of about twenty others. Saltykow [13] demonstrated three
cases before the German Pathological Society at Munich in 1914, and
referred to twenty-five cases which had been reported.
On reading some of the reports of multiple and mixed tumours I
have often thought it possible to offer an alternative explanation of the
authors’ findings. A suspiciously high proportion of the cases have
occurred in the thyroid gland and the uterus, the tumours of which
organs are notoriously prone to present unusual features. Many of the
reporters appear to have rigid conceptions of the morphology of the
malignant cell, and, though they have hastened to accept and apply to
their own material the researches on sarcoma production of the experi¬
mental laboratories, they have paid little attention to those other
4 Kettle: Polymorphism of the Malignant Epithelial Cell
observations which have demonstrated the extreme powers of poly¬
morphic growth possessed by the malignant epithelial cell. Where it is
possible to study the growth of these tnmonrs experimentally, doubtful
points may be cleared up and satisfactory conclusions arrived, at.; but
with human material this is, as yet, not practicable. One sees the
tumour in only one phase of its growth, and it may be . impossible to
interpret what is seen.
■ In these circumstances it must be realized that conclusions drawn
from the study of human tumours should be much more critically
examined before they are accepted than those arrived at from the study
of experimental tumours, which can be observed under conditions
enormously more favourable.
In the last twelve years a large number of tumours have passed
through my hands, including many possessing quite unusual features.
Some of these, from the complexity of their structure, would usually
be regarded q,s “ mixed tumours.” Thf re is, however, another possi¬
bility, and I think it is more reasonable to explain them as instances of
extreme polymorphic growth of carcinomata.
Absolute proof is, of course, impossible in the absence of any
method which would enable one to study their behaviour on prolonged
transplantation, but there is no doubt in my own mind that my
interpretation is correct. In any case I consider it most important to
make allowance for the morphological elasticity of the epithelial cell in
interpreting any anomalous growth. Failure to do this can only lead to
erroneous conclusions, and if the study of human cancer is to help at
all in the solution of the problem as a whole, the facts upon which our
theories are based must be beyond criticism.
The tumours which I have selected to illustrate my point lend
themselves to analysis fairly easily, and though I cannot hope to convey
by a few figures the impression formed from the study of many series
of sections, I have tried to bring forward the salient points as clearly as
possible.
Case I.— Pathological Register, St. Mary’s Hospital, 709, 1908.
Adeno-carcinoma of the Thyroid Gland disseminating as a Polymorphic-
celled Sarcoma. —The patient, a woman, aged 52, had noticed a swelling on the
right side of the neck, gradually increasing in size for three months. It was
accompanied by some alteration of the voice but very little pain. The patient
was admitted to St. Mary’s Hospital on November 7, 1908, under the care of
Mr. Maynard Smith, who operated on November 14, removing a large mass
Section of Pathology 5
which included the-‘right lateral lobe of the thyroid gland am! the carotid
vessels. Death occurred from hreach a -pneuuwda on November 10 , and at the
rost-iDortem meta^tases were found in the cervical glands, the superior
mediastinum- the glands in the posterior uituliAsrimim, and the root of th.e left
luag; and in the base of the left lung. Section* taken from the metastasis
- ttfrd Trdth the periphery of the mass removed at the
operation. show a rualHjpahX growth/having the structure at a polymorphic-
celled gfcreferua (fig, id. The cells are* extremely irregular in .size* and shape,
and many multimioleated giant cells are present. In tlm cells are
of ^ri a epa^t^silCl^ncrrpix ghinfl. The
gfqwifc baa tho characters of a polvm«jrph:ic*ce!!ed sarcoma And show; no
it*6pHh*lnU origin.
loosely packed together in alvscdi but elsewhere especially m the thor^ck
'deposits, they.show no gthuping at all, and are separated from one another fry
connective tissue. The nm-M vary in • their structure^ and often oontai.u
ufmsnaliy large tiueievdi Ilyporchromaiic ami pyenotu? forms are comiKou,
and xnitose^ *ira tunmoti& &nil iihyp^al^y Degen^tion forms and complete
pecroeis ocour with; ir&qwuQy, An uxamipation of the lateral lolw td
tfro opemtion entirely different |detee
vAV'7-
i-'iA'dpiTw
Tvi**V‘wvi —
. A - .V
• A\V‘ 1 * • ;’ I
. •/ /: ,c w , ; i‘ ;
Vy h‘kvv<ViiC?<;
J ■• \vi\ ; . i. . $
\Y?,|
■' - -v ' YVi /-; 7 - y' v * v.
.
:W<W/A'i)ti ' -y.
kyA^:<rjh>;‘
• •..;-iirp^h>■;
- •'• •••-'>•* - • . M»/iV'e,h v fld‘'d
, - • * V! i i ■
.• M'l .', 1 V. . .
•
6 Kettle: Pohnnorphum of ihe. Malignant Epithelial Cell
Sections from tiu* fvxh n allow amalignnnt : growth which is utfdtfcatmg the
normal thyroid tissue and the internal jugular vein, but has -the structure
of an arienacavciton^ ^rigi« ; tting from the thyroid gland (fig. 2)! It is com¬
posed of cubical a4h having regular spherical nuclei. These cells have a very
constant tendency to he >rrtoged round vesicles which contain a substancse
indt^tingriiehiihfe. la apjioaranee and staining reaction from the normal colloid
of the tiiyrohl gland; hi places, however, the growth loses its vesicular
character and assumes a solid alveolar structure. In one area the vesicles
become dilated then- colloid oohterd.s .disappear, and thdr lining cells tend
to grow into the acini io a pa|uljoma!oirs manner. In part of the growth the
stroma is very 8ca«feVr.^Q n W^P[g Occasional connective tissue trobeeuhe,
and delicate, capillaries which pemdnwte between the cells of the parenchyma.
*
\
Pro. % (Ciae I!,.'
SectJon.oF the primary growth, showing V&weies ituutidohig colloid» dilated
3^m, ymd solid
" j , m , ’ . /" \ u W.,v! (< s ’■ i*'’-' , r „ ' ;v\ ’'V' v ' 1
In some places 1{his pnrtiftu Of the growth presents mOtn abnormal characters.
Tti^ stroma t am 1 its cells assume a trabecular arrange-
as seen in 1'tg. },«tt large cells having a finely reticular cy toplasm may be
jue!/ with \ hg. •!);. T.heae cells have up : counterpart in the normal thyroid'
gland, hut their origin from thu cells of-..the -growth’can be dehoikdy traced,
and they may even • her arranged around small coUoid-cohtaiaihg vesidos.
At first glance it would seem that this tumour h ti nimao^ of the
thyroid associated with a polymovphic-cedled sarcoma., which may or may not
have' originated in its stroma, and would thus fall into line with ;>mjihir
Sectiiw (if Pa&totagtf 7
:
ttimcmrs j'ojjoi’ttjd by Waite LU j, 'ana ;!VyIo* anil Tether <Kk\ x\u. This,
however, is not the case, for it' can be. yduvsyn pnite. cl^aiiy that the saMb
matous part is derived directfy irc*r< the .<mrciiioiri«. v®#.:-S. s!k?\ys *Jm
UaftfcitioA of the- veaieuW fcype of growth into. the solid or trabecular type,
Hikl in tig, *J (taken from * gland at;, tire periphery of the to ass removed), poly-
V*ZV*
iM
Fiat, *3: {Case ty.
8 Katifcle : Polynwrpfdmn of the Malignant J£pii%elt<t3 tj&ll
morphism becomes still more advanned. To the left of fig, 4 the carstavnini
cells can be seen arranged in small columns or alveoli lying Ijtf a fairly
abundant fibrous stroma. To the right of the figure the groups of cells
become larger, and the stroma is reduced to delicate strands of connective
tissue.
t 11 f. 1 I ii.
Metastatic deposit in a cervical lymph gland. To the Icft cf the tha
carciuema ctdll^ are grouped together in trabeculfc ; to the right, a gradual traua
ioririatjoii v^curs, tUl tbo sarooiHatous type of growth illustrated ir, lig, l
f ully dev^Uipod.
C-asiv 1J : Fa.th? a.»Ktir a r.- Kkuistkit, St, Many's Hospital, »>93/i9l4
' Atjrrn'coriumnui s)f i!u- format with Qinnt^mUPti Sarcom<Uoh$ Slivmu.
The patient, a woman, aged 5b. was admitted into St> Mary s Hospital under
the care of MV. Krnesfc Lane. Sbs was a multipam, her youngest child being
17 years oldyy Tb^ro was no history of any previous local trouble- The
’tumour,. which/had been noticed lor t wo months; formed a well defined elastic
swelling in the -upper and aider quadrant of the left breast; The ; >ixiUarv
gLands. were slightly enlarged;, l^ocal excision .was ’m the
result of '•n^icn&coflfo.• the whole breast; together with the
contemts of the *xi$a,. removed. ton days later Thn ‘tissues removed at
the second -operation were thoroughly examined. but no - growth was found in
the breast itself or in any of -the axillary glands. The material from the first
operation consisted of a Am all mass of breast tissue surrounding' a firmer area
or new growth, which was -roughly oval in form, meastuiug about 3 cm, id iU
longest diameter, but was ill definedy bJe'ndmg irnperceytihiy with the 'stn-V
tissue ~:y "" V- * ''-V: \\ ’?;/
rounding mastitis
■Mrtm&eapm Plxamimliffu:^Eh# tes^st «Iiovfs advanced cfafbjiiio mastitis
with atrophy of the' glandular riemmts, and &n 'increase of dense fibxbu*
stromas peoa«ionaDy, ;ift. the Wigtibourheod - of small/ vessels, and around
groups of acini, there occur small aceumuiations of lymphocyte and plasma
< 2 efl$. There are also to be seen small eolfccUotiS of black and brown
pigtannb granules, either enclosed in phagocytes or lying free in the con¬
nective tissue. These are o^pecbt'ly nmncrr»u:s in the poripb&cy of fcli)s
HI
g«p
Fjo;-^ ;4QA$a:-TlV'd
Sootioji of tumoaV wir*^a. Iv 3 ?^ 4 i h* $ giant
ceflod ssroisa.
turubptY but are ucy&t' found in . a^Octaticvn with the giant colls to he
doscHhed later. They give"the' iron reaction, though poorly, and appear to
he P no impoilaitee Wytfml ~ .sia.ote. ; -proviou^ "toaioh* possibly an
*>1U n„wy-
The tainoin- itself presents >i abmplox bistolojyy (6g. .V) Tb« most obvious
future, is the presence erf an &i>tifa©liatl. new growth, au adenboafot.nbata
V' ; . > »
! I V.'V
•M
[fy.V^VwV;
nil !V
-An •-‘•Oi-v.f ,
Vut /
• •;l;,*, -■■t. -,h:m
.Vlii It;-
•• •*. ’ •■ yj
fJU
“* iV
* *V
\X 0
L_
Jt_L_ ...j.
vV'
10 Kettl (i\ PMijmorphism, vf ifte Malignant Epithelial ' Cell
which conforms in ©very respect; to a common type of mammary eurcmcmm.
It is composed of spheroidal or dubokial cells, fairly uniform in ami
possessing a sir/gle sphetival nucleus ; the cells are grouped together m alveoli
or trabeculae. Some of the alveoli are solid, hut fpr the most part there is a
distinct tendency to an acinous structure. The acini are not always regular.
They may be dilated and elongated, or folded, and compressed, but the adeno¬
matous nature of the growth is everywhere apparent. The stroma varies
considerably in structure jir different parts. It is always abundant, and may be
highly cellular, but in places it is dense and almost hyaline in appearance.
But the peculiar feature of the stroma is the presence of extremely cellular
areas apparently sarcomatous in nature (fig, (5). Their most notable, con-
Fig. 6 (Cano fl).
ILfgh-jriowfcr' viv;<v r»f tbc sr roma. tfbpwiiig. tjirge giant .calls-
‘•'.tfe Staffer cello lyiug iu clefts. In the - streura...
stituvUTtG are. largo giant cells, very similar in appearance to the giant edb of
a myeloma. • They are very irtegular in shape, with a finely ’ granular cyfofo
plasm mu! very many, often several doxen,. small rounded or oval nuclei
Associated with them are other cells which occur. in great numbers and-itrtf
'.^Jltitiordinurily variable in shape and & : -and in the number and form of
their imeim> In many of them mitotic figured can be seen, and degeneration
‘forms'are' common. •’•...Though their throws the giant cells into jn-omi-
fogbate*. Wo hard ami line can be drawn between them and the smaller
hblJs, At is always possible to distinguish intermediate forms, and there
caff fed no doubt .Umf. jbey are from .xtiae; ^ndtihe same source. The
Section of PnOwlogy 11
only eqiiiparable case with which I am acquainted is am vei>orte(l by
Bchlagenliaafer [15] of &o unmarried w^waia, aged 50, . who had two disfc'Umt
tumours in tba feft breast. Ooe had the sinjcinre of a giant-ceiled sarcoma,
the other was a- fc&m'ttohja. Though, the /turn ours ware separate, m mimerou^
placed the eareioonu*, spreads into the sarcoma. The axillary glands were
examined hi ter >• wh m. some o f them were found to eopiam mixed metatstees.
From his description/ md the figure illustrating 'hisarticle, Sehiagenhvjuter ^
case appear? to ’’tie'similar to mine. But whereas. he states explicitly that the
twofgrowtbs are quite distinct, and regard? their simultaneous oucurrenco'to
fch& iufcftiQ organ as merely a coi^W^nce/ixr my case the tuihoum am infciU^teliy
.Ideoded, avid it would seem that we. haye {o deal with a caraim-sarcomo.
Tsmptm^ ^peculations- as to development • of $ sarcoma in the stroma of u. '
m<k v (£&sh U K
SUd'Viug the fumift tiem of tfm ’* .imiie by a pvcyaesjs :ot'$PO&2tiirig
and pniyinu i..ut ori bt. KHrcr^aata ooib,
carcinoma are, however, rendered super durntb wy a more earsfui examination
of the growth, for I think it is clear that this is- not &’;■ mh&S Vvrmomv but
is ait example of epithelial polymorphism. I have akoady said th&t tbe>e i>
ho distiuetiou except that of siae-between, the largest giant; cells and (he
isolated f ‘ sarcoma cells 5 ‘: transitional fonus can easily he: distinguished.
Tins is W&H seen in fig. 6* where bot.h tyi.M?s of cell afo lyiag free in large
clefts or spaces in the dense, fibrous; stroma. 8irnila?ly ? jt is possible to
makeout the origin of these elements from the carciooin-i celts In hg. 7
groups of 4, sarcoma ” cells arc shown lying loosely packed together in irregular
spaces iti the strocna without aay^terc^llitJirvv^i/eyei;s Many of them
retain actual contact with one another and conform more in the-epitbeifal than-
12 Kettle; Polymorphism of - the 'Maiuj a a ni Epithelial Cell
to the meso b I as tic t ype, but at the periphery vt the spaces they land to
Separate into isolated elements which become spread put ia the meshes of the
^trouia. The proof that these ceils are carciriomatous in nature is obtained by
comparing this section with earlier and later ones of the series, when it
becomes obvious that they are derived from earclnoma alveoli by a process of
loosening and fraying, out of the peripheral layers. The remains of such an
alveolus can bp seen in the lower right hand earner of the figure, and by
following it through the series the separation of its superficial ceils into loose
isolated elements can be distinguished with certainty.' In another series of
' . ' • •
Fid< H (Case UK
*om i5i t>3 g tr-eoll pldmuU tg nf. the stroma, Ky a proct*
ot fusion rji the ca rol earn* colls with prolife nation, pf ibtjar ttucloi.
section? it is ppsaibjd to trace the direct •'origin.' of'.'the. giant cells tain tLuv
carcinoma. Fig. 8 shows aeini arranged in a chain in the douse .strpoiix
around a small capiikryv Traced through the series thin ring of growth
to be complete, but in the field illustrated there is a smaUKgap te the left
of the figure, * ^fetS'd ’ • >vbp've =this' the caremtuna cell? have based
together, their jp^^lfetshqi,ha*; become finely granular* th%& nuclei have
multiplied, wfih the result that giant cells are forimnl^difFe^iug in no wav
(row those elsewhk’e in the tumour. In other seeiieiiB of the series
Section of Pathology
13
the giant cells are replaced by carcinoma acini, and it also becomes
abundantly clear that there is no question of replacement by invasion of
the carcinoma by sarcoma.
Here again, then, what at first sight appears to be a “ mixed tumour” is
shown by more careful examination to be an example of polymorphism.
Case III.— Pathological Register, St. Mary’s Hospital, 807, 1917.
Adenocarcinoma of the Uterus : Polyp showing Areas of Squamous-celled
Carcinoma associated with a Sarcomatous Stroma. —The patient, a married
woman, aged 56, was under the care of Mr. T. G. Stevens, who performed
a hysterectomy. The uterus was slightly enlarged, and was the seat of a
firm white growth which involved the greater part of the body, extending
almost to the peritoneal surface. The cervical canal was normal. The
endometrium was extremely hypertrophied and shaggy, ,and springing from
the posterior wall in the region of the fundus were two small polypi.
There was no extension of the growth into that portion of the uterine wall
from which the polypi sprang. The tumour is an adenocarcinoma. It is
composed of irregular folded and branching acini and extends throughout
the whole thickness of the wall. The cells lining the acini are variable in
size and shape. Occasionally they are columnar with a darkly staining
protoplasm and a nucleus situated at the base of the cell, but more often
they revert to a transitional-cell type, being cubical, pear-shaped, or spherical,
with a clear, lighter-staining protoplasm and a centrally placed nucleus. In
many cases the cells are heaped up so as to form small papillomatous ingrowths,
and in some of the acini they have broken loose and lie free in the lumen.
There is no true metaplasia into squamous epithelium: prickle cells are absent
and typical keratinization does not occur. But there is more than a suggestion
of such a change in many of the large spherical cells with clear nuefei and
clear protoplasm, and occasionally cells are seen exhibiting hyaline degenera¬
tion which is difficult to distinguish from keratinization. The hyperplasia of
the endometrium ip extreme, and the picture is further complicated by the fact
that there is an irregular invasion by the malignant acini, which blend with the
hypertrophied glands, making it impossible to distinguish with certainty any
abnormality in the way of “malignant transformation” of the endometrium
, itself.
The chief interest of the case, however, is in the histology of the polypi
springing from the fundus. Their general structure can be seen in fig. 9.
They contain no glands but are solid, consisting of cellular tissue which has
a variable and atypical structure. Over a large area it consists of a delicate
collagenous matrix in which lie oval or fusiform cells. There are numerous
formed capillary vessels and occasional groups of small round cells. The most
striking feature of this part of the tumour is the presence of irregular giant
cells with numerous nuclei of various shapes and sizes (fig. 9 [a] , fig. 10). These
cells have a faintly staining protoplasm which in some cases has undergone a
14 Kettle: Polymorphism of the Malignant Epithelial Cell
globular hyaline degeneration. In other places the cells have a regular oval
form and are grouped in a manner which recalls the structure of a spindle-
celled sarcoma. Many of these are undergoing mitosis. The tissue was
sufficiently fresh to stain for fibroglia fibrils, but none were found in relation
to these cells. On a small tongue-like process at the side of the main polyp
S ' t f
Fig. 9 (Case III).
Low-power view of polyp, semi-diagrammatic, showing A, giant and spindle-
celled structure; B, giant cells in hyaline stroma; C, covering columnar
epithelium with squamous metaplasia; D, downgrowths of squamous epi¬
thelium.
the stroma is abundant and hyaline in character. Here occur small groups of
giant cells (fig. 9 [b] , fig. 11) similar to those already described as present in the
sarcomatous area. The presence of masses of squamous epithelium, often
Section of Patholog-y
Ku. iO (Carir liti.
HigJi-pWftr. v'icw o? art* A,. i}g* 0, shovfnggiAnt fc^JIs an$ a strand
of dowtriy packed spindle cells.
ii -(Caae IHJ,
JtIi 1 gh-ppOTr;Vi^w nf: area B, fig. d, Bbo'ViUg;opitberial giani c.e.lli
:l'i *’i[|
.
'{If.* 111 J/f/.vV *«< vi * t»
i\ i'*‘. < * Cv.r* 1 .\ 1 i '• <
16 Kettle
surrounded by sarcomatouscells, toward? iha/. middle of this polyp,-adds an
interesting eomplicatunj (l'jg. Ric], fig. 10). The polypi possess, an imperfect
covering of epithelium derived from tho adjfaOent mucous membrane. It is
absent over large areas ami even when present is often atypical in structure.
Its cells are usually columnar in form, and may be arranged in a single hi yer,
wm
l*ic. Vh '(C^ Jl;£y s
•'Pp*'ring of. $$$ D, hg. \l Tbn eoliuana* at hh$ cuvet-mg epitixdimu
arb Mmmg a ^minittusin sav e r &l Olefinite fc«mi$r&ataon
above Jimi' to fclio. right of the figure, spiiullu^tlff] to iba Jeft, MQ giant
•ceils--;i-' ’ *-■■•'• *\
but in many, places they have up(Jergow a polypoid bypetplasia, ami not
iti frequently they show k teudemyy to .revert k> a squamous t> pe. (fig. 3 V: jj
^ m
17
mmmm.
Fto. 13 {Cate Iflv.
dtstyfpg of area C T Bg,: ■;%.' polymorphism of tlie
potiphetal ws’lM. of ths-Sipjamous alveoli. Note the swindleand giani-ceil form*,
and the large t^ypkdl nu&Jei. ' '^ ”V V ,.
Bfetalogi^ally fcbe paiy|H m^ malignant and present jcnaiiyiaterestirjg.featums^
the o.imt imports at of them, (or nry present purpcme, being"' the • exhibition of.
epithelial polymorphism, :" l £h# of the column#' tpithcliura iut*o
squtihioxiB Hb obvious, and I believe it k also justifiable to: regard the giant and
spindle-celled elements of the stroma air derived frou’i the in filtrating maasen of
dqnaaidu^^pitheliAun. by a proet^ of polymorphic growth of these cells.
Section of ''PnitpluQU
l have referred to the its lands of squamOus epithelium winch grow in the
sabatanoe, of the polyp. They are derived irooi down grow the of the meta¬
plastic surface epithelium, and are atypical m that prickle coils are not fonnecL
M&my Aegenenitiofi, however, i* well marked, and in some places is extreme,
resnUipg m the forrnation of *maU masses oi kerniin which lie frep in the
nr^ersif ^a(tQpiasxn. These epithelial
masses a renwhahie •tendency .to. polyn.iforplnsm in two main directions •
{a) instead of nmfergbhvg kfrra&mgafci'on,- become enormously enlarged,
with ‘igreat piollferatiori of their nuclei: mstdting m the formation of giant
’^elfe -{ftfr 1J), This change occurs particularly in areas where the stroma is
Tire peripheral cells of the epithelial masses become spindle
Shaped? ami braair away. ope: from another, spreading.out into the stroma and
' .fmmnn# n s&twtm&tom form fij& IS).
18 Kettle; Po%m>m’pHm of the Malignant Epithelial Cell
.
0A8K IV. ••• Patio> uunii;:Ai.; Keoistkr, St. Mary'r HobcTiAL, 92& 1915 ;
No. 150, 1915,
A''h'7iiKo,.n niotn<'. •?/ ih(* Pro?,hit? it'tlh Metpplmin nt Hqumytovti-cdled
Carettwmn, ashicHdrd H'rfh Sui'Crwatau* Stroma *—This tumour occurred in a
man. aged 02;, who jvhs admitted into St. Mary's Hospital in November, 1915,
under the sain of Mr Clayton Greoad. An attempt at excision was made, but
intd trfdjop was too hr ami only » fevy fragments of the tumour eould
•be mnov<xi from tbe interior of the bladder into vvbich they projected. The
patient died a fortnight later, tod to the post-mortem to extensive growth of
the prostate was revealed. The Ui'»u‘ di*d the lumbar glands were invaded, and
there Were many seconder', nodrde* in the liver,
.Fim 'M l V)
Mofcasfcaeis tu an i\\v&: gland; .the. growth turn the struct lira of an. ftiiuiio
cjrrcptmn:f v
The miciwcopiu exiuninalion of the material obtained at ibe post-mortem
hKows an adetJocrnmiHOma of the prostategland* composed of irregular acini of
columnar yyVUs* lying in a fairly abundant Ttb>'o.iis< stroma. There $re no unusual
features to bo noted The aitu of .op^u£fapr Wfca "»t> inifedted
scopic fereparutioj^ from it we.ro uso.J.(^s; '.and ,W\e;nO-xdmipation was confined to
the 'deeper portions of the tumour. An TlUe gland is filled with new growth
hftvmg T*ho gcat^i diameters of an 'jibo-Hfib; *fc. varies ia
uideiroDt partes ifig, 1 4) - In places y.iii tftdk arc grouped in Jarge tvlynoli
w hmh eon .Lain occaVionnl acini; eCewbeYo the. Structure : xh that of a
malignant j>«.|uUifmxujw. cyst-aiJaiiaum; &**> 'areas whore, the
havo 'irndergoim a camudera.blc decree of mwosis. lu tho liver the, nmtas.Uses-
nre and felio growth 'TsSid the
Section of Pathology 19
adenocarcinoma iftk? squamous epithelium has occurred (fig. IS). I- fickle oellB
are not well bu^ keratiDization is often very- extensive. ’ The stroma,
especially in the centre ef the nodules, h abundant and denae. The most
interesting sections are thoseStates# .* f ragmen ter removed
at the operation, for in the«e the hisfoldjgical pkfture is extraordinarily
complicated, In some of them the epitHethdgrowth & pure adenocarcinoma,
in others it is pure squamous^ceUed carcmomai •while the transition of the one
into the other is well shown in a third series (fig: 16).. In respect of its
Drawing of rwoHstatie deposit in th*y liver. $quA0ioui$>celled mstaplatua
ot thu adonocarcincFtaa.
epithelial structure, therefore, the primary tumour falls into line -with its
motastasos. lii all the fragments the- stroma is exceedingly myxomatous.
In places it ia almost acellular, hat those areas are small., and for
the most pari it is thickly studded with highly atypical cells, the histology
being that of a polymorphic-cehed myxosarcoma. The general structure of the
stroma is well spendq fig. 16. The cells may be isolated, with single nuclei
and branching protoplasmic processes, or they may he spindle-shaped and
*20 Kettle
arranged in bundfe*, or they may have a rounded irregular lorni and
fairly cioaoly together. Variations in aiie are well marked, and many of the
cell* eon tain mitotic figures, usually atypical* Large multi nucleated giant
cells occur Uiu.17;.. imt although in Vny due ■section these appear to he distinct
entities, if truce*) through a-.senes-at.'.is seen that they frequently ■ become
continuous with each, other; they'are, in fact, lotted piasmodiaf masses Some
of the ceila con tarn l&tge or all globules* apparently a form of degeaenitioir,;
mmm
Flo 16 (Case V?).
Scirtiwtt of the growth removed at the sqpsssitwn* • There is direct trails
.formaiica ot lh* gfaudnl&r tarcnj^ma lptc/ c£iK srrd t,bv stroma b
di'i^VoottV BarcojcTiatoaB ip structure.
lji*y stain pink with’ eosin, yellowish brown with v?u* Gteson, and retain
Gram‘s stain. A. further complication >s the presence of small area? of
degeti€a4tod fcaittinoma cells, in same cases ' ££n$i&tingof -Kimt k^ciitin:
w
Setiion of Pathology
21
ili&pi found in the naigbteuri^ood of these (legenera^d.-arous/
mul thoughAorno of these may he of the foreign body type, others, 1 am
corivi!ieed r are of epithelial origin.
A her & prolonged examination of this tumour I am satisfied that it is yet
another polymorphism, but in no other case had the practical
difficulty o* demonstrating this been so great. The epithelial metaplasia is
qmlc obvious but the transition of the squamous cells into the sarcoma-like
eim tent:' is by no means so clear Thera is never any direct conversion of
healthy squamoas cells? into those of the mesoMasfcic typo, but the change is
always' .gradual Perfectly typical areas of squamous carcinoma show flight
irregularities ; then changes become more advanced, though the squamous :
character of the calls b still certain: finally, these alterations in structure
become so extreme that it is no longer possible to say that the cells are
I
fa
!• ** ir-w- ?t* X’FW'Zm
} i* *4» ^'' 4 * '^ ' • • • if' . V Wo ■» •_ 1 . V „j> lx
Flo. 17 (C^ XV),
Operation material. High ponei: viaw af a area showing giant
ce.Us aud myxojimtotis stroma. Traced in ^epal ^ex'WijBt> these giant cells are ; .
seen to joil! with each other.
epithelial in origin, hVorn these more atypical ureas to the definitely
“ sarcomatous ‘ tissue the 'change. • again -gradual. H is quite impracticable
to illustrate those various stages, for a couple of cloven figures would be
necessary, bub I have A$&dy dwtn; afcfc&uicm ta certain features vvhich arc
suggestive. I'^poeM&y I tiunk, are; the gmnfc cells, the bundles
of spindle cells in association with closely packed spheroidal elements, ami the
keraiuDoid degenerations so froquently present. An interesting field is illustrated
in fig. IH At the top of the figure k an island of squamous epithelium, and
the lower margin oX this'theedges bay# become ^txawd out and merge into
the stroma, so that it is : po longer possible todistinguish their outline,
of foratin, seen in*other '-sections : id • He .continuous' with the central
22 .'Kettle Polymorphism of the Malignaiii Epithelial Cell
keraiimsation of the epithelial nodule, lie among thoee ; and it is
clear that the squamous epithelium is uot only m ooht^ct with sarcomatous
tissue, but that its peripheral cells have acthally become transformed. To the
left of this part ot the field other epithelial cells have fused to form large
syncytia. Traced downward^ the epithelial cells become still more abnormal,
till, towards '• .tbh-limit pf the field, the sarcomatous structure is
Ft.,. i* (CftcC rVK
Operation mated*!. BbtrtfiJQg- puiyuiorphio -growth of the wriphetoit ceiis
pi am M&swes of hetati# an3 g/ojip^of unaltered
; «q^ainovifi:. eejlfe bo m P M tissue. <
Section of Pathology
23
approached. This, Shew, 3 regard as an example of pohmioiphism. The
^iojndulftr i;eUa become ajpasurioias, and the squatnou* cells teat) to assume
roeHobla&tie characters. It i»- .interesting to note that a high proliferative
activity of the tumour cells uiui plasticity of the stroma, conditions which
Krocnpeeher behoved ucceStf&vy tor this change to take place, are both present
sn this ease/ In tha maio part of the growth and in the extreme metastases
tlie stroma ia not peculiar lb Is only in the -small portion which projected
into the bladder that themes .advanced myxomatous degeneration. and this is
i.lie oniv situation ip which thv <mfcm:tedegrtHr of/polymorphism is seen.
Casp V ^I’vrnohoofrAb Ufuisttvo, riosriTAL/diMh 339, 1912
& > ? /;«Y\ s S'OK *n'' ' $* £ % ' % %$£■ " *" ' x ; i
th* 0tpit SjUndko,
rolled. Sarcoma.—I have so far dealt with “ Mixed Tumours which are
i/upahle of analysts in spite of thei.r coniplrxi(y ; and ham shown- that they
• ■ ..
Wm^:t
Fit.. 19 (Case V),
The growth has i-lie $U ; jtebur$ of & spindle-cetled sarcoma.
" ,i •" V.,' 1 . 1 ,.
- - ' ■ Iffli ffi
are really epithelial in origin. It is seldom, hawevety that ench a definite
conclusion can he readied from a purely histological st udy of these neoplasms .
usually; as in this case, pne r^ ^hly venture pii ah opinion. The patient,
'24 Kettle ; PolymotpMmi of the
Malignant Epithelial
F\o, 20 (Owe V).
Another are* the fHrnciUfe is that of a
cardnoaiia.
•flOv 21 '(Case V)v
Illustrating the blending of a^ypiciil squai&oua-celled eftromotna anct sarcoma;
At A the apj>$arftiJUt! saggast.* n trauhitfen of - the earcinoma Wto the
sarcoma.
presence of two different types of growth, a spindle-celled sarcoa-io.
bmm
j?io. 22 (Csse V)
An alveoles of squamous-celled carcinoma, showing Mypletil Bpiadie-csllttd
growth with the fonriaiixm of gifitot ceils;
s^uamous-celleS carcinoma. In places they are quite separate, but throughout
a large part, of the growth they are intermingled so that the ordinary stroma of
the caroincau*. is replaced by sarcoma*
26 Kettle ; Polymorphism of the Malignant Epithelial Cell
The sarcoma (fig. 19) m composed of Iti&ge ggrindle oallfc which arc arranged
in interlacing bundles. Many capillaries are present but them is seldom any
collagen, to be soon, possibly because tba feetm* employed contained no
mercury, m : . iliftt special staining methods for demonstrating inWrcelfoUt
substances could not bo used. 'Mitotic • Hgum are ' numerous, and th^r* *re a
considerable number of mub inudcatetV giant eel 1^.
The s(i;naau>UH-eei]ed cafdinpma, of which the growth maudy consisted hr
for the most part /typical, oxinlmmg pricblc <idb and horny degoneratiop.
Its colls arc grouped together irv large alveoli which lie in an abundant fibrous
stroma. There "bowid atypical growth. In aome
High-pawor vitvf ofpd&ioa A, fig. 21, *hc\s\ug the apparent trausttioa
between tbh carcinoma V'ife# mXvctmA Cc^>r^n& the |>f tho
sarcoma with that oC the carcinoma in l\<[ 82 ;
places the cell outlines become iodiatn>ctf prickie eelts are absent. and instead
■ of keratinizing, the central cells undergo nb.mptefce degeneration^ resulting jc the
formation of spiurai cell debris &nd leu oocytes. In other idtaai(on&
the cells : and spindfcshapod, and are packed togotb^r tfifcd
bundles (fig, 22}.' Giant- cells are formed containing a large single nneleus or
. .several smadior one# itnd. mitotic figures occur, ■ though they are seldom present
elsewhere fii the catcmoma. The structure of these alveoli so closely resembles
Secimi Qf PMHtitcvjy
■m
that ot the sarcomatous areas. that it seems movethan hkely that
both merely variations' >a ih& growth of Lhp eajrpitiQiaa well, hutm a
prolonged e&uoi&tt&tm M &3i I have not hem &hh
satisfy myself on fchp* point. In some sections .there appears to be a ioozemug
and {raying out of the oarcinorna cells. and a direct transfer motion of them. .
into sarcomatous tissue (tigs. 21 &uci 23). But I eanTiof f;KYjQe.rtaiw that this
is what has actually occurred ; and: though hath the n&Qpl&Hcm ura in places
highly atypical, tending to revert to a caramon t"3-:'.
whether the tumour as a whole should be regarded as an exttvjplo of epithelial
polymorphism, or whether the carcinoma md sfcreoma -arc•. •■;;.
Case VI—Pathological Register,. St. $ iAff $ x & ilo^n vo, 371 , i \ n *.
•*/ astocuileA with a Nfiltinolic Siirwuu.
—In the preceding coees, I ha'v« tried to show that what-•. appear to he highly
tfeompiex neoplasms >u‘o susceptible oi a-much simpler vr,])h\ cation? if due
• -. ; '': * . • ■
Diagrammatic drav, »«g of tumour ; a« melanoma; K, r^HiwRomu;
’ V:, snpefiiohvl Uarcmomatcm* ##**..;• P/*iUu*ceo>3 *ue>*'$.
allowance u*madedor the unstable morphology of Uto maiignaut, opiifchglml cmIL
The ■’tolfowmg tumour {alls into a .different category, for by rccogni^iag the
epithelial mUttitP&f &iv apparently Barcomatops aett; an alternative arid mor*.
complicated 0?:p!a»atiph i growth which might easily huve boon
dismissed as a melanotic sarcoma. : 3?he tumour was removed by Mr. Warren
Low from the fialm of tlm hand of a woman aged 75. It* had bean growing
for. nine nfe.iw:itb». On section it was seen to bp - composed of a so.it fleshv
Tmbstanee id which a few connective tissue trabecula* could be distinguished
^8 Kettle: Polymorphism of the Malignant Epithelial ; Cell ;
•fct the? base of. :ib there was a. small* pigmented, Iobulnt^ii growth which
.appeared to be quite distinct i>dai the maio tumour (fig. &4).
To take the small turnout fitst r this h a typical melapotm sarcdrea (fig: 2$),
It is composed of interlacing bundles of large spindle colls, very rich id melanin.
The pigment is not limited to the cells. lot masses in the
fibrous tissue trabecula? which separate the cell bundles; In places the cells
los6 their spindle shape and assume an Irragularly polygonal form, a change;
which is associated with loss of pigment.
The larger turnout- has a different structure, though at- first glance it ^iso ;
•appears to bo a sarcoma. It is composed of spindle-ceils, with large eifihgubiod
nuclei. arranged hi massive bundles which lie in different planes and frequcaitly
figurespebur, hut ate obmm'on. A fevy.^t^nds..
••.giv.co^ec€hre. txmnonuclear teucqnyf'f^, traverse the growth and
Fid. 25 (C**e VI).
Melanoma showing bundles oi pigmented spiadlG^olls and atoedti
of pcdygoual cells.
split io up into lobules : but no interstitial connoctiyo tissue can be demonstrated.
There is a complete absence of pigment thronghoat tbe whole tumour* and
although this is not incompatible with its being a part of the Djolanoma,
a closer examination gives uumistakable evidence of its epithelial nature.
On the superficial aspect, immediately henaath the covering epithelium, which
i* thin though intact, the cells become spheroidal in shape and grouped in solid
alveoli with much iri temping stroma■; they assume* in fact, a cavcioomatoifcs
{Mrixogenveut, though there is nothing suggestive of any par tic alar, type of
opithehum (fig- 27). A certain degree of differentiation is seen, however, in
the centre of the growth, for there occur here groups of polygattai cells with
h foaniy cyt.opiasm v and. .single* rather small nuclei/ which resemble vary closely
Secti/m of Patkol/M/y 29
of $ gkpd; though they \}onu:tfi no fat (fig; 28h The only
^iher.possibility- n that ih&t aro w a n.denng mneropfrages, hot this is negatived
% thevtecfc that iKoir^ development; bythe tr«^formation of the spitidle-coils
of the: tumour can-be traced with oeriaiofc>% . ‘ '
We have, then, two dfetiti.et; ; neoplaanis in'
^uamous-ccUod eareimonm and -ss, aiela?iomu v and the question of their
interdependence immediatelyarises. It is generally agreed, that melanom&ia
develop from ehiTjrriatophoreb, hut opinion is still divided ru* to the origin
of the latter, some regarding them as spiMastic tierivat jvgs svhile othevb; refer
them to the mosoblast. A study of the meiaimrnata themselves does not help
to decide the point, for though two dis tin a:i varieties, the carcinomatous and
the .sarcomatous/ .occur, they tend to- approximate to one type -and are not
really separable. So hit ns il is possible to draw any conclusions from
Fifl. 26 [C&sq Yl)>.
Higher magnification of B, fig, 24, asbovmig
sarcomatous structure.
histology, I am more ir»tdiend to place theta among the parcincnf&t^ because
&D epithelial tumour is capable of grooving as a sarcoma, hut. I know of no
iostaoye io which the reverse occurs. This case would sot to lend support
to t&b epith^t^'A’iewtiWu r iidrnt iittje difference ip &tfiwfcurtf between the
two growths except the ■pmmnm/or absence of melarjhu and itvTnigirt. be argued
that the tumour as $ whdbpMlows the $fcagas m the dbveloprperih of the
melanoma from the epitiu&om^ only valid* however^ on
the assumption that all tiruu npithelioraata to type • if it mn he proved
that the cpitholfal cell may, under varying conditions, give rise to a tumour
having a ^ru‘comatoU.s sttuetnt'G, it become* mi)x>ssible to aUiibute airy
sigiiifTcanGC to a parHcidskr sample: ot tbi&.'OOniirtion: •
30 Kettle: Polymorphism of the Malignant Epithelial Cell
Via.r, (Case VI).
ThSstructure 13 that of an undifferentiated carcitiomal
Area C v ug. 24.
Piu.. 28 (tW \ r l).
Area &> Jig. *howinfc toa*/otfnrtik>L‘ hi 8J>/a4|^ ceils into large-
clear cella at tilt; *«<b&ot>oua type.
Section ' of Pathology
31
Lacking evidence to the contrary, we must regard these two neoplasms as
quite separate: the polymorphism of the epithelioma is within the known
potentialities of the malignant epithelial cell, and there is really nothing to
show that the association of the tumours is more than a coincidence.
In describing these tumours I have purposely been as brief as possible
and have confined myself strictly to one field of inquiry. All the
tumours are interesting in themselves, but I have brought them forward
merely to illustrate my subject, not as individual cases; and I have
refrained from obscuring the main issue by a discussion of subsidiary
matters. In the first four the changes in the epithelial cells can be
traced from their inception, and all stages in the development of the
sarcomatous form can be followed with comparative ease. These
tumours, however, are exceptional; the majority of carcino-sarcomata
are incapable of analysis by histological methods alone, as is shown in
Case V. Case VI illustrates another aspect of the question. At first
sight, the association of an unusual type of epithelioma with a mela¬
noma would seem to throw light on the origin of the latter; but if the
possibilities of epithelial polymorphism are borne in mind, it becomes
obvious that there is no justification for drawing any conclusions
as to the derivation of this particular melanoma from squamous
epithelium.
I wish to make it clear that I do not assert an actual physiological
transformation of the epithelial cell; but I submit that it may undergo
such alterations as to become morphologically indistinguishable from
the connective tissue cell.
I have no theory as to why this change should take place. In some
of my tumours there is evidence of a heightened activity of the cell, and
the stroma is unusually hyaline or myxomatous. These conditions,
however, occur in tumours showing none of the structural variations
which I have described, and I cannot regard them as the sole, or even
the most important factors.
The explanation is probably much more complex and demands a
much deeper knowledge than we at present possess; but the recognition
of the extraordinary powers of polymorphic growth of the malignant
epithelial cell is, I hold, of the greatest importance in the histological
study of malignant disease.
32 Kettle: Polymorphisvi of the Malignant Epithelial Cell
REFERENCES.
[1] Nicholson, G. W. “ Three Cases of Squamous-celled Carcinoma of the Gall Bladder/’
Joum. Path, and Bact., 1908-9, xiii, p. 41.
[2] Murray, J. A. “A Transplantable Squamous-celled Carcinoma of the Mouse,” Third
Scientific Report, Imperial Cancer Research Fund, Lond., 1908, p. 159.
[3] Krompecher, E. “ Uber die Beziehungen zwischen Epithel in Bindegewebe bei den
Mischgeschwulsten ” [&c.], Beitr. z. path. Anat. u . z. allg. Path., 1908, xliv, p. 88.
[4] Fourth Scientific Report, Imperial Cancer Research Fund, Lond., 1911, p. 147.
[5] Fischer-Defoy und Lubarsch. “ Multiplizitat der Karzinome,” &c., Ergebnisse der
allg. Path. (Lubarsch und Ostertag), 1904-5, x, p. 924.
[6] Major, R. H. “Multiple primary malignant tumours,” Johns Hopkins Hosp. Bull.,
1918, xxix, p. 223.
[7] Ehrlich und Apolant. Berl. klin. Wochenschr., 1905, xlii, p. 873.
[8] Haaland, M. Third Scientific Report, Imperial Cancer Research Fund, Lond., 1908,
p. 175.
[9] Russell, B. R. G. Joum. Path, and Bact., 1910, xiv, p. 344.
[10] Taylor and Teacher. Joum . Path, and Bact., 1909, xiv, p. 205.
[11] Stahr. Centralbl. f. allg. Path., 1910, xxi, p. 108.
[12] Herxheimer, G. “ Das Carcinoma Sarcomatodes,” Beitr. z . path. Anat., 1908, xliv,
p, 150.
[13] Saltykow, S. Centralbl. f. allg. Path., 1914, xxv, p. 419.
[14] Wells, H. G. “Multiple Primary Malignant Tumours,” Joum. Path, and Bact.,
1901, vii, p. 357.
[15] Schlagenhaufer. “ Care. u. Riesenzellsarkom derselben Mamma,” Centralbl. f.
allg. Path., 1906, xvii, p. 385.
Section of patbolofls.
President—Dr. W. Bulloch, F.R.S.
The Conveyance of the Virus of a Human Acute Infective
Polio -encephalo- myelitis Occurring in Australia to
Monkeys, Sheep, a Calf and a Foal. 1
By J. T urton Cleland, M.D.
In February, March and April, 1917, and again in January, February,
March, and the beginning of April, 1918, a number of cases of an acute
polio-encephalo-myelitis occurred in New South Wales. Becords have
been obtained of over 130 of these cases, of which 70 per cent, were
fatal. The disease was confined almost entirely to the dry, hot,
western portion of the State. It was also recorded in 1917 from the
adjacent portion of Queensland, and Brisbane and Townsville in that
State. In 1918 cases occurred in the Goulburn Valley in Victoria.
The disease seemed to a very great extent to be limited by climatic
conditions, and showed a marked preference for the late summer and
autumn months.
All ages were affected, some of the patients being only a few
months old and others over 60 years of age. Convulsions, coma, and
rigidity of the neck, limbs or back were frequent; paralysis and
paresis, though occurring, were rare, and strabismus and oculo-motor
signs were occasionally present. Some patients showed mental
symptoms. The temperature was high, and hyperpyrexia, reaching
as high as 110° F. an hour before death was seen in some cases
near the fatal termination. The cerebro-spinal fluid was sometimes
increased and always clear and waterlike. In several of the cases
that recovered permanent paralysis remained, whilst three showed
mental disorder, which later improved or cleared up. The majority
of the patients that recovered, however, showed no aftermath.
au— 37
At a meeting of the Section, held April 15, 1919.
34
Cleland: Polio-encephalo-myelitis
During the prevalence of this disease, in the districts affected and
throughout the State, there was no increase of cases of ordinary
acute poliomyelitis (infantile paralysis)—a disease notifiable under the
Public Health Act—as recognized by the general practitioner. In
fact, in some of the affected parts there were no notifications of
ordinary infantile paralysis whatsoever, in spite of a number of cases
of encephalitis occurring.
In 1918 the disease was successfully conveyed to monkeys, Macacus
rhesus, hy materials from the brain and spinal cord of three human
cases. The material was preserved in glycerine and injected intracere-
brally. The strain obtained from one of these human cases was passed
through a series of monkeys to sheep, a calf and a horse. The monkeys
successfully inoculated by the various strains were twenty in number
and the sheep from the one strain thirteen, ^istological examinations
of the brain and spinal cord from a number of cases of the human
disease, as well as from the twenty monkey’s and thirteen sheep, the
calf and the horse, all showed essentially the same lesions. Congestion
of the brain was a marked feature. Many ©f the veins in the central
nervous system and the pia mater were sheathed with lymphocyte-like
cells. Though present to a considerable degree in nearly all the human
and animal cases, this condition was not uniformly distributed through¬
out the central nervous system in any individual animal, some parts
escaping in one case to be affected in another. The internal capsule,
pons and medulla were most commonly and distinctly affected ; the
white matter did not always escape. In most of the sheep the sheathing
of the veins was exceedingly marked. In addition cellular accumulations
or islands of small cells with rounded or irregular nuclei were frequent
in the grey matter, especially that of the pons, medulla and cornua of
the spinal cord. These were often traceable to the neighbourhood of
small vessels. Nerve cells in process of destruction and surrounded by
similar cells were occasionally seen. Their destruction appeared to be
secondary to the cell accumulations and to interference with the vascular
supply, rather than primary. 1
1 Neither in the human cases on which we made post-mortem examinations, nor in the
various animals to whom the disease was conveyed, was any evidence obtained that the
disease was due to an ordinary bacterial infection. Though Pasteur-Chamberland F filtrates
of infective material failed in monkeys and Borkefeld filtrates in sheep, it is possible that
repetitions of these may sometimes be successful. The epidemiology, the histological
findings and the successful conveyance to the animals indicated, all suggest that a virus,
very closely allied to, and possibly merely a mutant of, that responsible for acute poliomye¬
litis, is the cause of the disease. To what class of living organisms such viruses belong is
at present mere speculation.
Section of Pathology
35
The Disease as manifested in the Monkey, Macacus Rhesus.
Of the twenty successful transmissions to these monkeys, fire were
obtained directly from three human cases, two from a sheep successfully
inoculated from monkeys, and the remainder from monkeys. Successful
transmission was not obtained by intraperitoneal or intrasciatic inocula¬
tions nor by intracerebral inoculation of cerebro-spinal fluid from human
cases. The incubation period varied from five to twenty-three days,
being usually from five to twelve days. In half of the monkeys the
first symptom noticed was an anxious expression of the countenance;
this was followed by exaggerated muscular movements, the animal being
described as “nervous,” “jumpy,” “walking gingerly,” or showing
inco-ordination. The inco-ordination frequently became pronounced,
the animal, whilst moving about or trying to jump, swaying from side
to side and tumbling over and frequently hurting itself against the sides
of the cage. This inco-ordination of a type, due in almost all instances
to an exaggeration of muscular efforts rather than paresis (which was
present in some instances), was a predominant feature of the disease in
the monkey, being shown by nineteen out of the twenty animals
infected. On the other hand, paresis or paralysis of a limb or limbs,
though present during the course of illness in fifteen animals, was not
such an outstanding and constant feature, being slight in three,
pronounced in eight, and considered as a definite paralysis in four.
Even in marked cases some tone was nearly always left in the muscles,
so that the limb when raised rarely fell in a flail-like fashion. Squint
was noticed in two animals, and ptosis in three, being marked in two of
these. Other symptoms noticed were definite convulsions, but apparently
without loss of consciousness, in three cases. These were apt to be
brought on by disturbing the animal. A general trembling as in
paralysis agitans, or trembling only of the limbs and head, was noticed
in two cases; five of the animals uttered staccato or barking cries;
in several there was spasticity; and three were drowsy, somnolent or
intensely sleepy. Finally, after an illness usually lasting from two and
a half to six days, but in one instance eight days and in another eleven
days, the animal either died or was in extremis, and therefore killed. In
one animal an improvement had occurred at the time it was killed,
which suggested that it might have recovered or lived considerably
longer. It is probable also that amongst the other animals the illness
might have been prolonged for a day or so if chloroform had not been
administered. In thirteen of these cases, usually instances in which
36
Cleland: Polioencephalo-myelitis
the inco-ordination had been great, there was final prostration, the
animal lying on the bottom of the cage and showing frequent convulsive
movements of the limbs when disturbed, though these were occasionally
absent when the animal appeared as if almost dead.
The following is a summary of a typical case in a monkey, especially
chosen as being an animal successfully inoculated from a positive
sheep:—
A 62, Monkey 3845.—On the fifth day after inoculation it appeared to show
slight inco-ordination. Next day its movements were distinctly ataxic and there
appeared to be some weakness in one arm and leg. On the third day of illness
it swayed on movement, but the apparent weakness of the arm and leg was
lost. On the fourth day it was much the same. On the fifth day the hind
limb seemed paretic and movements were very shaky, jumpy and inco-ordinate.
The animal fell from time to time on the bottom of the cage and showed violent
inco-ordinated movements, almost convulsive in character. The animal was
killed with chloroform.
The Disease as manifested in Sheep.
Thirteen successful inoculations, confirmed by full histological
examinations, have been obtained in sheep. In ten of these the virus
was obtained from monkeys, and in the remaining three from previously
inoculated sheep. As a converse to the conveyance of the disease
from the monkey to sheep, the virus was conveyed from the sheep
to two monkeys, and from one of these to a series of these animals.
All the inoculations were intracerebral under an anaesthetic, and the
virus was suspended either in 33 per cent, glycerine or in normal
saline solution. The inoculations were all made within two days of
the death of the previously infected host of the virus. After an
incubation period of three to twelve days the first symptoms of
illness were noticed. The duration of the illness, until the animal died,
or was in. extremis and killed, ranged from one to five (or seven)
days, except in one case in which the animal died thirty days after
symptoms were first noticed. The early symptoms were somewhat
vague, as might be expected in an animal showing such few mental
characteristics as the domesticated sheep. They consisted in the
animal not feeding and in its keeping its head dependent. During
the course of illness convulsive movements or fits—sometimes intense,
during which the head was drawn back and the limbs “ worked,” were
noticed in eleven cases. In five the animal tended to walk in circles.
Quivering or fine tremors of the lips, ears or nostrils, sometimes
extending to the whole body, occurred in nine sheep; “ champing ”
Section of Pathology
37
movements of the jaws or grinding of the teeth occurred in three;
rapid or very irregular breathing was noticed, especially in association
with convulsive movements, in nine animals. Amongst other symptoms
occurring may be mentioned stiffness of the neck, or retraction of the
head in six ; some rigidity of the legs or stiffness in the gait in two;
“ staggers ” in one; restlessness in one ,* drowsiness in one ; weakness
in the hind legs in one; running from the nose or a mucous discharge
from the nose in two; and dribbling from the mouth in two. One
animal became unconscious on the third day. Whilst the animal was
undisturbed none of these symptoms, except the disinclination to eat
and the dependence of the head, might be observed, unless, of course,
convulsive seizures had developed. One animal, not included in the
above series of proved successful inoculations, actually recovered after
having had mild convulsions. Several other sheep also recovered after
showing slight symptoms suggesting that they had suffered from the dis¬
ease. The final stage was sometimes rapid, and in one case took place
in an hour. Details respecting this animal are briefly as follows :—
In the morning it was moving about and eating a little. In the afternoon
it was seen in the paddock turning round slowly in a circle, with its head down
as if trying to reach the grass. After making several revolutions it fell over on
its side and began nibbling, not grass but a small native plant ( Pimelea ) of
unattractive appearance. Shortly afterwards its head became retracted and
there were slight convulsive movements, whilst the lips and nostrils were
trembling and moving irregularly. It was breathing quickly and there were
* occasional to and fro movements of the forelimbs, less so of the hind limbs.
Later the head became distinctly retracted and the limbs rather rigid and
partly convulsed. The segments of the hoof of one of the front feet were
sometimes widely separated. The animal seemed to be unconscious. More
definite convulsive movements occurred occasionally. At the end of one of
these, respirations became highly in-egular and then ceased, and the animal
died an hour after it had first been noticed circling round.
A striking feature in connexion with inoculations made into sheep
has been that in a series of animals inoculated on the same day, in the
same way and with the same material, some have developed the disease,
some have apparently failed completely to do so, and some have mani¬
fested very slight evanescent signs possibly indicating a mild form of
the disease. In several instances repeated inoculations with material,
known by the results of inoculations into other sheep to contain the
virus, have failed. In one instance in which four inoculations were
made into one sheep, the material used in three of these was known to
have contained the virus at the time of the inoculation as shown hy its
38 Cleland: Polio-encephalo-myelitis
giving positive results in other animals, and yet this sheep remained
unaffected.
These results seem to show that in the sheep, while some individuals
are susceptible to the disease when the virus is actually introduced into
the brain, others are absolutely immune to it, whilst perhaps still others
may develop a very mild form of the disease. The results of the
repeated inoculations with virulent material show that the failure in
the first instance has not been due to some fortuitous circumstance
which has not been recognized, but was actually due to insusceptibility
{natural immunity).
It may here be pointed out that more than the mere presence of a
minute living parasitic organism is necessary in an animal host to
produce disease. In addition, a reaction on the part of the host to the
presence of the parasite or to its products may be necessary. If the
cells of the host do not react to the presence of the parasite or its
products, the parasite, if small, may live commensally in the host
without doing any damage. If the irritation caused be slight, the
reaction by the cells of the host may be so slight as to give rise to
no clinical symptoms, whilst immune bodies may in other cases be
produced sufficiently rapidly to annul the reaction at an early stage.
The results in sheep seem to suggest that the reaction of the cells
of the sheep to the presence of the virus or its products approaches
this border line. In some individuals the reaction to the virus is so
slight, or occurs in such situations, that clinical symptoms do not
appear, or are very slight. In other individuals the protective
mechanism is less effective and the reaction progresses to such a stage
in certain situations as to lead to death. In this may lie the explanation
of the haphazard incidence of ordinary acute poliomyelitis as well as of
this disease in human beings.
The Disease as manifested in the Calf.
Calf 3,848B received an intracerebral injection on April 25 of a
glycerine emulsion from the third generation of the disease in the
monkey. The details respecting the experiment in this animal are
as follows:
The animal remained well till April 30, when it was noticed that it kept its
head down towards the ground; if allowed to stand quietly it seemed inclined
to “ go ” slightly in the front legs, and then to get restless. There was no sign
of paresis. The animal was “ right off its food ” and there was regurgitation of
milk, this possibly indicating some paresis. At 6 a.m. it had been noticed to
Section of Pathology
39
be trembling all over (the morning was cool). On May 1 there was a clear
discharge from the nostrils; no food was taken. On May 2, when seen
at 2.45 p.m., it was lying on its right side with the head distinctly retracted
and the back arched. It was doubtfully unconscious. The abdomen was
moderately distended; respirations were rapid and shallow; there were
convulsive spasms, and there were rigidity of the limbs and muscular tremors.
The exposed eye was rolled downwards disclosing the white. General
convulsive seizures occurred every few minutes. The symptoms changed
after about twenty minutes, when the animal became fairly quiet and
respirations were slower and deeper. An hour earlier the animal was said
to have been walking about, but the legs were then weak and the gait was
circular, and towards the right side. The animal died at 4 p.m.
A histological examination showed the presence of the perivascular
cellular sheaths already described from other animals. These were not
so pronounced as was usually the case in sheep.
The Disease as manifested in the Horse.
Horse 3,908, a yearling animal, received an intracerebral injection
from the eighth generation of the virus from monkey 3,890 on June 28.
The first four generations had developed in monkeys, the fifth in a
sheep, and the last three again in monkeys.
We are indebted to Professor Stewart of the Veterinary School,
University of Sydney, for performing the operation for us and for notes
of the illness that resulted. The following are the details:—
The animal recovered well from the operation and showed no symptoms
of disease, beyond slight variations of temperature, up to July 7. On the
afternoon of this day it was taken with two “ seizures,” during which it
walked round towards the left. On July 8 it was holding its head down and
44 shivered” twice during the morning (it had done so once the day before).
In the afternoon it was standing with its head depressed, and when made to
move moved to the left side and threatened to fall towards this side. It showed
slight excitement on movement, with twitching of the facial muscles, a staring
eye, and apparently partial blindness. It staggered somewhat on moving.
The respirations were hurried and abdominal. Temperature, 103*8° F. On
July 9 the animal was worse. At 12.30 p.m. it was lying on its right side and
could not eat nor swallow. It was apparently more or less blind and took
no notice of food or drink. Its head was drawn towards the left side and
there were irregular movements of the left fore and hind limbs. It kicked
more vigorously with its left legs than with the right ones. It could not
get up, but sometimes raised itself halfway. The nostrils were working and
the mouth drawn at times to the left side. The ears and eyebrows, especially
on the left side, were twitching. It was grinding its teeth. When turned on
to its left side it was found that the head was not now arched to the right, but
40
Cleland: Polio-encephalo-myelitis
during apparent convulsive seizures the neck was arched still to the left and
the head burrowed more into the ground. By 1.45 p.m. the animal was in
intense and repeated convulsions, having dug a hole in the ground with its
head. These convulsions alternated with short quiescent periods ; then would
follow occasional rigidity and tremor of a limb, to be followed by further
convulsions. The animal was killed at 2.30 p.m.
At the post-mortem examination an area, about \ in. in diameter,
of blood clot and degenerated tissue was found in the brain. Histo¬
logical examination showed the presence of the perivenous cellular
sheaths noticed in other animals. These were slight in the spinal cord
but more pronounced in portions of the brain, though not so extensive
as the sheaths found in sheep.
Comments on the Inoculations.
A considerable amount of material, usually about 1 c.c., was used
for the intracerebral inoculations.’ The introduction of so much foreign
matter naturally led frequently to lesions at the site of inoculation.
When a lesion existed, it sometimes consisted of blood clot with
degenerated brain tissue, sometimes of a small cavity with ragged walls.
Smears and cultures made from these areas did not reveal the presence
of any bacterial organism responsible for them. Pus cells were rarely
detected in the areas. Microscopic sections showed blood clot and large
vacuolated reactionary cells in the wall. In other animals no macro¬
scopic lesion could be detected at the site of inoculation. The lengths
of the incubation periods, the post-mortem examinations, and the
results of smears, cultures and sections of the inoculated sites when
present, showed that there was no bacterial contamination which could
be held responsible for the conditions found. The incubation period of
varying extent, sometimes long, showed that the symptoms manifested
were not due merely to the inoculation of inert material into the brain,
as signs under these circumstances should have developed forthwith.
The inoculation of successful cases was made with material taken
from the brain and spinal cord not in the immediate vicinity of the
inoculation site when present. The virus must therefore have emigrated
from the site of inoculation into other parts of the central nervous
system.
Summary.
(1) Over 130 cases of a form of polio-encephalo-myelitis occurred in
man in the western parts of New South Wales in the late summer
and autumn of 1917 and 1918; 70 per cent, of the cases were fatal;
Section of Pathology
41
the outstanding features were coma and convulsions. Histological
examination showed intense congestion of the brain, perivenous cellular
infiltration round the veins of the brain, the spinal cord and meninges,
small cellular accumulations in the grey matter, especially that of
the pons, medulla and cornua of the spinal cord, and occasionally
degeneration of nerve cells. The perivenous sheaths occurred not only
in the grey matter but also in the white. They were frequently not
uniformly distributed.
(2) The disease was unaccompanied by any undue prevalence of
ordinary acute poliomyelitis (infantile paralysis).
(3) The disease was limited remarkably by climatic conditions,
being confined almost entirely to the dry western part of the State.
The mild and muggy coastal district and the cool highlands were with
one exception—in Sydney—exempt from definite acute fatal indigenous
cases. Further, with one exception, the Sydney case mentioned above,
which occurred in September (spring), all the recognized cases occurred
in the late summer and autumn.
(4) The disease has been conveyed from three human cases to
monkeys (Macacus rhesus) by intracerebral inoculations of emulsions
of the brain and spinal cord. From one of these monkeys a series of
monkeys has been successfully inoculated, and from these monkeys the
disease has been conveyed, directly or indirectly, to thirteen sheep,
a calf and a horse. The disease in the monkey is characterized more
particularly by exaggerated muscular movements and intense inco¬
ordination. Paresis and paralysis occur but are not recognizable in all
animals and are usually overshadowed by the exaggerated muscular
inco-ordination. The histological features in the monkey are similar
to those in man.
(5) The disease has been conveyed from a monkey to sheep, and
from sheep to sheep, and from sheep twice back again to the monkey,
and from one of these monkeys to a series of further monkeys.
(6) All sheep similarly inoculated intracerebrally with the same
material at the same time did not develop the disease. Some of
such animals have been proved to be immune as shown by repeated
inoculations of material known to be virulent. Other sheep have shown
slight symptoms suggestive of encephalitis and have recovered. The
disease in the sheep, a calf and a horse is characterized frequently
by convulsions. Coma occurred in the horse and unconsciousness has
been noted in the sheep. The histological lesions in the sheep, the calf
and the horse are similar to those found in man and the monkey, with
42
Da Fano and Ingleby: Encephalitis Lethargica
the exception that frequently in the sheep the perivenous cellular
sheaths are extraordinarily marked.
Conclusion.
The disease in question is a polio-encephalo-myelitis characterized
by perivenous cellular sheaths and small cellular islands. It is
conveyable to the monkey (Macacus rhesus ), sheep, calf and horse.
The' clinical disease in man, the absence of accompanying cases of
ordinary acute poliomyelitis, the conveyance of the disease to sheep,
a calf and a horse, and the clinical symptoms manifested by these
animals, as well as by the monkey, suggest that the disease in question
is an entity distinct from ordinary acute poliomyelitis (infantile
paralysis).
Demonstration of Preparations from Cases of Encephalitis
Lethargica.
By C. Da Fano, M.D. (Univ. Pavia), and H. Ingleby, M.B.
For the purposes of this investigation we were able to obtain
material from three cases:—
Case I. —Woman, aged 54. Admitted to St. George’s Hospital on June 10,
1918, under Dr. Ogle. For a week previously she had suffered from steadily
increasing drowsiness and headache. On admission she was in a stuporose
condition from which it was impossible to rouse her. She had bilateral ptosis
but no other paralysis, and general muscular rigidity. Temperature normal.
Lumbar puncture revealed nothing abnormal. Death took place ten days after
admission.
At the autopsy there was no macroscopic lesion except some milkiness of
arachnoid and slight injection of the cerebral vessels.
Case II. —Man, aged 49.—Admitted to St. George’s Hospital on December 19,
1918, under Dr. Collier. Three weeks before admission he felt sick and drowsy.
He improved for eight days, then complained of vomiting, pain in right
trigeminal area, and diplopia. He became delirious, and was finally sent into
hospital with a diagnosis of meningitis. On admission he was semi-conscious,
restless and delirious. There was marked cervical rigidity (later a generalized
muscular rigidity) and ophthalmoplegia of similar type. The cerebro-spinal
fluid contained no excess of cells. The Wassermann reaction was negative in
blood and cerebro-spinal fluid. He died on December 24.
Section of Pathology
43
Post mortem the most striking feature was the intense congestion of the
brain and meninges. The mid-brain was visibly swollen. Everywhere the grey
matter was a dull red on section. There was no exudate on the surface of the
brain or on the meninges.
Case III .—This material was obtained, through the kindness of Dr.
MacNalty, from a case of Dr. Forbes at Brighton. We have not yet been
able to get the clinical details.
The material obtained from these cases was fixed partly in alcohol,
partly in formalin, and stained by the following methods: Nisei's
toluidin blue, Cajal’s ammoniated alcohol-reduced silver, Bielchowsky
(Da Fano’s modification), Weigert-Pal and Marchi; in addition
sections were stained with hsematoxylin and eosin, iron hsematoxylin,
carmine, &c. Special reactions for iron, fat, and pigments, and certain
methods for bacteriological investigation of tissues were used.
All parts of the nervous system were examined, but, in common
with other observers,' we found that the mid-brain and pons were the
regions principally affected, though the lesions were by no means
confined to them. Histological examination showed the presence of
widespread lesions of inflammatory character consisting essentially in
dilatation and engorgement of the blood-vessels, punctiform haemor¬
rhages, perivascular and parenchymatous infiltration by lymphocytes
and plasma cells, active proliferation of the neuroglia elements and
degeneration of the nerve cells—all of which have been described by
different authors, whose work we propose to discuss in a longer
communication. Dilatation and engorgement of the blood-vessels were
especially marked in Case II, and here too the perivascular and
parenchymatous infiltrations were extremely prominent. The latter
was so intense that inflammatory cells covered several consecutive
microscopic fields. The intensity of the reaction, together with the
extension of the lesions to all parts of the nervous system is an index of
the severity of the process, and may be a factor of importance in the
differential diagnosis from other forms of encephalitis. Time does not
permit of a careful analysis of the different elements constituting the
so-called “ small-celled ” infiltration ; this will be dealt with in a future
paper.
We can likewise confirm the remarkable proliferation of neuroglia
cells as regards increase in both numbers and size. Whether they
really take part in the phenomenon known as neuronophagia is a point
on which we prefer to reserve judgement for the present.
No degeneration of nerve fibres has been observed with either the
Marchi or the Weigert-Pal methods.
44 Da Fano and Ingleby: Encephalitis Lethargica
With regard to the alterations in the nerve cells our cases show
changes which seem to us more severe and widespread than those
hitherto described. They range from- slight chromatolysis to complete
disappearance of Nissl granules, atrophy of the protoplasm, and
shrinkage, atrophy and final disappearance of the nucleus. In
Bielchowsky preparations the neurofibrils appear reduced in number,
stain poorly, and are sometimes shrunk together in a clump in the
centre of the cell. In very rare instances they seem to have disappeared
completely. A striking feature of most of our preparations is the
very great number of nerve cells, both near and at a distance from
the points of infiltration, containing on one side an accumulation of
so-called “ yellow pigment ”—a change which is hardly to be accounted
for by the age of the patients but which may possibly be due to the
severity of the disease.
Besides these alterations of general character which correspond,
more or less, to those already known and are tcf a point common to
many nervous disorders of inflammatory origin, our attention was drawn
to a curious appearance seen in certain groups of nerve cells, in the
protoplasm of which peculiar granules are visible. These granules vary
in number; some cells are packed with them, others contain very
few, and all gradations may be found between these two extremes.
Their position differs in different cells according to their number and
to the degree of degeneration of the cytoplasm. They are generally
spread evenly over the cell and are never accumulated at one end as
is the case, for instance, with the yellow pigment mentioned above.
The granules measure roughly 1 fi in diameter, but they vary from
the size of a filter-passing coccus to that of a streptococcus. In
their general appearance they recall that of the pigment granules
seen in red corpuscles in tertian malaria.
These bodies were first noticed by us as black masses in Bielchowsky
preparations of the mid-brain in the neighbourhood of the substantia
nigra, but as they were much smaller than the melanin granules in the
cells of this region, and were also present in cells well outside the
substantia, a search was made for them in other sections. We were
able to identify them in almost all our preparations from the medulla
. oblongata to the thalamus, and they could even be found in the cerebral
cortex and spinal ganglia. In Bielchowsky preparations they appear
brownish-black; with toluidin blue, polychrome, methylene blue,
Giemsa’s and Leishman’s stain they appear dark green. To
our surprise we could easily recognize them in sections stained with
Section of Pathology
45
haematoxylin and in unstained sections as small yellowish-brown
granules. This led us to suppose that they consisted of pigment, but
histo-chemical reactions threw no light on their nature. They do not
react to any of the tests for iron ; prolonged immersion in dilute acids
and alkalies has no effect on them; they do not stain with Sudan or
scharlach red, and attempts to test for sulphur were negative. The
presence of these granules is associated with rapid degeneration of
the cell, a portion of which may be swollen and diffusely stained
while other parts still contain Nissl bodies. There is often a striking
contrast between the eccentric, shrunken nucleus, and the comparatively
healthy protoplasmic processes. Some cells are so packed with granules
that the nucleus is almost invisible, the cell processes being sometimes
intact and having sometimes completely disappeared. Others are
reduced to shadows in which a varying number of granules still remain.
In silver preparations the rapid destruction and clumping of the neuro¬
fibrils in the cell body (though not in the processes where these still
exist) are in remarkable contrast to the condition seen in ordinary
accumulations of pigment where the neurofibrils are pushed aside but
not destroyed. We would point out that not all degenerated cells
by any means contain these granules, and this may explain why other
observers have failed to notice them. Granules are also present in the
tissue outside the nerve cells and are frequently found inside various
phagocytic cells.
The difficulty of explaining the presence of this granular, pigment-
resembling, material in the nerve cells and its connexion with cell
degeneration suggested investigation by bacteriological methods. Though
our researches are still incomplete, in sections stained by Giemsa’s
or Leishman’s method, followed by toluidin blue, we were able to
detect, in certain cells, bluish-white bodies, oval or round in form,
about half the size of red corpuscles. Some of these bodies appear in
cells in which there are no granules, others occur where granules are
present, and in this case there seems to be a granule in each body.
This corresponds with the observation that in Bielchowsky, and some¬
times in Nissl preparations, every granule appears surrounded by a sort
of halo. These bodies are also found in nerve cells in frozen sections
stained by Sudan III.
No similar appearance has been seen by us in preparations from
cases of poliomyelitis, but our investigations are still proceeding.
In our search through the literature of the subject we have not so
far come across any description which coincides with our observations.
Section of pathology
President—Dr. W. Bulloch, F.R.S.
Diffuse Emphysema of the Intestinal Wall (two cases), with
Remarks upon Pneumatoses . 1
By C. A. R. Nitch and S. G. Shattock, F.R.S.
De emphysemate diffuso intestini parietum, cum de
pneumatose commentariis.
Summarium disquisitionem sequitur.
PART I.
One thing which makes the remarkable condition we propose to
record in the present communication of particular interest is the fact
that its production as a post-mortem event may be absolutely excluded;
for, in the first case, it was unexpectedly discovered during an operation
for the treatment of pyloric stenosis ; and, in the second, at an operation
for what was thought to be an intussusception.
History .—The subject of the first was a schoolmaster, aet. 48, who
had suffered from troublesome flatulence and recurring attacks of indi¬
gestion with epigastric pain, about one and a half hours after food, for
fifteen years. The attacks lasted for a month or more, and the pain,
which at times was very severe, was always relieved by vomiting. In
1912 the pain became almost continuous and was accompanied by
increase of the flatulence and distension of the stomach. On the
advice of his doctor he consulted Dr. A. E. Russell, who made a
diagnosis of pyloric stenosis, secondary to ulceration, and advised an
operation. As the patient refused surgical treatment, his doctor taught
At a meeting of the Section, held February 4, 1919.
Sictimi of- Pathology 47
him to wash out ht* stomach with a rubber tube, and this be- carried
out daily for six years. The lavage conferred relief, but, as might be
expected,, he ■ became so weak and emaciated thatm dune 1918, he
only weighed st. He,then again saw Dr. Russell, who succeeded uj
persuading hisn tor .suhtmt to an operation, H& eaterfed: St, Thoiiiag’s
Hospital On June \91*.. He was very weak and thin. -life..stomach
waa sio greatly xhkted that atg fbxyar border vra# level wffch the crest
of the ilium. Theresas moderate gastric, peristalerc. i (C . A. R. N >
operated upcm hi?n. on duly 3 and found an extreme degree otlafcenoeis
. .R'k'-.i.
IV>rt,ioi'! <>i i.lUi amiirt .iutaifitie, from. tW «•*<*' of jtyUmc dtewiifawly
$$ it app eared wbtin (Aposed d wring lift- ; showingaumornus hlkh* p*£ ctg
bHiieaiii tW pcntbucuni $xi^t»\yn from a sketch made by J Mr. whilst
fche £at w§§rKposod flursDg life (Natuvul siw.)
r>Qtira< c.zviicatw.
Intern/■ tennis portu/ .it apparebat quum it/ aegri corpora inspieiebaiiitv
Siil> i^mbfAfiK ^4nr^ eyates qtiae nero infiat&e *mii,
iApud |jyk»riim du<i(l*miurivoidc*^Vinvi.rictrim sst, . (Magmtu/lixiis tffcttfralis*)
of the. pylorm, for which a posterior no-loop gastrojejunostomy wa&
•performed. -On drawing up fcbe great, omentum to prepare the field
For the anftfcfcoihosisu a Cod of small intestine, studded with . greyish-white
48 Nitch and Shattock: Emphysema of the Intestinal Wall
elevations presented in the wound. On close examination these proved
to be multilocular subperitoneal cysts, and on puncturing one of them
I was astonished to find that the contents were gaseous and not fluid.
The cysts were dotted more or less evenly over the whole circumference
of the bowel, and there were also a few, about twice the size of a pin’s
head, in the transverse mesocolon, and at the base of a few of the
appendices epiploic®. With the exception of the first 12 in. of the
jejunum and the last 12 in. of the ileum the whole length of the small
intestine was affected. The freedom of the first part of the jejunum
was fortunate, as otherwise an anastomosis would have been attended
with grave danger of leakage, owing tgt the multiplicity of the cysts.
The mesentery of the small intestine, and the walls of the stomach,
duodenum, and colon were normal.. The patient made an uninterrupted
recovery, and, two and a half months later, in answer to a letter, states
that though he still has occasional flatulence it causes him no pain nor
inconvenience. His bowels now act regularly without an aperient, he
has gained 2 stone in weight, and has resumed his work.
The lesion naturally falls into the comprehensive group which has
been designated Pneumatoses 1 ; a group comprising the various con¬
ditions resulting from the presence of air, or the formation of gas, in
the tissues; in contradistinction to dropsical accumulations of fluid,
whether in connective tissue or in serous, synovial, or mucous cavities.
At the present time a long list might be drawn up from such a patho¬
logical standpoint, although the generalization, by reason of the
diversity of the conditions included in it and their etiological dissimi¬
larity, is too artificial to be of any great clinical service..
In the following remarks the different forms of pneumatosis are,
for the most part, merely enumerated, so well and generally are they
known ; any comments being confined to the less usual varieties. The
group, if reconstructed, may be made to comprise :—
1 J. P. Frank, 4t De curandis hominum morbis. Epitome praelectionibus academicis
dicata,” Mediolani, 1812, lib. vi, “ Pneumatosis,” p. 38. “ De curandis hominum morbis.
Epitome juxta ejus praelectiones in clinico Vindobonensi habitas ; a nonnulis suorum audi-
torum edita.” Liber sextus. Editio secunda correctior. Vienna, 1821, 41 Pneumatosis,**
p. 19. The subject of pneumatosis is developed by Frank at considerable length, further
•detail being added in the later of the two editions above given. The formation of gas by
bacteria being then unknown, the authors arrangement of matter, and his deductions are to
this extent faulty.
Section of Pathology
49
(I) Bacterial Pneumatoses : Gas productions in the Living Body,
IN WHATEVER POSITION ARISING, DUE TO THE AGENCY OP Bacillus
aerogenes, Bacillus cedematis maligni, Bacillus cedematiens, OR
Bacillus coli.
Besides the various forms of Gas-cellulitis and Gas gangrene, there
would be included the Pneumo haemothorax resulting from the infec¬
tion of blood in the pleura, with aerogenic bacteria, now so well
recognized a complication of infected gunshot perforations of the
thoracic wall and lung; the gas production in the vaginal wall, in
Vaginitis emphysematosa ; and the Intra-uterine, which takes place
from the death and decomposition of the foetus. The emphysematous
variety of vaginitis is described as occurring in pregnant women, or
after parturition, in women the subjects of gonorrhoea, by the formation
of hard congested papules which suppurate and become filled with gas;
the gas being produced by Bacillus aerogenes.
Closed tympanitic abscess, due to gas-forming bacteria, without
perforation of the intestinal or respiratory tract: Of this a better
example could hardly be cited than that recorded by Hunter 1 : “In
one instance I have discovered air in an abscess which could not have
been received from the external air, nor could it have arisen from
putrefaction.” There was no communication found after death with
either the rectum or uterus, but there was a small communication
between the abscess and the bladder. It was only towards the latter
end of life, he remarks, that the air could have made its escape into
the cavity of the bladder, for it was'not possible to squeeze the air out
of the tumour when the patient was first seen; but just before death
tbe swelling became more flaccid. The swelling was situated in the
lower and right side of the abdomen, extending nearly from the navel
to the spine of the ilium on the right side. It was tense, and could be
made to sound almost like a drum. It had come on within a few
weeks. At the autopsy a cavity was found between the bladder, uterus,
and vagina, on the right side, something like an abscess. From the
side of this cavity there was a canal ascending to the brim of the pelvis,
and communicating with the tumour. Hunter excluded putrefaction
since there was no foul odour when the swelling was opened. This,
of course, only means that the gas formation was not due to the colon
bacillus.
' Works, Part IV.
AU38
*50 Nitch and Shattock : Emphysema of the Intestinal Wall
Pneumoperitoneum, from gas formation following perforation of
the vermiform appendix, intestine, or stomach. Here the pneumatosis
may, in some cases, be due to a bacterial formation of gas in loco; in
others, the intraperitoneal gas is produced partly in loco by the bacteria
in extravasated faecal material, and is partly that displaced from the
lumen of the stomach or bowel. The passage of gas from the intestinal
canal into the urethra, vagina or uterus, through fistulas, whether per¬
forations caused by ulceration, or malignant growth, or communications
of a teratological kind do not require comment. Nor does the tym¬
panitic distension of the stomach and intestine from the accumulation of
gases, brought about by mechanical obstruction, by the reflex inhibition
of intestinal tone, or by abnormal fermentation, &c.
Pneumatoses due to the Entrance of Air into the Serous
Cavities, the Connective Tissue, or the Alimentary
or Genito-urinary Tracts.
Pneumothorax. —The escape of air into the pleura, though commonly
the result of injury to the lung through the thoracic wall, or of the
thoracic wall alone (as when a subphrenic abscess is opened by the
thoracic route), is in rare cases due to perforation of the lung from
disease. So good an instance of the latter was recently observed at
St. Thomas’s Hospital by Dr. C. R. Box, that it may be here cited.
It is thus described in the museum catalogue of the hospital.
1866 A: The right lung of a child 3 months old. The upper lobe
has been longitudinally divided to display a somewhat irregular cavity
about the size of a walnut, which is partially filled with necrotic
material, and has resulted from the necrosis and disintegration of a
tubercular focus. The vomica communicates through a small circular
aperture with the pleural cavity: the pulmonary tissue around is thickly
strewn with miliary tubercles. The perforation was followed by pneu¬
mothorax. The lower lobe is shrunken from collapse. The patient
had suffered from cough for three weeks. Dyspnoea suddenly developed
(from the escape of air into the pleura), and the patient died the same
day.
In connexion with pneumothorax, lastly, must be added that pro¬
duced surgically by the injection of nitrogen to procure collapse of the
lung in the treatment of pulmonary vomicce ; and the forcible injection
of oxygen into the pleural cavity for thq complete evacuation of intra-
thoracic effusion.
Section of Pathology 61
Pneumoperitoneum, of. non-bacterial origin. In rate eases to be
presently cited, it has been ‘inferred that gaa may find its way into the
peritoneal cavity'from.;title• The entry of
rot, it may be in considerable amount, which not infrequently occurs on
opening the abdomen, in the Treudelenburg position, is a form of
poeutaoperifconeiua resuiting from the negative pressure produced by
the gravitation of the abdominal yiseera. The admission of air is devoid
of any adverse consequence, even if the abdominal parietes are sutured
• i 0 Ki, 2v, , ; .
Ti?o lung of an infant sbowiug «t small pefforutiou (marked witty* brisfcto)
over » tatoculnr cafitv, .from. which jimiuoiotboriiJt reftilUed. Dyspaaea sufl-
deEly develop'd; <!eatb ticcutnng tbe sama dnv.
Infanfcis jrointe m #0# ea*iiii-s e tofc^roukwo ortft cavitate ia pleunim uupof
apettu> xiftfcurMiM
without its evacuation. As m a pneumothorax, the oxygen and carbon
dioxide of the included air would, doubtless, owing to their greater
solubility, be absorbed first; the nitrogen, last. Mi', li. I. Pococsk, the
52 Nitch and Shattock: Emphysema of the Intestinal Wall
Superintendent of the Zoological Society’s Gardens, tells us that he
once saw a collection of air in the abdominal cavity of a newt, so
extensive as to force the animal to float in the supine position; on
puncturing the distended cavity it quickly refilled; death occurred shortly
afterwards. The lungs in this batrachian are two simple tubular sacs,
which lie free within the abdomen, and in immediate contact with the
intestines, there being no trace of a diaphragm. A rupture of the lung
under these circumstances would be followed, therefore, by pneumo¬
peritoneum, and this is apparently what had happened.
Pneumopericardium. —In gunshot injuries, the chest wall, lung, and
pericardium, may be successively perforated without immediately fatal
result, but there does not appear to be any case on record of air having
reached the pericardium under such circumstances. The production of
gas from bacterial infection of the injured sac has, of course, to be
aetiologically differentiated.
After penetrating wounds of the chest in the cardiac region, Mr.
S. Maynard Smith 1 has observed a peculiar double click corresponding
with the heart sounds, and heard on auscultation, or sometimes even
at the foot of the patient’s bed. As a rule, it disappears after forty-
eight hours. The absence of pericarditis shows that pneumopericardium
from the entry of air, or from gas formation, is not the explanation of
the phenomenon; and the only suggestion as yet made is, that it arises
in some way from the presence of air in the mediastinal connective
tissue.
The Presence op Air in the Genito-urinary, and
Alimentary Tract.
Akin in its mode of production to pneumoperitoneum arising from
the entrance of air during laparotomy is that which takes place spon¬
taneously into the Vagina, from which it may be afterwards expelled.
The occurrence was well known to Hunter (Works, vol. iv), from
observation and inquiries of his own. In one of his cases an examination
made during life, and again after death, upon the same individual, dis¬
closed no disease either of the vagina or of the uterus, a circumstance
which led him to think that the gas was “ secreted or let loose from the
blood.” The presence of air in the vagina, it need hardly be said, is
due to its entry under the negative pressure accompanying a temporary
displacement of the abdominal viscera, such as may happen during
1 “ Pericardial Knock,” Brit . Med . Joum 1918, i, p. 78.
Section of Pathology
53
reclining or stooping, and occurring in subjects with a weak vaginal
sphincter. Visceroptosis would doubtless predispose to the condition
by facilitating the production of such a negative pressure; and some
such defect is probably the factor which leads to this “ ballooning ” of
the canal. In one instance, however, the entry of air was associated
with a defective development of the labia and nymphse, and prolapse of
the anterior wall of the vagina. This case is from the Bussian, 1 and
in comment, it may be observed, that by a certain Bussian sect [Skoptzi]
mutilation of the female (and male) external genitals is practised as a
religious rite; not improbably the defect referred to resulted in this
way. In the same manner, when a vaginal examination is made with
the speculum, in the Trendelenburg position, a free entry of air may
take place as soon as the sphincter is passed and its action annulled.
The presence of air in the vagina is a matter of ancient knowledge.
In the earlier edition of Frank (loc. cit.), it is alluded to as “ garrulitas
vuIvob,” for which “ garrulitas uteri ” is less correctly substituted in the
second edition; and equally incorrect is the term “ garrulitas vaginas ”
sometimes used ; the first of the words, in each case, indicating, of course,
the noise occasioned by the escape of the included air. The expression
“ garrulitas ” is referred by Frank (loc. cit.) to the Boman epigram¬
matist, Martial. In the original it is used without any second
qualifying word, the site of the air being deduced from the context. 2
Uterine pneumatosis may arise from the inclusion of air in the
uterus after expulsion of the foetus. In other cases, as already
mentioned, it has a bacterial origin, and follows upon the death and
decomposition of the foetus.
Air may even find its way into the Urinary bladder in small quantity
when a catheter or the cystoscope is passed, in the Trendelenburg
position, should the viscus contain only a little urine: the air may be
afterwards evacuated with the urine, or found in the bladder when this
is opened suprapubically for the completion of a surgical operation.
The modus operandi of Kelly’s speculum for the cystoscopy of the
female bladder and ureteral catheterization, is dependent upon the free
entry of air which takes place into the viscus when the instrament is
passed in the Trendelenburg position.
A further instance of the same class is the entrance of air into the
Rectum when the speculum is passed in the knee-elbow posture, or with
1 Lancet, July 23, 1892, p. 238.
2 Liber, 7 ; epigram, 18; Marii Valerii Martialis Epigrammata. Ex editioni Bipontina :
A. J. Valpy. London : 1823.
54 Nitch and Shattock: Emphysema of the Intestinal Wall
the pelvis raised and the patient on the left side. The negative pressure
resulting from the gravitation of the abdominal viscera causes the bowel
to balloon up for several inches beyond the end of the speculum, and
greatly facilitates the inspection of the interior. And the same thing
occurs in the pelvic colon beyond the sigmoidoscope.
The most curious examples of rectal pneumatosis, however, are those
where air can be voluntarily aspirated into the bowel. The first caBe
of this kind is recorded by Marcel Baudouin, 1 2 under the title, “ Un cas
extra-ordinaire d’aspiration rectale et d’anus musical.” It will be
enough to state that the aspiration occurred for the first time, quite
unexpectedly, and much to the subject’s surprise, whilst he was swim¬
ming, the sea-water being afterwards evacuated. He found that by
making certain movements he could store water, and later on air, at
will. For the latter purpose, standing upright, he would bend the
trunk forwards so as to bring the chest nearly horizontal; the knees
were then grasped with the hands so as to give a firm point d’appui to
the upper limbs. After a short inspiration the arms were stiffened,
and a considerable effort and certain movements being made, air entered
the bowel with a muffled noise like that of inspiration through the lips
when half closed. The expulsion of air could be so regulated as to
produce notes of varying pitch, and even recognizable airs. Since the
publication of this case several others of the same kind have been
recorded, as will appear from the subjoined list which Dr. Arthur
Saunders was good enough to compile. 3
The regular aspiration of air into the (Esophagus and the immediate
dilatation of the latter when the straight tube of the oesophagoscope
has passed the lower sphincter of the pharynx (or upper sphincter of
the oesophagus) is a striking phenomenon, and may be viewed as largely
if not entirely due to the negative pressure or vis a fronte set up by
the descent of the diaphragm, and the expansile movement of the
thoracic wall: for it is a matter of clinical observation that the passage
of the instrument is accompanied with an involuntary inspiration:
during the examination, the patient, it may be said, is in the strictly
supine position, with the head lowered. The slow, minor rhythmical
movements of dilatation and contraction observable in the tube when
1 La Semaine M4d. t Avril 20, 1892, No. 19, pp. 144-146.
2 “ Musical Anus,” V. E. Allaben, Weekly Med . Rev., St. Louis, 1892, xxv, p. 611. “ Un
nouveau cas d’aspiration rectale et d’anus mfesical chez la femme,” Marcel Baudouin ; Gaz.
Md. de Paris, 1898, p. 266. “Les Anus musicaux en Extrdme-Orient,” Dr. Michaut.
Gae . Mid . de Paris, 1898, p. 324.
Section of Pathology
55
so dilated up, are probably due to the fluctuations in the negative pres¬
sure occurring with respiration. This is more probable than that they
represent the beats or so-called pendulum movements of the normal
intestine, as distinguished from its peristalsis and the segmentation
movements discovered by Cannon. This is a subject, however, worthy
of further physiological study.
Apart from oesophagoscopy a similar occurrence from displacement
of the viscera, is at times observed during operations upon the abdomen,
the air being aspirated into the stomach, whence it may be expelled by
external pressure.
The aerophagy and subsequent distension of the stomach in hysteria,
although not a phenomenon in precisely the same category, may be
alluded to here. And quite apart from any neurosis, some are able to
swallow air by a voluntary effort, and in such amount as to produce a
visible abdominal swelling. In the horse, aerophagy is familiar to
veterinary surgeons; certain animals acquiring the habit to such a
degree as to be known as “wind- or air-suckers.” The acute form of
tympanites of the rumen in cattle, which follows surfeit with green
clover or grass, is due to the liberation of gas from the ingesta, and not
to aerophagy. The distension may cause death from heart failure : it
is at once relieved by puncturing the rumen with a trocar and cannula.
The foolish practice amongst operatives in engineers’ shops, of inserting
the nozzle from a compressed air supply into the mouth of a fellow
workman, or over the anus (outside the trousers), may be mentioned to
close this group, for in both cases it has been followed by fatal results.
Lastly, air may enter a Joint, certainly, at least, the knee, on its
being surgically opened. When the knee is flexed and the synovial
membrane exposed by dissecting through the fibrous capsule (for the
removal—e.g., of a loose body) the membrane is found firmly withdrawn
over and between the articular ends of the bones, and on its being
incised the negative tension within is at once relieved by the entry of
air, which can be expressed at the conclusion of the operation.
Into the category of pneumatoses from the admission of air would
fall, also, the Inflation of Abscess cavities. Setting aside the minor
examples where a periglandular abscess discharges into the lower part
of the trachea, and becomes thereupon temporarily filled with air, we
can adduce one example,' which was recorded by Mr. H. H. Clutton , 1
and of which the specimen is contained in the museum of St. Thomas’s
Hospital.
1 Trans. Path , Soc. Lond ., 1987, xxxviii, p. 130.
56 Nitch and Shattock : Emphysema of the Intestinal Wall
Specimen No. 910: A tongue with the larynx and parts below.
Behind and to the right side of the oesophagus and pharynx there is
an extensive, somewhat irregular cavity, lined with granulation tissue.
Bods of glass have been passed from the cavity (which reaches below
as far almost as the arch of the aorta) through a small circular aperture
of communication, into the trachea, and through a second, larger, oval
one about £ in. in chief diameter, into the left side of the oesophagus;
this lies at a slightly higher level than the tracheal; both are well
defined. From a man, aged 24, subject, to epileptic fits. On
September 13, after a violent fit, he noticed pain and swelling in the
neck, from which the disease dated. Death occurred from septic
broncho-pneumonia. That the abscess had;opened into the adjacent
passages appeared, during life, from the presence of pus behind the
pillars of the fauces. After leaving the hospital (October 4, 1885), he
attended as an out-patient. On October 6 there was scarcely anything
to be seen on inspection of the neck, but on digital examination in the
position of the abscess, crackling could be felt: this disappeared on
pressure, but reappeared when the patient was directed to cough, or to
strain, with the mouth and nose closed. October 13 : Air could no
longer be forced into the cavity. He was re-admitted on October 23,
with broncho-pneumonia, and died on November 3. The cause of the
abscess was, conjecturally, some trauma of the oesophagus occasioned
by the swallowing of a foreign body during the epileptic fit.
Emphysema of Connective-tissue from the entry of air. The
emphysema, whether subcutaneous or of the deeper tissues of the
mediastinum, after injury to the lung and thoracic wall; the inter¬
lobular emphysema of the lung itself, following rupture of its vesicles,
or extending from a mediastinal emphysema by way of the root of the
organ, are things merely to enumerate. And equally so is that of the
neck following wounds of the larynx or trachea; or that arising during
tracheotomy from the impeded exit of air caused by faulty manipula¬
tion in the insertion of the tube.
The emphysema of the neck which may accompany paroxysms of
coughing in phthisis, or pertussis in children, results from the rupture
either of pulmonary tissue or of bronchioles in the vicinity of the hilum,
whence the air is driven upwards through the mediastinal connective
tissue, and so beyond the confines of the thorax. In a few instances
the phenomenon has been observed after the lodgment of foreign bodies
in the air passages, the mechanism of its production being the same
57
Section of Pathology
as in the diseases cited. Eppinger 1 views the multilocular sacculation
of the trachea found in some cases of respiratory obstruction as due to
the inflation and dilatation of the mucous glands. To-this it may be
added- that the emphysema following acute obstructions, were its
precise origin traceable, might in some cases be found to arise from
the rupture of such distended glands, for these are distributed not only
in the wall of the trachea, but in the bronchi and their subdivisions.
Cervical emphysema as a complication of pulmonary influenza is
referred to by three speakers in the “ Discussion on Influenza,” held at
the Royal Society of Medicine, 1918. 2 From the neck the emphysema
may spread over the whole body. The respiratory symptoms may be
unimportant, and paroxysms of coughing absent. As pointed out by
Sir Bertrand Dawson and General W. S. Thayer, this creates a diffi¬
culty. The emphysema accompanying influenzal pneumonia is most
probably due to the fact that the pulmonary infection is of a mixed
kind, and that the pyogenic bacteria bring about perforation of the
terminal bronchioles, the final result being parallel with that seen in
a haemorrhagic inflammation.
Emphysema of the neck is a well established complication of
“ gassing.” Of this there are three examples in the collection of War
specimens in the Museum of the Royal College of Surgeons. These
antedate the introduction of “ mustard ” gas, and were due to the
action of chlorine alone, or combined with phosgene. In one (No. 128)
death occurred fifty-one hours after “ gassing.” Post mortem : Much
froth on the lips and nares; emphysema of the mediastinal and peri¬
bronchial tissue, none of the subcutaneous tissue of the neck. When
admitted, thirty-six hours after being gassed, the patient ^as cyanosed
and unconscious. In the second (No. 130), death took place after
thirty-six hours, the patient being cyanosed, unconscious, frothing at
the mouth, and expectorating yellowish fluid tinted with blood. Post
mortem : Lung nearly solid from oedema; interlobular emphysema,
and extensive emphysema of the connective tissue of the neck. In the
third (No. 126), death ensued fifty-eight hours after gassing; there
was marked cyanosis. Post mortem: At the lower part of the lung
air had escaped into the interlobular connective tissue; there was
emphysema of the connective tissue of the neck, both superficial and
deep, extending from the mediastinum. When admitted, December 20,
1 “ Path. Anat. des Kehlkopfes und d. Trachea/* Klebs* “ Handbuch der pathologischen
Anatomic,” Berlin, 1880.
* Proc. Roy. Soc. Med., 1919, xii, pp. 60, 64, 100.
58 N itch and Shattock: Emphysema of the Intestinal Wall
1915, the breathing was irregular, and gasping; the r&les in the chest
were audible several feet away; there was marked cyanosis. The
patient had be'en gassed probably the day previously.
The macroscopic anatomy of these three specimens is practically
identical. In each, the lung is almost solid from the (artificial) coagu¬
lation of the albuminous exudate filling the alveoli; scattered through
it there are other areas in which compensatory emphysema has taken
place. One factor concerned here in its causation may be the rapid
production of compensatory emphysema which takes place in the small
areas of pulmonary tissue distributed between those which are filled
with serous exudate and thrown out of action. The intra-alveolar
effusion resulting from chlorine gassing, with its accompanying com¬
pensatory emphysema, is of rapid onset. That the latter per se may
suffice to bring about a rupture of the alveoli appears borne out by the
clinical observation of Dr. T. E. Elliott, that in phosgene poisoning
where there is pronounced pulmonary oedema, with little coughing,
subcutaneous emphysema, although rare, occurs. In this connexion, it
is of interest to know that experimentally the rabbit may be killed by
the contralateral emphysema and pneumothorax produced when
collapse of the opposite lung is brought about by the insertion of a
laminaria plug in the bronchus. In the case of chlorine gassing the
violent cough set up in the earlier stage is doubtless the second factor
which renders subcutaneous emphysema more frequent than in the
other.
The artificial production of emphysema has been practised for
various purposes: in horses, to conceal bony eminences and give a
delusive appearance of fatness; by the Chinese in the treatment of
sciatica and chronic arthritis; and even in children by inhuman parents
in order to excite pity for the purpose of begging, the skin being
punctured behind the ear, and the subcutaneous tissue inflated so as
to simulate hydrocephalus (J. F. Frank, loc. cit.).
The dishonest custom, once common, of inflating the subcutaneous
tissue of calves, after killing, is at present illegalized in this country.
There is one grave, morbid condition, in the treatment of which
a form of pneumatosis is practised, however, which is so efficient that
it is fully established in veterinary medicine. In the so-called “ drop ”
or “ milk fever ” of cows which arises, in a small percentage of the
animals, a day or so after calving, and leads to fatal coma, it is the
practice to force air into the udders through the teats, each of which
has a central canal, at the bottom of which the lactiferous ducts open.
59
Section of Pathology
The striking and regular result of this treatment is almost immediate;
the coma rapidly passes off and the animal completely recovers. The
pathogenesis of the disease, and the modus operandi of the injection
are, as yet, undetermined. This therapeusis replaced the injection of
potassium iodide solution into the ducts—a procedure based on the
hypothesis that the disease was due to bacterial infection. The sub¬
stitution of air arose as the result of an accident: by an oversight the
solution was not put into its receptacle, and air was unwittingly pumped
in in its place, with identically the same benefit. The disease so plainly
.suggests a parallel with post-partum eclampsia in the human subject
as to raise the question whether a similar mode of treatment may not
be indicated in the latter.
It has been asserted that persons in the habit of playing on wind
instruments not infrequently suffer from a painful inflation of the
cheeks, arising from the forcible introduction of air into the connective
tissue through lacerations of the buccal mucous membrane. We have
been unable to obtain any confirmation of this statement, although
pain in the cheeks is a well known result under such circumstances.
Mr. Herbert Tilley has seen a submucous emphysema arise when
a fine Eustachian bougie had, by misadventure, perforated the mucosa
of the tube, inflation being afterwards carried out through a catheter.
The emphysema spread into the corresponding side of the soft palate
and pharynx, and even to the subcutaneous region below the lobule of
the ear and behind the angle of the jaw. And in a case witnessed by
Mr. H. J. Marriage, the air extended down the neck as far as the
clavicle during an attempt to inflate the tympanum, after the mucosa
of the tube had been injured by the Eustachian catheter.
In the St. Thomas’s Hospital Reports, xxxvii, there is tabulated
the case of a female child, 1& years old, in whom a subcutaneous
emphysema appeared on the left temple and left side of the face, after
a paroxysm of coughing, but the site of the trauma in this case was
not ascertained.
A local subcutaneous emphysema of some practical interest is
observed now and then at the site of punctured wounds limited to the
skin and muscles of the abdominal parietes, whether due to gunshot
missiles or pointed instruments (W. H. C. Romanis). The entry of
air is occasioned by the negative pressure produced by the expiratory
movements, the aperture itself being oblique in direction, and so
-valvular in kind. The importance of its recognition arises, as Mr.
Romanis observes, from the possibility of its being erroneously taken
6o Ntfcch and Sbattock: Emphysema Pf the Infmtimil Wall
ns evidence of intestinal perforation, whereas the peritoneal cavity
itself is intact..■■ Something of the same kind i? observed at times in
paracentesis of the chost, when a local inflation of the subcutaneous
tissue about the jmnetuvo occurs f'roiii a like cause.
As still less known is subejlfcaneoiTS ertiphysema Of the neck it» birds,
of which there is a curious specimen in the museum of the Boyal
l oiloge of Hurgeons :- -
A. 401? ; A young skylark (Alauda arfensis), 14 dflys old. The
neck is remarkably ami symmetrically swollen from emphysema of
m; a :
A skylark (Ahw.dn arven*is) , U flay'd old ^bowing emphysema of tte «u>» :
cutaneous tissue, of the nock due to injury vdb*r cd Uu trachea, or of unc £$ Mir
air aacB lit the mot of tljc neck. .'Th.p neck ot tfaiMlrd is readily discmtihkr
parsing throufiiti the froiit of tiio eavity. {Nanuui &Uti.)
Fujutut' cy[di*:atio.
Ayra ,t lAfttiu iHi < 'iisi *), die* wn quatuordecim eujun in eerviao cuto' mon-
iifftitta'* trachea, ^eeufufc -y«rvit:a3is qui cum pulmuno
n*)nrtaHt^r oomniXifdoatj p»re?iitf;>- f.ofitro tortffosc pyrTorutris eat in progeme
lijondiu (MagpitadlpiS liatr.nvU*.)
the subcutaneous tissue. Two other birds. fromthe sairse nest were
ijutte rsormiU. Superiorly the air ekteinls beneath the mandible to
the tip of the beak, but not between the oyefl, nor o*er the vertex
Section of Pathology
61
of the skull; nor does it reach over the front of the thorax or front of
the abdomen, though it lies between the wings and passes downwards
to the sides of the thighs, omitting the lumbar region.
The anatomical distribution of the emphysema can be easily repro¬
duced after death by inflating the subcutaneous tissue of the neck in
any small bird, its higher limitations being due to fascial attachments.
The air sacs of birds were described simultaneously by Hunter, 1 and by
Camper, in Holland. Suffice it to state that they are quite distinct
from the spaces of the general connective tissue, and receive their air
directly from the lungs; some lie in the neck, some in the abdomen,
and others extend into the shafts of many of the long bones, which are
filled with air instead of marrow. Hunter (loc. cit.) remarks that when
birds break any of such bones the surrounding parts often become emphy¬
sematous. “ Besides the attachment of the lungs to the diaphragm,
they are also connected to the ribs and to the sides of the vertebrse.”
“ Such adhesions are peculiar to this tribe of animals, and . . . necessary
in lungs . . . out of which it is intended the air should find a passage
into other cavities.” “ There are openings in the lungs by which air is
transmitted to the other parts, and the diaphragm is perforated in
several places with holes of considerable size, which admit of a free
communication between the cells of the lungs and the abdomen.” “ At
the superior part the lungs have a communication with the large cells
of a loose net-work, through which the trachea, oesophagus, and great
vessels pass as they are going to and from the heart.” (Hunter,
loc. cit.)
In the accompanying figure is shown the trilobed upper limits of the
air sacs at the root of the neck in a nestling tit, as they appeared when
inflated. The projection occupies the fossa bounded by the united
clavicles, and lies immediately in front of the trachea (on the left-hand
side), and the cervical spine. The pharynx is remarkably capacious
and passes into an oesophagus proportionally wide, which enters the
thorax without expanding (as in some birds) into a reservoir or crop,
and eventually opens in front of the lungs into a more thickly walled
glandular stomach. In the common pigeon a‘tripartite extension of
the air sac projects in the same way for a short distance into the root
of the neck, as may be easily demonstrated by inflation through a
cannula tied into the trachea after the crop has been opened and
emptied of its contents through a free incision from the front. The
1 “ Works,” iv, p. 176.
“ Of Air Cells in Birds.
<>3 Niteb and Shafcfcock;: Mrnphymtut of ike Intestinal Wall
dietribotion of the aic sacs in birds may be displayed radiographically
by the injection of bigrorrth mucilage into the trachea, after expression
of the air from the sac* and lungs,
A proper homologue of 3«eh «n emphj^sema would he limited, in the
bn man subject to injuries implicating the frpsrtai, masillaty, or other
accessory smhtjcA, '££ the tyriipamtm and niakioid eeUs. In the sit nation
first mentioned the complication m a recognised one. f» the St.
Thomas* ? Hospital Reports {100$), lor instance, there, is a ease of
fracture involving the outer wad of the .frontal sinus, itt a than, aged 52,
m fflfom emphysema of the forehead and left temple ensued from the
forcible extravasation of air, produced either by sneering, at by blowing
FlO.; 4.
The »*eb of n uestiim? ut 1 1 ‘arm - ij viowod fr«m Use frt-nt, the featbeBs
alooohuVmg <>e*u ronsovetl. IjyiaK heaeftUi this skin, uiuuwllately iti'. front, of
tbo n*c.lt«a loo t-bo loft-band sido) aod-tbc curvieitl portu‘i! : of tba Sfitrott coluttin,
thoro isi a miobod clevssticm ftllfivt with uir, which represent* the lug;Smut part of
thf“ osmpjex. nir-Bfi? about the vessel# at tfe coot I'f- tbeott.i'k, (Natural Size.)
.. pii/urae. explitnlyi.
A»i* ininiivturiv: {Ptitui cervix a fionto eapecta, plutais evulnis, Ante
trachebiuet cotJimqftm vartebraitoin mbfifitratilreWUiontift tripartite wereinfiata.
qnea pertain piprcmam rtL'pf&essWit&t Sncoyb intrAtborecitti eii.ni palmoiiibus coin
niumenutifi. na.tur;*!is.)
the nose to get rid of blood in the nasal cavity. The patient recovered.
But we are not aoipiauited with a comparable result arising after
perforation of auy of the other cavities enumerated, either from surgical
Section of Pathology
63
operation or disease. The well known emphysema at the root of the
nose which may be produced by forcible expiration after fracture of the
nasal bones, is not, of course, a homologue of the escape of air from an
air-holding bone.
In this admirable paper (p. 185), Hunter has the following sugges¬
tive sentence: “ How far this construction of the respiratory organs
may assist birds in singing deserves investigation, as the vast con¬
tinuance of song between the breathings, in a canary bird, would appear
to arise from it”—a subject that has since been elaborated. Dr. J. A.
Murray has reported 1 a case of sudden death in a Chilian sea eagle from
the rapid overdistension of an abdominal air sac as a result of valvular
closure of the mouth of the sac by blood clot.
That an inflated air sac might rupture during singing, and the
accident be followed by subcutaneous emphysema, is credible enough.
Nevertheless, an inquiry at the different aviaries of the Zoological
Society yielded the definite information that no such occurrence had
been observed either in singing or other birds; nor had it been seen
in any birds examined after death, a practice invariably carried out;
and the result is too striking to have escaped notice. In the case of
the lark, such a theoretical explanation certainly cannot be advanced,
since the bird was only 14 days old. The emphysema may have arisen
from the parent bird having punctured one of the cervical air sacs
from the throat, or having introduced some foreign body, whilst feeding
the nestling; for the pharynx and oesophagus are very capacious, and
the beak of the lark is long and sharply pointed. In this bird there is
no dilatation, or crop, at the lower end of the oesophagus, the latter
passing (within the thorax) into a more thickly-walled, glandular
stomach, and the latter into the gizzard. Or, taking into account the
distance between the upper limit of the air sacs and the pharynx, the
perforation, more probably, took place into the trachea, which lies
immediately in front of the oesophagus, the opening having been of
such a kind as to admit of the escape of air into the connective tissue
without its return by the trachea or through the oesophagus.
Air Embolism or Intravascular emphysema. — Although this
commonly takes place in an open wound from the incision or rupture
of a vein in the neighbourhood of the thorax, and results from the
negative pressure or vis afronte, produced in the veins by the inspira¬
tory expansion of the chest, there are rare exceptions. In a case which
1 Proc. Zool. Soc. 9 1919.
64 Nitch and Shattock: Emphysema of the Intestinal Wall
recently came to our knowledge, it arose daring urethroscopy. The
examination was being made in order to deal with a bleeding point at
the site of a stricture. During the inflation of the urethra by means
of the Wyndham Powell aero-urethroscope, the patient collapsed and
died, in spite of recourse to artificial respiration. After death air was
found in both of the ventricles of the heart. Here the air was,
without doubt, pumped into a bleeding vein, the mouth of which was
probably rendered patulous by its involvement in the indurated tissue
at the site of the stricture. The presence of air in the left side of the
heart as well as in the right does not present any difficulty, seeing that
the blood can be translated after death from the right side to the left
by the employment of artificial respiration, and that this was carried
out in thfe case under consideration. As a matter of fact, moreover,
it is not difficult to drive air after death from the right heart, through
the lungs, into the left. Observation: In a cat, shortly after death,
an ordinary double hand bellows was connected up with the right
external jugular vein; the bellows was distended after pinching the
exit tube; the air, suddenly liberated, and the vein tied. The front
of the chest was then removed and the pericardium slit open; the right
ventricle was found inflated. The animal was now submerged in a
long tank of cold water, and the heart being held so that the left
ventricle was uppermost, the latter was incised gradatim in its long
axis midway between the interventricular grooves; blood, freely ad¬
mixed with minute bubbles of air, escaped. After the intake of air,
again, under negative pressure, the contraction of the right ventricle
does not immediately cease, but supplies a vis a tergo which may propel
part of it through the lung into the left side.
In connexion with the passage of air through the lungs during life,
one remark may be made—viz., that in the dog a considerable amount
may be introduced into the circulation through a vein without a fatal
result, the gases becoming dissolved in the blood. Under such circum¬
stances, when the body is immersed after death, in hot water, gas is
liberated. Air might thus be found in the left side of the heart without
its having traversed the lungs in the gaseous state. It is well known
too, in surgery, that a certain amount of air may be heard to enter a
vein, in operations about the neck, without a fatal result. The appear¬
ance of gases in the blood and from the tissue-lymph in caisson disease
is, it need not be said, a liberation due to too rp,pid decompression of
the body after its subjection to an abnormal degree of atmospheric
pressure, and a consequent excessive solution of the oxygen and
nitrogen of the air in the blood.
Section of Pathology
PART II.
To return nowto the .first of the-two casts with which the present
communication is concerned, As already stated, the exterior of the
whole of ithe small ihtestjihe, etjapaaienciiog' about a foot feeyood the
dundetunn, was covered with henitspitencal or hemiovoidai blebs of
gas which eoUai)sed ah puncture, The condition Was associated with
a close striding immediately bevohd the^ sad. accompanied
with a long-standing dilatation af the stomach, the lower border of
which was level with the crest of the ilium.
I XAMINWTION OF Pon.TIfX OF THE INTESTINE EXCISED
m k?n<; Life.
For the purpose of ihVestigatiaii a Vcshaped piece hf the intestine
was excised transversely to its long axis, so as to leave the mesenteric
border id tact, the gap frying immediately sutured without any untoward
consequences, Its mucous membrane was raised in rounded, confluent
Etc.. 6, ' . . ■
(A) iX aarrtn? piece of Mh* >uimH mte*ti/i<^exc'-fe?d djirifcg Uf<s, vi Gyred front
tito timer a>p*ot.. The muooofc ixibwhmti* if m bauiierain6nce»
by tbe pr«i>o|aoo of ga* jj> tho HobaiUfiojGV. A.L .e‘i»d a 'got!ton vt ..tfre divided
aiiiscular coat lh sbowa. (Nnluntl
(B) a section tuacU: U»roq$fr '# portion of tfce same -piece oC small in testing,-
showing the multiple, tht? mucosa ; the muscular caat is* rccog.
m?,nbJo at the te p of ihp ftpfeetiftea. {Twice natural siize.)
}' ! U}xmie cjylicatio.
(A) tx.-pofam •1tit^tmfc.-6xci*a. MfiinbrAua mucosa projicitur ut in
bnliit* aqmirTis, an emphy wmate art tom parictum. Apxid utrumquc extreiuitotom
niaoMht$ur portio tanicae fnaturalis.)
vettfcaU^ ojusdmo poftlo ois infcostmo tequi oxoiaac. jrffoii>
atraa tot Atavito $&*[ five ey&Uss quae suib-uiqtrihtanA .jamcoati projicmufcur, fclr aero
iuffotyk mill. (Bis ma§qiiicata,)
6« Nifcch and Shafctook-j' .'Empkusema of the Intestinal Wall
; ' ■ |
elevations, obviously filled with gas. On the peritoneal aspect, the
intestine at this particular spot wae not mat, although at first
thinness and translucency of the wall led to the belief that the gas
cysts were beneath the peritoneum.
Hixtok<$y .Sections, cut in paraffin and stained with Ehrlich s
bs iiiafcojiylm and eosin yield the following results : The wails of the
spaces (which are limited to the sulminchs# consist of ordinary con¬
nective tissue in which there- is an ntfcor absence of siBftli-celled infil¬
tration or of any of the mark!-: of '■inflammation. Their inner surface
is. lined with a yioipie endothelium which is most, satisfactorily'seen
when part- of a trabecula is viewed on the fiat; the cells for Hi art
extremely thin, eontimlotifi rnhaanveod dre ftinnsbed with large oval
Mfcftxset'piC.. showing hbtr gjjtlai>hdh>U Umiig of ili« cyst#, 1ft lbe
upper it is thHitter tb*n in the Unvot* and includes it flattened'. nialhhjuc.if.ak*d
oell. Tht? hiKhoJogica) sigr;^ of infUnimatiori are quite.obaebi; ( ■ ubi.)
ligvrat- expl&aiw.
r&ctione* microsCQpkde nystintxi quaruiudatu iutra pa^iehes iubesimi
; .^Ltulae. qjulttk; eyffUffi ictus fcoguntHiv
CeUui*na& -nm- multi# no.cWw, jmxadiia ust. IntUimnatiouin ixuia- v>taIitBr
absent, (* obf.l
nuclei of the aeojil type. Here and there a flattened, multi nucleated
giant , cell fa intercalated between them. In the connective tissue of
the subnuicoBa in the neighbourhood of the cysts, and between the
layers of muscle, the strands of sympathetic, fibres and the nerve cells
of Meissner ’h and Auerbach’s piexuse* sxe particularly distinct, and
normal: Both the 'mucosa and the muscular wall are quite intact.
Section of Pathology
67
Certain of the spaces have a thin wall of connective tissue differentiated
from that around by its concentric disposition. The presence of so
complete an endothelial lining indicates that the spaces here shown
are lymphatic rather than clefts produced by the inflation of the con¬
nective tissue the walls of which have become lined with proliferated
lamellar corpuscles.
Pathogenesis.
(1) Is the Gas secreted !
The secretion of gas in the swim bladder of fish naturally suggests
such a question, especially as this organ is developed from the alimen¬
tary canal, and in some fish retains its connexion with it, so that the
gas, as is well known, can be liberated through the mouth : in others
the sac is closed, the removal of the surplus gas being then effected by the
sequestration of portion in the oval, a vascular sacculus which admits
of being shut off from the rest by means of a sphincter, from which it
is absorbed. Of the gases in the bladder, the 0 is secreted by the
epithelial cells of a highly vascular specialized gland, the gas-gland,
and is derived from the oxyhsemoglobin of the red blood cells: the N
probably diffuses from the blood plasma into the cavity as a result of
the unequalized nitrogen-tension. The gas-gland in Ophidium is a small,
somewhat reniform organ, which projects into the lumen. Its minute
structure is described and figured by Reis and Nussbaum. 1 The
secreting cells, of which the cytoplasm contains a certain number of
discrete gas vesicles, are of large size, and intimately connected with
the capillaries, some of which penetrate the cells as deeply as their
nuclei. As already stated, the cells which line the intestinal spaces
have no intimate relation with capillaries, they present no special
features, and no secreting function can be assigned to them.
Before leaving this subject the question may be put whether gas
introduced into connective tissue is intussuscepted by its cells in the
gaseous form. With a view of testing this the following observation
was carried out: Nitrogen was injected beneath the loose skin of the
back of a mouse through a fine needle. In order to render it sterile
the gas was driven through a piece of glass tube filled with cotton wool
which had been baked, the needle and rubber tube with which the glass
1 “ Weitere Studien zur Kentnissdes Baues und der Funktion der Gasdrtlse und des Ovals
in der Schwimmblase der Knochenfische (Ophididae, Percidae), Anatomischer Anzciger , 1906,
xxviii, pp. 177-191.
au— 39a
68 Nitch and Shattock: Emphysema of the Intestinal Wall
was connected being boiled and dried immediately before use. In
order to discover whether gas had been intussuscepted by the cells,
the animal was killed with chloroform, and the examination made by
peeling away films of the subcutaneous tissues bounding the cavity,
and studying them immediately in 50 per cent, glycerine, beneath a
cover glass. The animal was killed on the fourth day, the elevation
over the back being still well pronounced, though slightly diminished.
On slitting up the skin a capacious unilocular cavity, with a smooth
interior, was opened; the delicate connective tissue bounding it was
transparent, moist, and devoid of any congestion. The microscopic
details were quite normal, the lamellar and other cells being clearly
displayed : none of the cells contained any vesicles of the gas.
(2) Is Gas liberated from the Tissue-lymph !
Short of a proper secretion, however, there is the possibility of a
more simple liberation of gas from the plasma in the tissues. In caisson
disease, it will be recalled that the gases liberated in the blood, and
from the lymph in the tissues around the capillaries, on rapid decom¬
pression, are those of the air dissolved in abnormal amount under the
increased pressure to which the lungs and rest of the body have been
subjected. Whilst it is true that no pressure approaching such occurs
within the stomach or intestine under pathological distension, neverthe¬
less the normal excretion of carbon dioxide from the human skin in
cutaneous respiration proves that no such degree of decompression is
necessary for the liberation of the gas from a free surface, and its
diffusion into the surrounding air. In the human skin the ingress of
atmospheric oxygen and the egress of carbon dioxide from the plasma
probably take place only through the thinner epithelium lining the
sweat coils; perhaps only through the intercellular cement. In the
Dublin Medical Journal (January, 1841, p. 454), there is recounted a
case in which gas was believed to have been visibly excreted from the
skin whilst the body was submerged. It runs thus: “On the I2th of
May, 1840, I (Sir Francis Smith) was consulted by a gentleman who
told me that he often suffered from an enormous development of gas in
the stomach, which he discharged by eructation; that he likewise
occasionally experienced a development of gas from the bladder, and
that his skin acted in a similar manner, as he had observed in the bath.
On the morning of the 15th I found my patient in a bath at 79° F. of
common river water (Seine). His heart, shoulders, abdomen, and hands
Section of Pathology
69
were literally covered with minute bubbles of gas. On being questioned
the attendant at the bath stated that he had never previously witnessed
anything of the kind. On removing the hands and arms from the water
the bubbles disappeared, but gradually returned on again immersing
those parts. The bubbles were of the size of a pin’s head; on wiping
them off they disappeared, but gradually formed again. The experi¬
ments and observations continued nearly twenty minutes, and towards
the end of the bath, the edges of the metallic reservoir were coated all
round, but more particularly towards the upper end where the shoulders
had been, for a depth of from 1 to 2 in. with small bubbles.”
The appearance of gas bubbles upon any foreign body when
immersed in aerated table water (water artificially charged with carbon
dioxide) must be so familiar as to immediately suggest that this is the
explanation of the phenomenon just referred to, the carbon dioxide in
the latter case having been naturally held in solution. If the aerated
water from a table syphon is allowed to stand until all effervescence has
practically ceased, the tip of the finger, if vertically immersed in it,
shortly becomes covered with minute bubbles ; and this occurs as
abundantly on the finger nail (even when placed uppermost) as else¬
where. Had this simple check of observing the finger nails been made
in Smith’s case, any doubt regarding the explanation of the observation
could at once have been resolved. The liberation is determined not by
the higher temperature of the finger, but by the roughness of what is
submerged. If a perfectly clean and polished glass rod, on one side
of which an area has been roughened by a file, is placed in, scarcely
any gas bubbles are generated except over the roughened surface ; here
they form in abundance, and reappear as often as removed; the bubbles
being at first of the most minute size, and appearing as well when this
area is uppermost as when it is lowest: any bubbles arising from the
water below, if allowed to ascend against the smooth parts of the rod,
bound off without adhering to it. The abundant and continuous libera¬
tion of steam from boiling water following the addition of small frag¬
ments of earthenware, is a well known expedient in the chemical
laboratory, which exemplifies the action of the same factor.
It is not a little curious, historically, that Hunter 1 refers to two
observations, by others, similar to the later one of Smith’s, and that
he criticizes them in almost precisely the same manner, and discredits
them on the same evidence as that just independently adduced. He
1 Works, iv.
70 Nitch and Shattock: Emphysema of the Intestinal Wall
observes, in proof, that it matters not what the substance is that is
immersed, if it is but warmer than the water. The hubbies of air do
not appear to arise entirely from the degree of warmth of the water,
hut also, in some measure, from a solid body being immersed in it;
for simply heating the water to the same degree will not separate the
air. And in a footnote he adds : “ Dr. Pearson found that there was
no appearance of bubbles during bathing in warm water that had been
previously boiled so as to expel the air from it. The human body, when
immersed in the bath at Buxton, and kept at rest in it for some time,
was covered with bubbles, but.these bubbles appeared in the same
manner on any solid body that was placed in it.”
In cutaneous respiration, as in pulmonary, the tension of O in the
atmosphere being greater than that in the blood, a passage from
without inwards results; whereas the tension of C0 2 being greater in
the blood than in the atmosphere, the passage of this gas takes place
from within outwards. The elimination of C0 2 from the human skin
is so small that, when the body is submerged, it would be dissolved
without appearing in the gaseous form; and the higher the tension of
C0 2 (if naturally present in the water) the less the amount that would
leave the cutaneous vessels. In regard to intestinal respiration, the
gas most diffusible through the wall is C0 2 ; then, far below, 0 and N.
The relative solubilities of these gases in water are approximately
90 : 2 : 1. If air is introduced into the lumen of the intestine, its
oxygen becomes diminished, its C0 2 increased, in accordance with the
opposed tensions of the same gases in the tissue plasma or blood. 1
[The amount of C0. 2 ip solution in blood plasma, if any, is so minute
as to be negligible; for practically none can be extracted from blood
serum by means of the tonometer. As Dr. G. A. Buckmaster has
shown, the transport-C0 2 of the blood is combined in some way with
the haemoglobin, which acts as the carrier not only of O but of CO.,
alternately.]
In cases of obstructive congestion of the intestine, the tension of
C0 2 in the blood, one may suppose, would lead to the passage of the
gas towards the lumen, and to its ultimate liberation, seeing that it
would eventually escape the solvent action of the plasma in the intes¬
tinal parietes. The converse passage of C0 2 from the lumen into the
intestinal wall will, naturally, occur should the bowel be filled with
C0 2 at a higher tension than that in the blood or the tissue plasma;
1 G. StraBsburg, Pflilger's Arehiv , 1872, vi, p. 93. A. E. Boycott, Journ. of Physiol
1905, xxxii, p. 343.
Unction of Pathology
71
and similarly of 0 and N, mutatis mutandis; for the passage occurs
only between gases of the same kind.
These phenomena, however, are inapplicable to the case under
consideration, since the gas, whatever it may be, is not disengaged from
the free, inner surface, but lies within the walls of the intestine, where
its liberation, after solution, would require an amount of decompression
that is out of question.
The discharge of gas from the stomach in gout and hysteria was, in
Hunter’s opinion, indicative of a secretion or liberation from the blood.
He writes (loc. cit., p. 97) : “The stomach appears not only to be
capable of generating an acid, but also to have the power of producing
air; which last effect, I believe, arises from disease. When the gout
falls on the stomach the quantity of air thrown up is often immense,
and the same thing may be observed in some cases commonly called
nervous. I am inclined to believe that the stomach has a power of
forming air, or letting it loose, from the blood, by a kind of secretion.”
This view has not been substantiated. The gastric pneumatosis
of hysteria is regarded as due to aerophagy; and that of gout, to the
liberation of gas from ingesta.
(3) Mechanical Causation.
The gas between the intestinal tissues may have come from the
lumen of the stomach or of the intestine. In this connexion, reference
may here be made to the alleged presence of gas in the peritoneal
cavity apart from perforation of the stomach or intestine. Three
examples of this have been recorded by Sir Rickman Godlee, in the
Transactions of the Clinical Society (1877, x, p. 115):—
(1) The first was that of a man who had had dysentery, had
suffered from syphilis, and was the subject of phthisis, and advanced
amyloid disease of the liver accompanied with ascites. The enlarged
liver could easily be felt, reaching down to within 1J in. of the umbilicus,
but the area corresponding to it had a tympanitic resonance except
quite at the upper part. It was only on pressing the finger through
this tympanitic region that the liver could be felt, and then a dull
percussion note was obtained. At the autopsy no gut was found
superficial to the liver. There were several ulcers in the colon above
the sigmoid flexure, but no perforation. There is no mention in the
notes of the state of the peritoneum, but the author states that he was
nearly sure there was no recent peritonitis.
72 Nitch and Shattock: Emphysema of the Intestinal Wall
(2) A woman suffering from obstruction of the bowels from tumour,
the obstruction having been complete for three weeks. The abdomen
was much distended ; and she suffered from paroxysmal pain. During
the lumbar colotomy which was performed for the relief of the
obstruction, a mass of fat was first taken for the colon ; and then
a protrusion of peritoneum distended with gas made its appearance in
the wound. It was thought to be the colon, but as it did not look quite
natural, another search was made. The peritoneum was punctured ;
and after the escape of a large quantity of gas and a little grumous
fluid, the distension subsided, and the bowel was then easily found and
opened. At the autopsy on the following day no perforation could be
found, although it \vas carefully searched for. There was very early
general peritonitis, and a little somewhat older, with some lymph
around the caecum corresponding to an ulcer as large as a threepenny-
piece in the mucosa, filled with slough. The bowel at the seat of
stricture was quite entire.
(3) A male, aged 72, suffering for three weeks from obstruction and
much distension. At the lumbar colotomy, the first thing that presented
in the wound was a knuckle of peritoneum distended with gas and
containing a little clear fluid; the gut was found, and opened in the
usual way. Some little care was needed to retain the peritoneum in
the wound. The patient recovered, with only slight tenderness of the
abdomen after the operation. Death occurred ten weeks later. No
perforation could be found.
The author was inclined to view' the pneumo-peritoneum as due to
“ osmosis ”—i.e., to the passage of gas from the distended intestine,
in a state of solution, through the wall, and its subsequent liberation at
the peritoneal surface. Criticized from the physiological standpoint,
already explained, such an hypothesis is untenable. The pneumo¬
peritoneum was in all three cases probably due to the rupture of
subperitoneal collections of gas; these having formed in (1) in connexion
with the ulceration of the colon; and in (2) with the sloughing ulcer
of the cfflcum : in the third, where death occurred ten weeks after the
lumbar colotomy, the data are insufficient to justify a guess. An escape
of gases into the intestinal wall from the lumen of the stomach or
intestine under pressure, involves, it may safely be assumed, some form
of trauma. This may be furnished by the presence of an ulcer; or
arise de novo as a result of extreme distension. The passage of gas
from retroperitoneal tissue into the peritoneal cavity will naturally
be facilitated by the stomata present in the parietal serous membrane.
Section of Pathology
73
During the application of a purse-string suture to the distended
colon, preparatory to the insertion of a Paul’s tube, in cases of cancerous
obstruction, a minute escape of gas not infrequently takes place from
each puncture as the needle is carried horizontally through the wall.
Mr. B. C. Maybury, who has often noticed this whilst operating, is
confident that the needle does not penetrate beyond the submucosa;
and that the gas does not come, therefore, from the lumen of the
bowel, but lies in its wall. The phenomenon appears only in those
cases where the distension is extreme.
The following observations made after death will further illustrate
what is under consideration:—
Dr. C. R. Box tells us that he has on one or two occasions seen
a local emphysematous or bullous condition of the intestinal wall
brought about after death, at the site of an intestinal ulcer, from the
forcible washing out of the gut with water admixed with air: and that
something akin may happen when the stomach or bowel have been
washed through, should the water be driven beneath the cut edge of
the mucosa. 1 Quite recently a similar observation was made at St.
Thomas’s, by Dr. A. Mavrogordato, in a case of punctiform ulceration
of Peyer’s patches : after the intestine had been washed through from
a pipe, and slit up, groups of water bullae were found about the sites of
the lesions.
Observation : October 2, 1918. There died suddenly a particularly
well-developed man, from pulmonary thrombosis. The body was
transferred to the cold chamber until 1 o’clock p.m. of October 2, and
then to the mortuary. The autopsy was made on October 3, at 3 p.m.
The lower part of the ileum, devoid of valvulae conniventes, was
thoroughly washed out; cut up in lengths, and forcibly inflated with
a syringe fitted with a stopcock. Blebs of air appeared regularly
along the attached border; and sometimes, in addition, beneath the
peritoneum of the bowel in its immediate neighbourhood.
After a local damage to the intestinal mucosa, air can be readily
forced, after death, into the other tunics.
Observation: A piece of human intestine, the lower end of the
ileum, from the source already given, was everted, and a small oval
area of the mucosa, 1 cm. in length, scraped away. It was then
reverted, tied up, and connected with a syringe and stopcock. On
inflation an opacity indicative of the escape of air, quickly arose at the
1 “Post-mortem Manual,” 1910, 1st ed. p. 156.
74 Nitch and Shattock: Emphysema of the Intestinal Wall
injured spot. The opacity took the form of fine transverse lines, the
air insinuating itself between the fibres of the circular muscular coat:
as the escape continued the air appeared more superficially in coarser
longitudinal lines (probably the subserous lymphatics) and blebs beneath
the peritoneum. The chief collection of air, however, was along the
attached border, where the wall is unsupported by peritoneum. On
slitting up the intestine, no air was found beneath the mucosa. In
another observation, the air travelled in the same way, from the spot
from which a small area of the mucosa had been scraped off, between
the fibres of the transverse muscular coat, both over, and on either
side of, the lesion, whence it extended subperitoneally towards the
attached border.
A similar result ensues if a fine subcutaneous injection needle
connected up with a rubber bellows, is run horizontally into the
muscular wall, in the long axis of the bowel: air is driven between
the circular muscle fibres; and sometimes, also, lengthwise, in
coarser lines, beneath the serosa. If the needle is inserted near the
attached border, the serosa rises in wider blebs which reach the
latter. The position, however, in which inflation is most readily
produced is the submucous tissue. If the bowel be slit up, and laid
on the front of the finger, with the mucosa uppermost, the needle
can, with care, be passed into the submucosa without perforating
the muscularis. When the air is driven from the bellows, the
mucous membrane is immediately raised over an extensive area, from
which it can be easily shifted onwards with slight pressure. The
absence of submucous inflation when the bowel is distended after
injury to the mucosa is attributable to the fact that the pressure
within the lumen forces the mucosa against the muscularis; when the
entry takes place in the axis of the undistended bowel, a submucous
pneumatosis is readily brought about.
Better than observations made after death, however, is the following
which was carried out in the living subject. A syringe was filled from
a reservoir of nitrogen, and connected up with a glass tube containing
cotton wool sterilized by heat, and this with a fine subcutaneous needle.
In a man upon whom a colostomy was to be performed, a loop of the
pelvic colon was brought out through an abdominal incision, and
secured in the wound in the usual manner. The bowel was then
held at one spot, in a longitudinal fold (like the skin for a subcu¬
taneous injection) and the needle inserted into the submucosa from
the outer, intact surface. Some of the N was then driven from the
Section of Pathology
75
syringe, with the immediate result that a considerable area of the bowel
swelled up, and became whiter than the rest, from inflation of the
submucous tissue. After a minute or so, small blebs of the gas made
their appearance beneath the peritoneum.
In cases of extreme intestinal distension, the caecum has been found,
when exposed during life, to present gaping rents in the peritoneum, as
much as 2‘5 cm. (1 in.) in length : and some of these have been seen to
form whilst the bowel was under observation (W. H. C. Romanis). This
is direct proof that trauma of the intestinal wall may result from over
distension. And, again, in reducing ileo-caecal intussusceptions after
laparotomy, rupture of the peritoneum investing the caecum may be un¬
avoidably produced towards the close of the manipulation, when the
caecum becomes supremely distended by the included bowel. As sug¬
gested by the following experiment, the actual site of the mucosal
perforation in intestinal tympanites, may be th$ crypts, wfiich give
way under distension:—
Observation: A piece of the fresh small intestine of a young cat
was kept in warm water until rigor mortis had passed off. The mucosa
was cleaned by repeatedly filling the bowel with water, and kneading it
whilst filled. It was then kept firmly distended with carmine gelatine
under pressure of a syringe, whilst immersed in warm water, and
kneaded, for fifteen minutes; after this, the gut was tied up, suspended
in cold water, and finally in Eaiserling’s formol solution. Microscopic
examination was made upon transverse sections cut by the freezing
method, and mounted in Farrant’s medium, so that no shrinkage took
place, the use of alcohol having been .throughout excluded. The crypts
proved to be, all of them, distended with the gelatine : their outline was
somewhat undulatory, apparently from an increase in length hindered
by the limitation at their deeper ends where they abut upon a somewhat
dense submucosa of connective tissue. The jelly is sharply circum¬
scribed and clearly not extravasated, although the epithelial lining of
the crypts is mostly detached; here and there, nevertheless, it has
escaped to a small extent into the mucous and submucous coats.
In the older literature there are to be found two examples of
enphysema of the intestinal wall, but in neither can the effects of post¬
mortem decomposition be excluded in their causation. And the same
uncertainty applies to the case of emphysema of the wall of the stomach
occurring about the site of a simple ulcer, mentioned by Brouardel. 1 The
patient who was convalescent, was suddenly seized, after eating an apple
' 1 “ Death and Sudden Death/’ 2nd eel., p. 252.
tjMm
msmi
mm
-*■ ■ -v
76 ?$itch Aud Shattook: Emphymua $f.;;fhe. JntestiriaJ Wall
t,art, with vertigo; fell -down, and died shortly niter being pot. tc« bed
Post-mortem : The " cicatrix. “ was found torn, and the “ organ was dj.s-
jjehded with gages Which had penetrated beneath the mucous■ membrane
<>f the stomach, so that.the walls seemed to be inijotod"' The sudden
onset of symptom? shows.tkat the. unhealed dicer perforated m the usual
manner--Vi?.,. from the partial detachment of its margin, and. no.t from
tho aute-niortem. formation of gasr
The two earlier examples of <vtrsiin»i emphysema come from Haller
and ^eahhalonaif r (Frankie '-d-l - A reference to the original acenupis
enables m to give the foik>w'iug details■:. HaUci * .“ Pathological
A fiort^nitak hi tbe • fi\.Hr ; -«1Uti6ntied‘' \vitlj
c*ra)itte gelatma, dbarvvto" tb-ft dntk} of fcbe mjectioYF the tirvpte'. Benkakb
mmm * ,(3S ^nrjeet.iva- •>{ tbit ftn«} bfmoath bin the
^iiinv^r^ uml tmispuhir uoats Jr* tbe gebtHi.f' ocoupyiae rho
lumen then’ k an upvtixudiug villa?. (..: oirj.i
Figurae
w^.ry^opieft intetiu). fcemiis {FsM^ntUs^ pordkU-Dtium-
erat coll»i Ov<l«dk itvjpeu. Injochk>nis ro?tt^ie*. ?*> crypto jjiitndubtrv- uif.okk
kohjA
1 This, tiiifc of the 1 -few o{ 11ullcnV-. works pot pkblbh«?d on U-itio.. apparently oVfos
i£ngii?tt to f.tio iRvt tlm ttie untUoi* Wag l/Vesitieii* or iik; 'IkUanci.c | Moorsity .v,
.GiHtmgen.
Section of Pathology
77
Observations,” 1756, London. Observation 26: Upon a case of tym¬
panites in a woman, in the year 1751. The intestine was distended to
an enormous size, and the air had raised vesicles on the outside between
the muscular coat and the external membrane, which when opened
gave an intolerable odour. He remarks that air might conceivably reach
the abdominal cavity by rupture of the vesicles In this case the gas
was probably forced through lesions in the intestinal wall occasioned by
the pressure within the lumen ; but this pressure would be still further
increased after death; and a full proof that the emphysema was
present during life, is wanting.
The second is mentioned by Combalousier in his erudite work,
“ Pneumato-pathologia seu Tractatus de flatulentis humani corporis
affectibus,” Paris, 1747. Combalousier, however, merely cites the
observation, which appeared anonymously (I. G. D.) in the “ Commen-
tarii Academiae Scientiarium Petropolitanae ” (St. Petersburg), tomus V,
p. 213 (1730-31). The distribution of the gas in this case was both
submucous and subperitoneal. The title of the communication is:
“ Aer intestinorum tarn sub extima quam intima tunica inclusus.”
“ Inverso intestino, super interiore facie . . . ejusmodi tumores
seu elevationes pari numero forma et amplitudine, qua in exteriore
superficie, conspicuae erant; earum enim nonnullae contractions, aliae
circulum efformantes et ex earum numero nonnullae adeo protuberantes
ut fere cavum canalis obturarent.”
The author furnishes no details of an autopsy, nor does he definitely
state that the intestine was from the human subject. The paper that
immediately follows—by the same author, in fact—deals with a subject
of comparative anatomy: “ De Quadrupede volatili Russiae observa-
tiones.” A third specimen of about the same date is that in Ruysch’s
Museum. 1 It is thus described with an illustration, under No. 26 :
“ Hominis intestini jejuni portio. Lit. A, tumorem designat qui a flatu
subortus est, postquam exterior tunica leviter fuit laesa.”
(4) Is the Gas of Bacterial Origin t
Although the intestine presented no congestion or other signs of
disease, it is nevertheless conceivable that the access of a coliform
bacillus, or of a highly attenuated strain of Bacillus aerogenes to the
intestinal wall might have resulted in the production of gas in loco.
\ Frederici Ruyschii: Opera. Amsterdam, 1737. Musaeum Anatomicum Ruyschianum.
sive Catalogus Rariorum quae in Musaeo authoris asservantur.
78 Nitch and Shattock: Emphysema of the Intestinal Wall
The examination of a series.of sections stained with carbol thionine,
failed to reveal any bacteria either in the walls of the cysts, or in the
tissue around; ignoring the spurious elements resulting from the escape
of granules from mast cells, readily differentiated by their variations
in size, and immediate distribution about such cells. In the microscopic
sections, again, there is a complete absence of the small-celled infiltra¬
tion which is so conspicuous in the second case to be presently
described.
To sum up; the balance of evidence is slightly in favour of a
mechanical causation—an effusion of gas, i.e., from the lumen of the
alimentary canal, through a rupture, or an ulcer, of the mucosa.
Over-distension of the small intestine cannot have been the source of
injury, seeing that the obstruction—viz., the pyloric stricture, lay above
the site of the emphysema, and that there was no second obstruction
below: the absence of the latter being comfirmed by the fact that
pursuant to the gastro-enterostomy, no symptoms of any kind whatsoever
persisted. When exposed, moreover, at the operation, the small intestine
was quite normal in respect of tension. * The condition may be explained,
perhaps, as due to the forcible displacement of air and gas from the
dilated stomach, presumably through an ulcer which lay immediately
beyond the pylorus; the gas passing first into the submucosa, and
thence through the muscular wall into the subperitoneal tissue, its
wide extent along the bowel being facilitated by the intestinal peristalsis.
That the lavage of the stomach, for so long practised by the patient,
was a source of injury to the gastric mucosa is very unlikely; not
overlooking the fact established by direct observation, that the mucosa
of the human intestine and stomach, with their muscular and peritoneal
coats, are not only devoid of common sensation, but insensible to
cutting or to the thermocautery. 1 The lavage was carried out with
a soft rubber tube.
On this view there is one detail calling for notice—viz., the absence
of blebs from the duodenum and first part of the jejunum, where the
latter was opened in making the gastro-jejunostomy. The explanation
of this may lie in the remarkable activity of the peristalsis peculiar to
the duodenum: at such periods the gas in this part of the intestinal
wall would be shifted onwards into that beyond.
1 Lennander, ‘‘ Observations on the Sensibility of the Abdominal Cavity,’’ English
translation, by A. E. Barker, 1908.
Section of Pathology
79
The second example of intestinal emphysema which has fallen
under our notice, concerns a woman, aged 40, who was operated
upon (by Mr. Nitch) on May 27,1919, for obscure abdominal symptoms
referable to the right iliac region. She was quite well until twelve
days previously, when she was suddenly seized with acute colicky pain
in the right iliac fossa. The pain subsided in a few hours, but recurred
a week later, and gradually became more intense until she was operated
upon, on May 27. There was no vomiting, and only slight constipation.
Upon examination, a tender, elongated swelling, was found which
stiffened and relaxed every few minutes, so as to suggest an intus¬
susception. There were no signs of peritonitis; the temperature was
normal; pulse, 72. At the operation, the walls of the caecum and
ascending colons were found inflamed, thickened, and crepitant on
pressure; beads of gas, moreover, were freely distributed in the
surrounding connective tissue, and in some of the appendices epiploicae.
The vermiform appendix, and termination of the ileum, were unaffected.
There were several calcified tuberculous lymphatic glands in the ileal
mesentery ; no tubercles were seen on the peritoneum. After the
excision of the caecum with the ascending colon, and a third of the
transverse, &c., the continuity of the bowel was restored by lateral
ileo-transverse colostomy; the abdomen being finally closed, without
drainage. Recovery was rapid and uneventful.
The parts removed comprise the caecum with its appendix, and most
of the ascending colon, together with the termination of the ileum.
On slitting up the caecum its walls were found thickened throughout
from submucous emphysema, the ileo-caecal valve being also involved;
the mucosa of the latter was deeply congested, but without ulceration.
There was a second patch of congestion, about the size of a sixpence,
at the upper part of the caecum. The connective tissue and appertaining
fat about the caecum and ascending colon, contained large numbers of
gas blebs, ranging from a minute size to that of a pea. After the parts
had been hardened in formol solution, the examination was completed.
The termination of the small intestine was divided longitudinally,
the incision being carried through the valve into the caecum; it is
remarkably contracted, its mucosa being thrown into regular, closely
set, circular folds like valvulae conniventes ; the production of circular
folds, indicating a close contraction in the longer axis of the bowel, as
well as in the transverse. Its walls are quite free of gas ; no ulceration
is discoverable: its interior contained a small amount of green, bile-
stained mucus. On longitudinally bisecting the ascending colon, a
•SO Nitoii Btiafctock *. Eiiipki/mmi of the Intestinal Wall
• : ■ ■ ' ;
venaafkablfc yojtditiou presented itself. The omcQU& uiRrabiane is raised
in heniispherieal by a. dijiuse Rubmiicdtis
einphyaema, the tissue being like a appugg 4 ; or a soc!,jdu of hing. The
elevations tire mi: prormfyyjt. ajwt interdict tafc$.so, eoinpadSy, as do'block
the lumen. The \me of the >husotihui« is straight and intact, and the-
mucous .membrane itself a. readily traceable uvcv the cavernous areas
resnltingfrouithe pnetimatosia. The ca'euru si mi larljv thfiii gl i less :
Fie.
\4 'the ascendingwith the cincurn, dimug life frdUi
the ua"f nmpliy*emM. of the in lest mal WiiU ; m 'wtui in longitudinal
• soetwu. The.muchui juembniue is thrown into a SOd ios of pronvimml, ititer-
digi luting elevations. bv to ob-Tn.mt the lumen * a> u result of diltuse emphy
the .j?iiihTMKH»ur< C'vvt.. .Tho emphysematou.H U*H>ie is so Uniformly and
linriy in Hated its almost to ^uitibh* • lung. The at'ermi was similarly' affected„
llttfc to a lossi tiogveh. The srmiii intestine -wa*. atiuivoived., i>n obstru'etton was
jpresftnt Mtitermi fcfe proximal or distal «idc of the iUlbetfcd arna ; nor. -was. auy
uleerati»»u (liHeovorubio in the muco-o. The portion shown is the moH du*ta!
pan of that excised. iNfuuml size/)
Piijtn'iie, e.rplicalio.
Intotiiii pMiotuui emphy*arn&; exomplurn secundum. Coil ascendent is
portiiQ iti tougmi.diuonv seot-u. Membrane. mucosa in eminentm* rotundas,
<iuibu# mtostmi lumen valcb; dermnuitur, clevatur* Kmmeutiae vesicaiis
pHi*vi> nbique cot?^trn<it^o -pnti.fc fefeifc pulmonis toxtura) aero geneiato in tunica
subnjuhofefi- Crv^taei mi liter, in gratta autem rainore affectum lujfc. Lnteifcim
tenuistermmatia valde eontateta sod alitor nocmalis .fait.
Nihil obstruutiemis ultra utratnquo extremitatein partis fj.Hec.tae iKllu.it; nee
ulcus alictfbi m m&nimim mocosfi favontum est, Appendix vermiform is excosari
potor.y lumentofcurn ohilteTUtum $st. (Magnitiidinia natutahe.)
&ec$M pfPa tholtryij
affected, the ekvafcrent of the lautsoaft feing hoi fnmi kr iiSegred , and m
general: that the lumen is but-slightly Oimiahhep. The valve 13
involved in the same manner^"hot the ohitd^tm cCftsfe abruptly at 1 he
small iotestMt*;- The 'verm*{$£/« appehtlix,; lastlyy Is-; firth, ahh heloft’
the normal in diameter W on lonuttitdm.il bisection, it proved to be solid
throughout.
jS
A microscopic Motion of thfe.cmpbyStMnitb'i^ coipj i froui Cs&ftvviBg the
*pxwH w tko Shhnntca«&- The zzfmi $to thickly hi ^United with pojyarcrrpbs,
■(U the ear Met sUg&S the himiutioji *)f gi*£ h ftceompanUjd ' m tilt an exudation of
smira, oa may "bo recognised in the te^kest of the iraiwqnluv, The section ;i&
from the nelg^Uouthoad oi the mq»i distal portion, (-J ohj.)
io momtitans: • mibxnucojda . moiifitrans' cjuarum • pennies oeilniis polymnrpbo*.
eia^athms ^Ungitur at iu trabeaiiiA
nraaefori app&ret. (| obj.)
82 Nitch and Shattock: Emphysema of the Intestinal Wall
The microscopic examination of the wall of the ascending colon in
the neighbourhood of the distal end of the emphysematous portion,
shows that the mucosa with its glandular structures, as well as the
muscularis, are unaffected. The vacuolation is limited to the sub¬
mucous connective tissue. The smaller spaces are partly filled with
homogeneous exudate containing polymorphs, large numbers of which
infiltrate the septa between the lacunae. The spaces have no
differentiated lining. Sections prepared from the emphysematous ileo-
cspcal valve exhibit similar appearances ; in these there are conspicuous
numbers of multinuclear giant cells in the tissue bounding the spaces.
In this case there was no obstruction, either distal or proximal to
the affected area, which might have resulted in hyperdistension and
trauma of the mucosa; nor was there any ulcer the base of which
might have given way and allowed of the effusion of gas. The
emphysema cannot but be ascribed to an infection of the wall of me
caecum with a gas-producing bacillus, notwithstanding the failure to
demonstrate the presence of such in histological sections, either in the
exudate or in the cells. The histological picture is that of a somewhat
acute infective process which involves not only the submucosa, but in
places, also, the muscularis. There are no vacuoles in the giant cells
to suggest these are gas-secreting; and it may be observed that giant-
cells are not present in the proper gas-gland of the swim-bladder
of fish.
It must be borne in mind that the ease with which gas is shifted
onwards in the submucosa, and from the submucosa into the sub-
peritoneal tissue, may lead to its presence far away from a site of
bacterial infection, and so obscure the pathogenesis of the emphysema.
Such an occurrence is well illustrated in gas gangrene, where the
subcutaneous emphysema is due, in the first place, to the passage of
gas from the infected muscles through the perforations in the deep
fascia which tx*ansmit vessels to the skin. The bacillus may have been
of the coliform group, as in certain of the cases of intestinal emphysema
described in the human subject (e.g., that by Camargo, 1891: a man,
aged 60, who died from pulmonary tuberculosis) and in swine: or
it may have been a highly attenuated strain of Bacillus aerogenes.
Towards the close of the war in France there occurred an interesting
case, under Captain Yaucher, which was communicated to us by
Miss Muriel Robertson. A soldier received a trifling injury to the
lower part of the leg; and without any change in the wound, or
any general disturbance, the limb commenced to swell, and became
Section of Pathology
83
emphysematous, the emphysema extending at last to the thigh. On
aspiration of the emphysematous tissue, Bacillus aerogenes was
cultivated, its diagnosis being authenticated by the recognized tests.
Mr. W. H. Battle has furnished us with a photograph by Dr.
F. Bryan, showing a closely similar, external emphysema of the
subperitoneal connective tissue of the pelvic colon and appendices
epiploicse. The photograph was taken after death, the parts being
exposed in situ. There was a perforation of the rectum, consequent
probably upon an injury produced by an enema tube: the patient was
an inmate of a lunatic asylum. The autopsy was made in cold weather,
eighteen hours after death. In the same asylum, a second, similar case
was observed, following the administration of an enema by the same
attendant. How far the emphysema here was due to the expulsion of
gas from the lumen of the damaged bowel, how far to the bacterial
infection of the injury, it is impossible to determine.
Of the different examples of emphysema and gas-cysts of the human
intestine (and a reference to the literature will show that they are not
a few) 1 the pathogenesis of each would need discussing on its own
merits. In some the emphysema results from trauma of the mucosa
caused by over-distension, the gas being furnished by that within the
lumen of the intestine, augmented, it may be, by that produced in loco
from a secondary infection of the lesion. In others, the emphysema
may arise, apart from over-distension, as a result of local bacterial
infection; associated, or not, with the presence of an ulcer. And in a
third set, it may arise from the forcible introduction of gas from the
lumen, through the base of an ulcer; increased, it may be, by an
ensuing infection of the intestinal wall.
In the particular case described by the authors referred to, 2 it is of
interest to observe that the condition involved the small intestine, and
that the patient was suffering from pyloric stenosis accompanied with
secondary dilatation and hypertrophy of the stomach, for which
posterior gastro-enterostomy was carried out. Death occurred shortly
after the operation, from haemorrhage from the gastric ulcer with
which the stenosis was associated. No bacteria were cultivated from
the cysts, and none were demonstrated either within the cysts, or in
1 T. Shennan and D. P. D. Wilkie, Journ. Path., xiv, 1910.
* Loc. cit.
84 Nitch and Shattock: Emphysema of the Intestinal Wall
their walls. The conclusion of the authors was, that there was no
positive evidence that the gas production was the immediate result
of bacterial action.
Intestinal Emphysema in Swine.
And not to pursue the subject further, the same condition in swine,
since it was first recorded by Hunter, has a literature of its own.
This is fully given, up to 1906, by Alfred Jaeger. 1 In the specimen
(small gut) described by the latter, some of the gas certainly occupies
lymphatics, as shown by the tubular form of the spaces and the
presence of a differentiated wall. The author figures, in addition,
cell groups in which multinucleated elements are conspicuous. The
mesenteric glands likewise contained gas which had found its way into
the lymph sinuses. The pathogenesis was bacterial. The bacillus
cultivated from the walls of the spaces was (as in three further cases
examined by the same author) an aero-anaerobic, Gram-negative, gas¬
forming, short, stout bacillus of the coliform group : the cultures were
made from three to five hours after the animals had been killed.
Intestinal emphysema has been observed, also, in a few cases in,
apparently sound, sheep. The Hunterian specimens (which escaped
Jaeger’s notice) are best known through the reference to them in
Sir James Paget’s “ Surgical Pathology,” third edition. In the new
catalogue of the Pathological Section of the Museum of the Royal
College of Surgeons, 2 they are thus described:—
1141T. A portion of the rectum of a hog, of which the peritoneal
coat is in many places, and especially by the sides of the meso-rectum,
covered .with, clusters of thinly walled cysts, many of which are
pedunculated; and all of which contained gas.
This preparation is engraved in Plate 37 of Hunter’s works, and
is described as: “A portion of intestine of a hog, the peritoneal coat
of which is covered in several places with small pellucid cysts
containing air. It was sent to me by my friend, Mr. Jenner, 8 surgeon,
at Berkeley, who informed me that this appearance is found very
frequently upon the intestines of hogs that are killed in the summer
1 “ Das Intestinal Emphysema der Suiden,” Archiv.f. Tierheilltunde, xxxii, 1906, p. 410.
* Descriptive Catalogue of the Pathological Specimens contained in the Museum of the
Royal College of Surgeons of England. New edition, by Samuel G. Shattock, with the
assistance of Cecil F. Beadles, October, 1911.
* Edward Jenner: the discoverer of vaccination.
Section of Pathology
85
months.” And, in the “ Observations on Digestion,” 1 Hunter says (to
illustrate the fact “that air is either formed from the blood, or let
loose by some action of the vessels, both naturally and from disease ”) :
“I have a piece of the intestine of a hog which has a number of air-
bladders in it. Mr. Cavendish was so kind as to examine this air, and
he found ‘ it contained a little fixed air ; and the remainder not at all
inflammable, and almost completely phlogisticated.’ ”
Of this last quotation it may be stated that “fixed air” denotes
carbon dioxide; “inflammable air,” hydrogen; and “phlogisticated
air ” is nitrqgen.
The value of the chemical data, however, is marred by the possibility
of some interchange having taken place between the gases within the
cysts and those of the air, seeing that the transport of the material at
that period would have occupied a considerable number of hours.
No. 1142'1, is a similar portion of intestine, with cysts which
contained gas, dried.
De exemplis duobus intestinorum emphysematis, aere
intra parietes intestini incluso.
Disquisitionis stjmma.
In exemplo primo laesio inexpectate reperta est dum operatio
chirurgica (gastro-enterostomia) conficiebatur pylori adversus stricturam
cum ulcere simplici sociatam. Ventriculus flatu distentus erat plurimos
per annos, et ad ilii cristam nuper extendebat. Supra intestinum tenue
totum, duodeno excluso, sparsae sunt aeris bullae quae sub tunicA peri-
toneali plerumque projectae sunt.
Portio parva ex intestino affecto excisa est ut laesio accurate inda-
garetur. In Me portions bullae sive cystes sub membraM mucosA,
solum jacere inveniuntur; endothelii cellulis bullae intus tectae sunt.
Laesionis pathogenesis: Bacillorum aerogenium actio excludi potest
scrutatione microscopic^, sectionibus secundum artem tinctis. Excludi
potest quoque aeris secretio intestini in parietibus. Vix dubitari potest
quin laesio causata sit aere propulso de ventriculo inflato ulceris per
basem quod juxta pylori stricturam positum est, intestini peristalse in
aerem promovendo adjuvante.
In exemplo secundo excisum est caecum cum colo ascendente et
extremitate intestini tenuis, adversus, ut putabatur, intestini intus-
1 “ Works,” iv, p. 98.
au—39 b
86 Nitch and Sliattock: Emphysema of the Intestinal Wall
susceptionem. Partibus excisis tunica coii mucosa in eminentias
rotundas quibus intestini lumen valde deminuitur, elevari reperta est.
Uminentiae vesiculis parvis ubique constructae sunt, tanquam pulmo,
aere generato in tunica submucosa. Caecum similiter, in gradu autem
minore, affectum fuit; intestini tenuis terminatio valde cbntracta sed
aliter normalis.
Nihil obstructionis ultra utramque extremitatem partis affectae
adfuit; nec ulcus alicubi in membrane mucosa inventum est. Appendix
vermiformis excusari potest; lumen totum obliteratum est. Aeris
generatio hie ascribi debet parietibus intestini infectis, ut inflamma-
tionis acutae indicant nota. Dolore excluso aegra vix patiebatur;
atque intestino ablato celeriter sanata est.
PROCEEDINGS
.EMTiSti BY
SIR JOHN Y W. MauALISTER
US’BBJt TOE, or
THE EDITORIAL COMMITTEE
VOLUME THE TWELFTH
session irnfl i'1
SECTION OF PSYCHIATRY
LONDON
I.ON UM A NS, GRBEN A CO.. PATERN0STfcREG \V
3010
Section of |>6£cfotatr\>
OFFICERS T fFOR THE SESSION 1918-19.
President —
William McDougall, M.B., F.R.S.
Vice-Presidents —
Bedford Pierce, M.D.
E. Farquhar Buzzard, M.D.
lion. Secretaries —
Bernard Hart, M.D.
G. F. Barham, M.D.
Other Members of Council —
Sir Robert Armstrong-Jones, M.D.
C. H. Bond, M.D.
Helen A. Boyle, M.D.
Maurice Craig, M.D.
A. W. Daniel, M.D.
R. L. Langdon-Down, M.B.
C. A. Mercier, M.D.
F. W. Mott, M.D., F.R.S.
C. S. Myers, M.D., F.R.S.
Sir George Savage, M.D.
R. Percy Smith, M.D.
H. Campbell Thomson, M.D.
John Turner, M.B.
Representative on Library Committee —
R. H. Cole, M.D.
Representative on Editorial Committee —
G. F. Barham, M.D.
SECTION OF PSYCHIATRY
CONTENTS.
November 19* 1918.
William McDougall. Major R.A.M.C.(Temp.), M.B., F.ll.S. page
President’s Address : The Present Position in Clinical Psychology ... 1
December io f 1918.
Bernard Hart, M.D.
The Methods of Psychotherapy ... ... ... ... ... 18
March 11, 1919.
C. Stanford Bead. M.D., Major R.A.M.C.
War Psychiatry ... ... ... ... ... ... ... 85
April 8, 1919.
William Brown, M.A., M.D.Oxon., D.Sc.Lond.
War Neurosis : a Comparison of Early Cases seen in the Field with those
seen at the Base (Abstract) ... ... ... ... ... 52
July ii y 1919.
C. G. Jung, M.D., LL.D.
On the Problem of Psychogenesis in Mental Diseases... ... ... 68
The Society does not hold itself in any way responsible for the statements made or
the views put forward in the various papers.
London :
Jt<HN Bale, Sons and Danielsson, Ltd.,
Oxford House,
X3-91, (treat Titchfield Street, Oxford Street, W. 1.
Section of ps^ebtatrs.
President—Dr. William McDougall, F.R.S.
PRESIDENT’S ADDRESS.
The Present Position in Clinical Psychology . 1
By William McDougall, Major R.A.M.C.(Temp.), M.B., F.R.S.
In choosing a subject for this address, I have felt at liberty to go
outside the boundary of psychiatry , and I propose to put before you a
slight sketch of the present position in clinical psychology. First, it is
necessary to explain what I intend to denote by this term. It may be
said that there is not and cannot be any branch or section of psychology
that can properly be so called ; for the clinician necessarily deals with
his patient as an entire organism and cannot, in considering his mental
life, abstract from any one part or function of the mind, to con¬
centrate his attention upon another: his psychology therefore must be
concrete and must deal with the mind as a whole. This is true, and it
follows from this truth that, when our knowledge of the human mind
shall have become an adequate and well-established science, that science
must be the theoretic basis for all who are practically concerned with
the working of the mind, whether they are chiefly and immediately
concerned with the normal mind or with minds in disorder.
But, as I shall presently show, it is just because we have hitherto
had no such psychology, that there has been growing up of late years a
specialized form of mental science which may conveniently be desig¬
nated clinical psychology . There can, I think, be little doubt that a
century hence the present time will be held to be remarkable for the
great advances made in our understanding of the mind, and it will be
1 At a meeting of the Section, held November 19, 1918.
D— 9
2 McDougall: The Present Position in Clinical Psychology
recognized with gratitude that clinicians have played a great and leading
part in this achievement. My purpose is to attempt a rough sketch of
the way in which this achievement of the clinical psychologists will
appear to the historian of science in that future age.
In order to understand the rise of clinical psychology as a semi¬
independent body of thought, we must glance at the state of academic
psychology in the later decades of last century. There is some founda¬
tion for the jibe that there were then as many psychologies as
psychologists; yet there were certain doctrines which, especially in
the psychologies that claimed to be scientific rather than philosophical,
dominated the scene.
The chief of these were: (1) A tomism, or Sensationism; (2)
Associationism; (3) Hedonism.
Sensationism, the theory that all mental states, broadly spoken of
as presentations or ideas, are aggregates formed by the compounding
or clustering together of smaller fragments of conscious stuff, the
elementary sensations; one idea differing from another merely in the
number and variety of the units of sensation combined in it (hence the
name mind-dust theory).
Associationism, the theory that all this compounding and clustering
of units to form ideas, as well as all the succession and interplay of
ideas, was ruled by the one great principle of association.
These two great principles were natural complements, and, there¬
fore, were almost inevitably and everywhere combined. This com¬
bination was very widely accepted, owing not only to the seductive
simplicity of the notion, but still more perhaps to the fact that it lent
itself to combination with the increasing knowledge of the structure of
the brain, to form a purely mechanical and materialistic theory of mental
life. For the mental elements were regarded as being functions of the
brain-elements or cells, as the sound of a plucked string is a function
of the string; and the ideas or clusters of elements were likened to the
chord heard when many strings are plucked or sounded together.
Association was a function of the connexions between brain-cells ; and
all the play of mental life was but a matter of the ringing up of brain-
cells and groups of cells by the spreading of the nervous impulse
from group to N group, according to the simple principles of mechanical
association.
British thinkers, Locke, Hartley, the Mills, Bain and Herbert
Spencer, to mention only a few of the • most distinguished, were
chiefly responsible for the immense success of these two principles.
Section of Psychiatry
3
To some thinkers these two principles alone seemed sufficient to
account for. all thought and all action ; for to will was to have an idea
of an action or movement, and these ideas of movement were, like all
others, subject only to the great law of association. This was the theory
of ideo-motor action, dearly beloved of so many of our French colleagues,
and unduly emphasized by many of them. But others could not over¬
look the fact that men commonly act, not merely because an idea of
action comes into their minds, but because they have a purpose, seek
some end, or strive to achieve some effect; and, looking round for some
formula to define that end, they said—It is pleasure! 'In acting, in
seeking, in striving, men, they said, are always moved by the desire
of pleasure. There you have the third great principle of Hedonism.
The psychologies which did not base themselves upon these
principles were in the main highly metaphysical and not such as to
engage the attention of physicians struggling with the problems of
mental and nervous disorder. And so we find that these physicians
adopted, almost without exception, the mechanistic psychology founded
on Atomism, Association, and Hedonism.
This psychology, however, was wholly inadequate to the needs of
psychiatrists. Its specious principles afforded little or no help when
brought to the practical test of use in the interpretation of mental
disorder.
And the natural consequence of its acceptance by psychiatrists was
that those among them who were moved to research devoted themselves
almost wholly to the attempt to discover the material basis, the neuro¬
pathology, of mental disease; this tendency being strongest where the
mechanistic psychology was best established—namely, in England
and Scotland. While the practical physician used the psychology of
common sense and common speech, supplemented by his own in¬
tuition and large experience of men; a condition of affairs - illustrated
by the majority of the older text-books still in use.
I will further illustrate the position by reference to the writings of
three leaders of psychological medicine, .in Germany, France, and
England respectively.
Professor Ziehen, whose works have enjoyed a wide circulation, repre¬
sents the pure principles of mechanistic materialistic psychology based
on the three principles mentioned above. His psychology claims to be
a physiological psychology; in reality it is a speculative and highly
dubious brain-physiology which for psychiatry is utterly sterile.
Psychology of this sort seemed at one time to have achieved a
4 McDougall: The Present Position in Clinical Psychology
triumph in its interpretation of the varieties of aphasia, but it is, I
think, now generally recognized that this triumph was illusory, and
that in the main it obscured and distorted the facts.
Professor Pierre Janet may justly claiih to be the father or founder
of clinical psychology. Starting with the principles of the mechanistic
psychology, and, like other French writers, attaching great importance
to the notion of ideo-motor action, he greatly developed the conception
of mental dissociation. But valuable as was this contribution, his work
would have remained on the purely descriptive plane, had he not broken
away from the mechanistic psychology by introducing a new conception
quite incompatible with it—namely, he conceived the mind to be per¬
vaded by a synthetic energy, variable in quantity, whose function
is to hold together in one stream of consciousness the various sensory
elements, and in defect of which dissociation of consciousness into
partial streams occurs.
In this country, the transition from old to new doctrine which I
am attempting to sketch is illustrated in the most striking way by the
work of Dr. C. Mercier. This brilliant writer, after having expounded
the mechanistic psychology, with great force and confidence, has made
the discovery that in presence of all problems of action it leaves us
utterly helpless. Thereupon, instead of undertaking a radical revision
of his psychology, he announces our need of a new and distinct science
—namely, & science of conduct (which he proposes to call praxiology )—
and writes a new volume to lay the foundations of this much needed
science. No happier illustration of the inadequacy and sterility of the
mechanistic psychology could be found. In taking this course
Dr. Mercier was unconsciously following the example of John Stuart
Mill, who began by adopting and expounding the purely mechanistic
psychology of his father; and then, discovering, like Dr. Mercier, that
it threw no light on problems of conduct and of character, sketched
out a new science to fill this gap, proposing to call it Ethology.
Thus does history repeat itself even in the realm of science.
These three thinkers I have cited fairly represent the many others
who have vainly striven to bring the mechanistic psychology to the aid
of medicine. No wonder, then, that others have thrown aside all
academic psychology in approaching the problems of the disordered
mind ; and it is perhaps well that they have done so ; for their relative
freedom from the paralysing shackles of the mechanistic psychology has
enabled them to make progress; but their repudiation of all academic
psychology has inevitably resulted in those peculiarities of the clinical
Section of Psychiatry
5
psychology of our time which mark it off from the main stream of
psychological tradition and development.
This method of approach and these consequences are best illustrated
by the work of Professor S. Freud, who, whatever verdict may ultimately
be passed on his psycho-therapeutic methods, will certainly rank as
one who has given a great impulse to psychological inquiry. Freud’s
psychological work may be said, from the logical point of view, to have
begun from the wrong end. Without any preliminary attempt to
consider first principles of mental life, to analyse consciousness, or even
to define the terms which he uses, this daring and original inquirer has
wrestled at first hand with the problems of conduct and especially
with the problems of disordered conduct as presented to him
by his patients in all their concreteness and complexity. Thus
approaching, he has been deeply impressed by the great fact that
much of human conduct, both normal and abnormal, proceeds not from
consciously reasoned motives nor from any chain of association of clear
ideas, but from a great impelling force that works within us, expressing
itself only very obscurely in consciousness as vague feeling and un¬
easiness. This he has recognized as the sexual impulse; and, having
been deeply impressed by the far-reaching effects of this upon conduct,
and by the obscure and devious modes of its operation, he has gone on
to bring under the same heading whatever other forces of a similar
nature he has seemed to detect as co-operating with and subserving
it, or which the vagueness of common speech seems in any way to
to connect with it. In this way, in his reaction from'the mechanistic
psychology, he has brought to light two great allied facts: (1) The
impulsive, demoniac, illogical nature of much of human thought and
conduct; (2) the very partial and inadequate way in which con¬
sciousness or self-consciousness reflects or represents the workings of
this impulsive force. Freud’s insistence on these two facts is his
fundamental contribution to psychology; and it is the recognition and
emphasis of them, thanks largely to his labours, that is the key-note of
clinical psychology at the present time.
Freud’s development of these two truths has been marred by several
errors: First, his attribution to the sexual impulse of much of conduct
that is not properly so attributable, and his consequent exaggeration of
the role of sex; secondly, he has not wholly freed himself from the
errors of the mechanistic psychology, in spite of his detachment from
tradition, so natural are these errors to the scientific mind; two
especially he has retained—(a) instead of repudiating the mechanistic
6 McDougall: The Present Position in Clinical Psychology
determinism, he claims that he has for the first time established this
principle in psychology; (b) instead of repudiating Hedonism he has
made it his own and attempted to combine it with his recognition of
the impulsive nature of conduct, as what he calls the pleasure principle,
in a very confusing way that largely vitiates his thinking. A third great
blemish is, that, having repudiated the traditional terminology of
psychology and having heglected to define his own terms by careful
analysis, his terminology is often obscure and misleading, and, as a
further consequence, the large unanalysed conceptions with which he
operates tend to become anthropomorphic agencies—the unconscious,
the censor, the foreconscious, &c.
But in spite of these large blemishes and beyond the two funda¬
mental principles we may, I think, see in his work permanent
contributions to psychology which are of especial value to clinical
psychology and are playing a great part in its development. Notably
(1) the conception of active continued repression of distressing
memories; a conception distinct from and much more fertile than
the dissociation of Janet; (2) the conception of conflict in the mind
going on below the threshold of consciousness and capable of giving
rise to disorder of thought and conduct ; (3) the symbolical
significance of some dreams and of some forms of waking thought
and conduct, and the value of these as indicators of conflict and
repression; (4) the conception of the “ affect ” as a quantity of energy
that attaches to ideas and gives them their impulsive force in the
determination of thought and conduct.
Let us now glance at the way in which others have contributed to
the further development of these lines of thought. I refer first to
Adler, who, working by methods similar to Freud’s, has diverged widely
from him. His chief contribution has been to secure recognition by
clinical psychology of two great impulses which seem to have escaped
the. notice of Freud. He has recognized the great part in human life
of an impulse of self-assertion, and of one of only less importance, an
impulse of self-abasement or submissionand, applying to these what
may perhaps without impropriety be called the Freudian method in
psychology, he has assigned them an immense r61e, and seeks to show
that their distorted working is the source of all the neuroses, just as
Freud finds that source in the sex-impulse. And, though he has
without doubt exaggerated their role in the neuroses, we must forgive
this natural exaggeration in gratefully recognizing that he has secured
recognition by clinical psychology of these two important impulses.
Section of Psychiatry
7
An English clinician has in a similar way secured recognition for
another great impulse. Mr. W. Trotter has discovered the gregarious
impulse and, in a brilliant and persuasive little book, has treated it by
the Freudian method , that is to say, postulating this impulse, without
first stopping to inquire—What is its nature ? What are the limits
and scope of its action ? but, sweeping into its province whatever human
activities are social or in any way dependent upon or related to the
social groupings of mankind, he has made it appear as the mainspring
of well-nigh all human activity, normal and pathological.
An American clinician has performed a similar service in regard to
yet another fundamental impulse of the human mind. Dr. Boris Sidis
has, by applying the Freudian method, sought to show that fear is the
source of all the psychoneuroses, all those troubles of thought and
conduct which Freud attributes to the sex-impulse, and Adler to the
self-assertive tendency and its opposite. And, though, like them, he
must be judged to have overdone his part and proved too much, he yet
may claim the credit of having given to fear a secure place in clinical
psychology. But this place has been overwhelmingly established by
the observations of a large number of physicians upon the psycho¬
neuroses of war; for they have learnt that many, if not all, of the
modes of neurosis may be generated by the terrifying experiences of
the battlefield, that is by fear, or, as they commonly prefer to call it, by
the instinct of self-preservation. Thus fear takes its place alongside
sex, self-assertion, and the gregarious impulse, as one of the great
impelling forces of thought and conduct, which work independently of
the promptings of pleasure and override the principles of mechanical
association. '
We may, I think, assume that clinical psychology has not yet come
to an end of its advance along this line, and may confidently expect
that there remain other fundamental impulses of like nature to be
discovered by it playing their parts in the genesis of mental and
nervous disorders.
Now, it is of the essence of these great fundamental impulses, thus
revealed as the underlying motive powers of so much of thought and
action, both normal and abnormal, that they are purposive or teleo¬
logical, and are not to be deterred by pain nor turned aside from their
biological ends by pleasure. They override and dominate for their own
purposes all the mechanisms of association and the Hedonistic influences.
Therefore, their recognition in clinical psychology necessarily leads to
a complete break with the mechanistic psychology. Freud’s own
8 McDougall: The Present Position in Clinical Psychology
teachings show clearly the purposive character of much in human
conduct that had been regarded as merely the fortuitous outcome of
mechanical haphazard association ; that in fact is rightly claimed by his
disciples as one of his greatest’ achievements. Thus he has himself
undermined both the mechanistic determinism and the Hedonism which
he professes to maintain. And, although clinical psychologists commonly
use the phrase “mental mechanisms,” this is only for lack of a better mode
of expression; and some of them have grasped the radical transformation
of psychology that must result from the recognition of the great
r61e of these primary impulses; a transformation from the deterministic
mechanical psychology to a teleological and indeterministic psychology,
a radical transformation, because, in spite of the ingenuity of German
metaphysicians, mechanical process and purposive action remain utterly
and fundamentally different. Most notable among these is Dr. C. J.
Jung, who in his “Analytical Psychology” has forcibly shown the
practical clinical importance of this revolution, insisting that, so long
as we regard the symptoms of our nervous patients as wholly and
mechanically determined by the past, we miss their true significance
and render our psycho-therapy relatively sterile; he insists that we
have constantly to bear in mind in all our procedures the fact that
conduct is determined by ideals of the future that we strive towards,
as well as by the events of the past.
Jung also has made a further great step of a more speculative kind.
Repudiating the excessive sexualism of Freud and insisting upon the
importance of the food-seeking impulse, especially in childhood, he
regards all the primary impulses as differentiations of one fundamental
energy, the life force which sustains all our strivings, both conscious
and unconscious ; thus approaching, but from a very different direction,
the conception of the elan vital which the greatest of contemporary
thinkers, Professor Bergson, has so eloquently expounded.
Turn now for a moment to that other distinctive feature of clinical
psychology—the increasing recognition of the part played in conduct
and mental life by processes that remain hidden from consciousness.
It is difficult to make any general statements about this, because the
greatest obscurity and confusion still reign. The facts have not been
brought to light by clinical psychologists alone. Others have been
impressed by their importance and have prepared the way: Schopenhauer
and Hartmann, and F. W. H. Myers notably.
Janet, with his conception of dissociated sensations and ideas, has
attempted to give greater precision to the conception of unconscious
9
Section of Psychiatry
mental process; and others who, like Janet, have made large use of
hypnosis have brought forward, as justifying the conception, all the
striking facts of post-hypnotic suggestion. Morton Prince especially,
following in the line of Janet, has striven to introduce some clarity into
the vagueness which enshrouds this region, by his demonstrations of
co-conscious personalities and co-conscious ideas; and to my mind he
seems to have made out his case for the truth of these conceptions
in certain abnormal cases. But his conception does not cover the whole
ground ; it does not cover the unconscious or subconscious operations of
normal life; and on these Freud has rightly insisted.
The reality, the richness, and the importance of these subconscious
operations of the mind have been brought home to many of us with a
new force by our experience of the functional disorders of warfare;
for no one working among these cases can have failed to come across
many instances in which the symptoms, both bodily and mental—
amnesias, war-dreams, phobias, anxiety states, paralyses, contractures,
epileptiform seizures, headaches, tics, have been undeniably traceable to
emotional conflicts and repressed tendencies and ideas, which have
operated wholly or partly beneath or without the clear consciousness of
the patient.
But Freud and most of his disciples have followed in the line of the
“Unconscious” of Hartmann, of Myers’ “Subliminal Self,” and
the “ Unconscious Mind ” of other authors—that is to say, they have
tended to confuse together in one unanalysed mass whatever contents
and operations of the mind are not clearly conscious at each moment,
and to make of this an anthropomorphic entity, a demon, a god in the
machine, whose nature and powers remain entirely unlimited and
incomprehensible. And Jung and his followers seem to me to fall in
some degree into the same error. I say error, because this way of
treating of “The Unconscious” seems to me unscientific; it tends
towards a vaguely mystical attitude which, however much in place in
religious or metaphysical thinking, does not directly promote, but rather
checks, further scientific inquiry into this problem.
I venture to think that this error is again the outcome of the
contamination of clinical psychology with the fallacies of the mechanistic
psychology, which it professes to repudiate. For that psychology, all
mental life was a succession of clearly conscious ideas. It ignored the
fact that these ideas are but the eddies and ripples on the surface of a
stream, deep within which are the currents and forces of which those
eddies and ripples afford only very imperfect indications. This truth is
10 McDougall: The Present Position in Clinical Psychology
manifested all down the scale of animal life—the instinctive strivings
of the animals generally bring them surely to their biological*ends,
without clear consciousness either of those ends, or of the means by
which they are achieved, or of the objects which, by impressing their
senses, guide their successive steps. And it is not otherwise with man;
he also is borne on to his biological ends, for the most part but dimly
conscious of those ends or of the mental forces and processes by which
he achieves them. *>.
Just because the mechanistic psychology had ignored these surging
hidden streams of the life force, those who, revolting from its
inadequacies, have found themselves confronted by evidence of their
reality in man, have been startled by the revelation and have seemed to
see beneath the only form of mind recognized by the older psychology
another system of forces greater and more mysterious, which they have
thus been led to regard as a distinct mind or entity—The Unconscious,
the Subliminal or Subconscious Self.
A third way in which clinical psychology is diverging widely from
the mechanistic psychology is by its discovery of the mind's wealth of
innate endowment. The mechanistic psychology inherited Locke's
dogma that each mind starts out upon its course of individual experience
as a tabula rasa , a blank sheet on which experience writes as chance
determines.
The recognition of the primary or instinctive impulses, of which we
have already spoken, carries clinical psychology a long way beyond this
primitive and untenable ppsition, showing the strong native bias of the
mind to select and react upon impressions from the outer world, not
only according to its individual past experience, but also and chiefly
according to its inherited constitution. But among clinical psycho¬
logists there is a strong tendency to go further than this, to Relieve
that much of the development of the individual mind is literally a
recapitulation of the racial mind, a gradual unfolding at the touch of
experience of modes of thinking and feeling and doing gradually
acquired by many generations of ancestors. Only by this assumption
can they explain the striking uniformity of symptoms which characterize
certain mental disorders, and the equally striking uniformity of thinking
and feeling revealed by primitive myth and custom among the most
diverse races of mankind.
This line of work in clinical psychology promises to contribute very
importantly towards two of the greatest problems that confront the
human intellect—one strictly biological, the other of more general and
philosophical import.
Section of Psychiatry
11
The one is the problem of heredity. If that wealth of inherited
forms of thought and feeling, towards which clinical psychology seems
strongly to point at present should be further substantiated, this result
will decide the issue of the great controversy between those who deny
and those who affirm the inheritance of acquired characters. For while
it may, perhaps, be plausibly maintained that a few simple instinctive
modes of feeling and action may have been impressed upon the race by
natural selection alone, every demonstration of a greater richness of this
inherited structure of the mind renders this explanation more hopelessly
inadequate and drives us back upon the Neo-Lamarckian view, that the
experience of each generation impresses itself enduringly upon the race.
The other great problem is that of the constitution of man, the age¬
long controversy between materialistn and what in the widest sense may
bd called spiritualism. For so long as it is held, with the mechanistic
psychology, that congenitally the mind is a tabula rasa and the brain
little more than a mass of indifferent nerve-tissue waiting to be moulded
by impressions from the outer world, it may seem plausible to hold
that all mental potentialities are somehow comprised in the material
structure of the germ-plasm. But, with every addition to the
demonstrable wealth of innate mental powers and tendencies, this
hypothesis becomes more impossible and incredible. And it may safely
be affirmed that, if anything like the wealth of innate endowment
claimed now by some—e.g., by Jung in his latest work—should become
well established, then all the world would see that the materialistic
hypothesis is outworn and outrun, and that each man is bound to his
race and ancestry by links ^ which, conceive them how we may, are
certainly of such a nature that in principle they can never be
apprehended by the senses, no matter how refined and indefinitely
augmented by the ultramicroscope or by the utmost refinements of
physical chemistry. I venture to insist upon this contribution of
clinical psychologists towards the solution of these great problems,
because few of them seem to have adequately realized the bearing of
their work on these issues, which so far transcend in interest even
the fascinating and important questions with which they are more
directly concerned.
There are many other features of interest in the present position on
which I might dwell if time allowed. I have had time to touch only
on these few which seem to me the most significant. I have said
nothing of the burning questions of method in psycho-therapy, and to
do so would perhaps be presumption on my part. But I would like to
12 McDougall: The Present Position in Clinical Psychology
say one word in the nature of a warning criticism. We are repeatedly
asked to accept satisfactory clinical results not only as evidence of the
value of the therapeutic methods applied, but also as evidence of the
truth of the psychological doctrines on which they claim to be based.
The whole history of medicine seems to me to show the danger and the
fallacy of this claim. How many accepted therapeutic procedures
have been shown to be worthless! How many others, whose value has
been proved, have been founded upon, or held to prove the truth of,
hypotheses which are for ever dead. And we are relieved from any
compulsion to accept such evidence when we notice that the exponents
of different methods, based upon different psychological doctrines, claim
equally brilliant therapeutic results in the same class of cases ; and how
even the same clinical worker continues to achieve equally brilliant
therapeutic results before and after a radical change of doctrine and
procedure. I insist on this as a warning against dogmatism, as an
appeal for mutual tolerance and the open mind in this great field
where we all wander, groping more or less blindly, among the deepest
mysteries of Nature.
I have tried to hint that clinical psychology, now launched upon a
great career, is in the position of a brilliant and wayward child, which,
throwing asidp the traditional wisdom of its parent as of no account,
sets forth to acquire a new wisdom ab initio and which, though making
great strides, is hampered through retaining all unawares some of the
prejudices and errors that it believes to have put off. And this brilliant
child, as it advances, will inevitably find that there was truth as well as
error in that parental wisdom. For the mechanistic psychology was not
the whole or even the better part of psychology, it was the work of a
sect, a series of persuasive and brilliant writers, who evolved it by
deduction from principles set up by physical science, rather than by the
patient and detailed study of human and animal life; and it enjoyed a
great vogue because it harmonized with the materialistic tendencies
of the great age of physical discovery.
But we are now in the age of biological discovery, and, since Darwin
initiated this new age, there has been growing up a biological and
inductive psychology, a science not springing full blown, like the
psychology of James Mill, or of Herbert Spencer, from the reasonings
of one powerful mind, but a science, based like other sciences on a vast
mass of minute and careful observation, a slowly growing product of the
co-operation of a multitude of workers.
This science is showing the same main tendencies, the same trends,
Section of Psychiatry
13
as clinical psychology. And it is a bigger thing than clinical psychology
because it is based upon a wider field of observation and induction ; it is
greater as the whole is greater than the part. Clinical psychology
cannot afford to ignore this greater stream and to remain in splendid
isolation. It is to be hoped that it will renounce the effort to do so,
that the brilliant child will return to the parental fold, bringing rich
gifts, but gaining in return a greater breadth of view, a greater sanity
and balance, a more precise terminology, a greater clarity of thought,
and with these, a greater power of dealing effectively with those most
distressing of the disorders that afflict mankind, the nervous and mental
diseases.
The Methods of Psychotherapy . 1
By Bernard Hart, M.D.
The urgent problems presented to us by the war psychoneuroses
have naturally led to a greatly increased interest in psychotherapy,
and to the devising of many new psychotherapeutic procedures. So
numerous and so apparently diverse have these procedures become that
a superficial glance at the rapidly growing literature might lead one to
suppose that the methods of psychotherapy are legion, and that any
attempt to collate and compare them must necessarily be a task of great
complexity and difficulty. ' A closer inspection shows, however, that all
the available methods are ultimately dependent upon the employment
of one or other of three basic principles, and that they differ only
in the extent to which these principles are combined, and in the
particular technique by which they are applied. These three
basic principles are suggestion, persuasion, and analysis.
Certain schools of thought profess to rely entirely or almost
entirely upon one only of the three, and name the method they
practice according to the principle selected. Thus Babinski, and the
many followers, of Babinski who have arisen in this country since the
War, employ suggestion, Dubois and D4jerine advocate persuasion,
while Freud, and the schools which have developed directly or
1 At a meeting of the Section, held December~10 # 1918.
14
Hart: The Methods of Psychotherapy
indirectly from Freud, employ some form or other of analysis. In
actual practice, however, these various schools do not confine them¬
selves to a single principle, but in each case there is an admixture of
other principles. Thus Dejerine, although a persuasionist, unquestionably
uses suggestion to a very considerable extent, and the same criticism
applies, though to a less degree, to Dubois, and to the practitioners
of analysis. In spite of. this fact each school tends to regard itself as
the sole possessor of the promised land, and to treat its rivals as foolish
mortals floundering uselessly in outer darkness. Now it is clear that,
if we are to find our way through all these acrimonious discussions and
disputes, it is necessary to determine precisely the nature and relation¬
ship of the three basic principles, suggestion, persuasion and analysis,
and the extent to which each of these principles is employed by the
contending schools. The present paper is an attempt to progress some
little way in the direction of this goal.
Suggestion.
Suggestion is a widely used term, and is employed in medical .
literature as a convenient and satisfying explanation for all sorts and
kinds of phenomena. Often, indeed, it is put forward as an ultimate
and completely sufficient cause, much as if it were comparable in
majesty and power to the law of gravity. Now this can only be
justifiable if suggestion is a very exact conception, clearly defined and
limited, and capable of precise formulation, and our first problem must
be to determine how far the concept of suggestion fulfills these con¬
ditions. If we turn to the literature of psychotherapy we find that
Dubois and Dejerine sharply differentiate suggestion from persuasion.
Many of the followers of Freud, on the other hand, hold that per¬
suasion is essentially identical with suggestion, and that the method of
psycho-analysis is absolutely distinct from either of them. A third
school, again, maintains that psycho-analysis is merely an insidious and
prolonged form of suggestion. Turning next to psychopathology, we
find that Babinski regards suggestion as a sufficient explanation of
hysteria, while other authorities ascribe the phenomena of neurasthenia
to autosuggestion. Finally, psychologists tells us that suggestion is
a normal process in the human mind, and that it is responsible for
our religious and political views, our patriotism, caprices and
prejudices.
Now it is clear that something which explains hysteria and
Section of Psychiatry
15
neurasthenia, and is a characteristic of normal health, which is
responsible for our religion, politics, caprices, prejudices, and thera¬
peutics, must either be a very inexact conception, or denote a factor so
widespread and universal that it is useless to invoke it as a weapon
of explanation. It explains everything and therefore it explains
nothing.
It will.be well, therefore, to investigate more closely the sense
in which the word suggestion is used by these various authorities, to
determine whether this sense is always the same, and whether the word
is not sometimes used to denote processes which we already know under
other names, and finally to inquire whether it is possible to formulate
an exact conception to which the term suggestion may usefully be
limited. A convenient starting point for this investigation may be
found in McDougall’s definition of suggestion as “ a process of com¬
munication resulting in the acceptance with conviction of the com¬
municated proposition in the absence of logically adequate grounds for
its acceptance ” [4].
Now the opening words of McDougall’s definition “a process of
communication ” immediately exclude a certain number of the
phenomena which some authors bring under suggestion, but even with
this limitation it is questionable whether the definition does not cover a
field so wide that the conception is of little use as a practical weapon of
explanation. Most of our beliefs are held without any logical basis,
though by the manufacture of rationalizations we endeavour to find
such a basis when out beliefs are attacked, and we are constantly
accepting propositions in the absence of logical grounds for their
acceptance. The mind of man moves so frequently and universally
along this road that to cite the process as an explanation of some par¬
ticular phenomenon is hardly more satisfying than to explain the
peculiar features of some animal or plant by the existence of an atmo¬
sphere. To begin with, if we adopt as a reasonable measure of
“ acceptance with conviction” our preparedness to act upon an idea, it
may be said that every commiftiicated idea tends to be accepted with i
conviction provided that it does not conflict with other ideas. If it is
announced to me that dinner is ready, I accept the proposition; and
proceed to move into the dining room without instituting an inquiry
into the logical basis of the assertion, unless the announcement is made
at a time when I am normally expecting to go to bed. This is the
process termed “ simple communication,” and there is no need to invoke
any special function of suggestibility to explain its action. Such a
16
Hart: The Methods of Psychotherapy
process would appear to be all that is necessary to account for certain
of McDougall’s conditions favouring suggestibility, “ lack of organized
knowledge ” for example. The acceptance by an uneducated man of a
proposition patently impossible to anyone with special knowledge of the
subject is psychologically identical with my acceptance of the pro¬
position that dinner is ready. When, however, a communicated idea is
accepted when there are or should be conflicting ideas present, an
obviously different process has come into action. If I am informed
that one of my friends is playing golf, and I believe this assertion in
spite of the fact that this same friend is sitting by my side, then clearly
we are confronted with a phenomenon into which some other factor
than simple communication must enter. This other factor is evidently
a neglect or inhibition of ideas which are incompatible with the com¬
municated idea. The first amendment to McDougall’s definition which
we shall therefore venture to propose is that the term suggestion should
only be applied where such a neglect or inhibition of conflicting ideas
is present. When, indeed, the phenomenon is due merely to neglect,
the psychological process is so essentially different from that which
underlies inhibition, that it would probably be advantageous to exclude
it from the conception of suggestion. If, for example, we accept a
proposition when we are fatigued which we should not so accept in our
normally vigorous state, this occurs because fatigue has lessened the
integrative capacities of our mind, and conflicting ideas are not brought
into contact with the proposition which they would otherwise destroy.
The process here is psychologically almost identical with the simple
communication already described, and essentially similar to the
acceptance by an uneducated man of a proposition which is in fact
impossible. It would seem advisable, therefore, to reduce the limits of
suggestion still further, and to confine it to those cases where there is
an actual inhibition of conflicting ideas. This reduction brings sug¬
gestion into an interesting relation to attention, for in the latter
there is an inhibition of irrelevant ideas, whereas in the former
there is an inhibition of relevant ifleas. The comparison opens
up a promising avenue for speculation, but it would lead to fields
outside the scope of this paper, and cannot be pursued further here.
If it is agreed that the essential process in suggestion consists in
an inhibition of conflicting ideas and the resultant acceptance with
conviction of a proposition based on illogical or non-logical grounds, we
may next inquire whether this is a process with which we are already
familiar under other names. A little consideration will show that we
Section of Psychiatry
17
are very familiar with this process, and that it has received many other
names. It is the process which I have called elsewhere “thinking due
to the action of a complex ” as opposed to “ rational thinking ” ; it
occurs whenever our stream of consciousness is directed by emotional
or instinctive forces, and it is responsible unquestionably for most of the
movements of our mental machinery. The lover does not fervently believe
in the perfections of his lady because he has logically deduced those per¬
fections from the facts at his disposal, but because all his thoughts and
perceptions are twisted in a definite direction by the emotional systems
which constitute his love, and against that directive force all the logic
in the world. is impotent. Many of the beliefs and opinions of the
normal man are due to mechanisms similar in kind, though less
grossly obvious. It may be said, indeed, that the greater part of our
thoughts and activities are due to forces of which we may or may
not be conscious, but which are assuredly not logical in character.
Logic plays a part in directing the minor currents in the stream, but
the power which drives the stream and determines its main course
originates in emotional systems analogous to that which we see in
action in the lover. The effect of such an emotional system is to throw
into the stream of consciousness ideas belonging to the system, to
reinforce currents in harmony with it, and to inhibit currents which are
incompatible or in conflict with the goal which it is trying to achieve.
These emotional systems are known by many names, bias, prejudice,
intuition and so forth, but their action is the same in each and every
case, the forcing of the stream of consciousness into a direction which
will subserve the goal of the system, and the inhibition of all ideas and
tendencies which would conflict with that goal. ” Now this action is
precisely that which we have seen to be characteristic of suggestion,
and it will immediately be clear that suggestion is merely a particular
example of the activity of an emotional system of the kind described.
To use the terminology which we have employed elsewhere, suggestion
is a variety of “ complex thinking.” 1 11 How large a variety it constitutes
is a matter of definition and arbitrary limitation. But its utility as
a weapon of explanation obviously depends on the preciseness of the.
definition and the narrowness of the limitation, for if w T e make the
conception so wide that it practically includes all types of “ complex
1 Vide the author's “Psychology of Insanity/* Cambridge University Press, Chap. Y.
11 Complex” is used therein in a more extended sense than that generally given to it,
and indicates any affective system capable of directing -and influencing the stream of
consciousness.
D— 10
18 Hart: The Methods of Psychotherapy
thinking,” it will also include most of the mental activity of man, and
its value as an explanation of some particular phenomenon will be
almost negligible.
These considerations enable us to understand the apparently dis¬
crepant views as to the nature and action of suggestion held by the
various authorities whom we have quoted. The discrepancies are due
to the wider or narrower limits assigned to the concept of suggestion by
each authority, and in part also to the absence of any clear cut concept,
or of any definite limits. While in some cases suggestion is regarded as
including the whole sphere of “ complex thinking,” in others it is
narrowed down to include‘only hypnosis and closely allied phenomena,
and between these two extremes every intermediate grade may be
found. Those who explicitly or implicitly embrace the first extreme
interpretation, and who bring under the head of suggestion every
nfental process due to the action of an emotional factor, naturally
explain a vast number of phenomena thereby, but factors of this kind
are so universal that the explanation is correspondingly unsatisfying
and incomplete.' The explanation is true enough so far as it goes,
but it does not go far enough to be of any practical use. If our know¬
ledge is to be advanced we require to know what is the particular
emotional factor involved, and what are the precise circumstances of
its operation. A perusal of the literature makes it very clear, indeed,
that'the indiscriminate use of the word suggestion in these cases is
altogether pernicious, because too often it is regaided as a completely
satisfying explanation, and the necessity of making further inquiries
is entirely neglected.
It is evident, then, that if the conception of suggestion is to be
practically useful it must be narrowed down to limits which will mark
off a definite variety of “ complex thinking,” and which will not include
any and every variety to which the word has been hitherto loosely
applied. These limits will naturally be a matter for arbitrary selection,
but it will be agreed'that they should be so fashioned as to include
within their boundaries those processes to which the word suggestion
is universally applied, and only such other processes as can be shown to
be closely allied thereto. In this way the common signification of the
word will be preserved as nearly as possible. Now the processes which
are universally regarded as typical instances of suggestion are the
phenomena which occur in hypnosis, and the allied phenomena which
are capable of being produced in the waking or normal state, and if
we are to find an exact conception of suggestion it must be sought
Section of Psychiatry
19
by an investigation of the essential features of these phenomena. In
the typical instances in question a proposition is explicitly or implicitly
stated by one person, and is accepted with conviction by another
person, and it would probably be best to apply the term suggestion only
to those cases where this direct relation between persons exists. This
limitation is, in fact, partly but not completely implied by the
opening words of McDougall’s definition “a process of communi¬
cation.” The amended definition of suggestion resulting froip these
various considerations would therefore read “ a process of communi¬
cation whereby a proposition is communicated by one person to
another and is accepted with conviction by the latter in the absence
of logically adequate grounds for its acceptance, and owing to the
fact that conflicting processes which are or should be present are
inhibited.”
It is evident that even this amended definition does not give us a
conception with sharply cut limits, for it is easy to adduce a whole
series of instances linking up the typical examples of suggestion to
almost any and every variety of “ complex thinking.” If we are
to establish a sharply cut conception, it must be shown that in each
case where a proposition is accepted in this manner the acceptance is
due to the action of one particular psychological mechanism, and we
may next inquire how far it is possible to accomplish this.
Now in all cases of “ complex thinking ” the essential feature of the
process is that the stream of consciousness is directed by a force which
we have loosely described as an “ emotional system.” Although these
“ emotional systems ” may apparently be of all sorts and kinds it will be
found on analysis that they all derive their propulsive and directive
power from the incorporation within them of one or more of the great
instinctive forces of the mind. The demonstration of this vastly
important fact is the noteworthy achievement of McDougall’s work on
social psychology. If all “complex thinking” is due to the action and
interaction of instinctive processes, then suggestion, which is only a
variety of “ complex thinking,” must also be dependent on forces of
this character. Now if it could be shown that suggestion, in the
limited sense we have proposed, owes its effect to certain particular
instincts, or to a definite combination of instincts, 'we might then be
able to formulate the exact conception of which we are in search.
Several attempts have, in fact, been made to explain the process of
suggestion by the action of such particular instincts or their combination.
McDougall [4] ascribes it to the interaction of the instincts of self-
20
Hart: The Methods of Psychotherapy
assertion and self-abasement. Trotter [5] practically identifies sugges¬
tion with herd-instinct, while Freud and his followers [3] maintain
that the motive force is provided by the sex instinct. Space will not
permit of a detailed examination of these various views, but it may be
said that none of them is entirely satisfactory, and none of them
provides the clear cut conception we need. The evidence would seem to
indicate, indeed, that the phenomena commonly ascribed to suggestion
are not due to the action of any one instinct or combination of instincts,
but that the motive force may be derived from different sources in
different cases.
The conclusion to be drawn from these considerations is that, even
within the narrow limits with which we have attempted to circumscribe
it, suggestion is not a well defined conception capable of affording a
complete explanation of any phenomenon. When a phenomenon is
ascribed to suggestion we have learnt little more than that it belongs
to the sphere of “complex thinking,” and is therefore due to the
action of an emotional, or more properly, instinctive factor. Such a
classification can obviously form only a first stage of the investigation,
and to obtain anything that can be reasonably called a complete
explanation we must ascertain the particular emotional factor at woik,
and the precise circumstances in which it acts. This criticism applies
to many of the attempts that have been made to explain the mechanism
of the psychoneuroses, such as the theory of Babinski and his followers
which postulates suggestion as the essential cause of hysteria. This
theory demonstrates an obvious fact of observation, but leaves out
everything worth explaining—why the patient is so abnormally
suggestible, what is the particular emotional force responsible for the
suggestion, and why he has developed these particular symptoms and
not others. The answer that is sometimes given to these further
inquiries, that the patient has an hysterical constitution, is a refuge
strictly comparable to Moliere’s famous explanation of the hypnotic
properties of opium, but hardly worthy of admission within the portals
of science.
Another word frequently cited as a convenient explanation for
various phenomena is autosuggestion, and here again usage is so locse
and ambiguous that the need for definition and limitation is imperative.
One sense in which it is used is, for example, to explain the process by
which a patient who is convinced that his arm is paralysed actually
develops a functional paralysis of the arm. Now the process by which
the actual paralysis follows the conviction is probably direct and
• Section of Psychiatry
21
inevitable, the two stages being little more than different aspects of one
and the same fact, but whatever its nature may be it has certainly
nothing to do with suggestion. The suggestion lies farther back in the
sequence of causes, and is responsible for the acceptance with conviction
of the proposition that the arm is paralysed. Once this proposition is
so accepted the actual paralysis follows inevitably, but by a mechanism
in which suggestion plays no further part. In this sense, therefore, in
so far as the word is not definitely misleading it is merely tautological.
Another sense in which autosuggestion is employed is to designate
those varieties of “ complex thinking ” in which a direct relation
between persons is not involved. That is to say, it designates all
“ complex thinking ” except suggestion in the narrowed meaning we
have advocated for that word, and is proferred, for example, as an
explanation of our politics, prejudices and so forth. Here again }he
term would seem to be misleading and redundant. A third sense in
which autosuggestion is used is to describe a process whereby one
seeks to narrow down one’s field of consciousness and to fill it with
a single idea as, for instance, when we endeavour to produce a pseudo-
hallucinatory sensation by fixing our attention on a small area of our
skin. The process here clearly presents some resemblance to the
production of similar phenomena by hypnosis, and in this limited sense
the use of the word autosuggestion is probably justifiable.
We may sum up the position now reached as follows. All the
processes ascribed to suggestion are in reality examples of “complex
thinking,” and how large a section of “complex thinking” is to be
included under suggestion is a matter for purely arbitrary selection and
limitation. Probably it would be practically advisable to limit the
term to processes of communication involving a direct relation between
persons, but even here no specific elements are present. In every case
the only essential feature is the action of an emotional or instinctive
factor, which is the essential feature of all “ complex thinking.”
Processes of this kind are*, however, so common in the human mind
that to explain any particular phenomenon by ascribing it to “ complex
thinking” or to “suggestion” is altogether inadequate. The explanation
can only be accepted as satisfying and complete when we have
ascertained the particular emotional factors responsible, and the
conditions under \vhich they have produced their results.
This preliminary investigation of the nature of suggestion has
necessarily been somewhat lengthy, but it has enabled us to achieve
a standpoint from which our main problem, the use of suggestion as a
22
Hart: The Methods of Psychotherapy
therapeutic agent, may be easily attacked. The therapeutic aim of
suggestion is to implant in the mind of the patient a certain conviction,
and this conviction generally consists in the firm belief that a symptom
has disappearrd, or is about to disappear. Its utility in the psycho¬
neuroses is dependent on the fact that many of the symptoms of these
disorders are the result of beliefs held with conviction by the patient.
However intricate and lengthy the chain of causation which has
produced them may be, the penultimate link in the chain is the
conviction that certain symptoms are present. A functional paralysis
of the arm, for example, may be the final result of a long chain of
psychical causes, but the penultimate link is the conviction that the
arm is paralysed. Now the object of suggestion is to destroy that
conviction by implanting in the mind the opposite conviction, namely
that the arm is not paralysed, and if this process is successful the
chain of causation is broken at its penultimate link, and the symptom
disappears. Suggestion is able to accomplish this by virtue of its
capacity for inhibiting conflicting ideas and tendencies, whereby the
action of the ideas and tendencies responsible for the symptom is
blocked, and the conviction communicated by the suggestion is permitted
to flourish unchecked. This capacity is dependent upon the employment
of an emotional or instinctive factor, and, in the narrower conception of
suggestion we have proposed, this emotional or instinctive factor is one
involving a direct relation between two persons, the doctor and the
patient. The consideration of the wider question, how far and in what
way emotional or instinctive factors which do not involve this direct
relation between persons may be employed as therapeutic agents, will
be postponed until we have considered the nature of the second basic
principle, persuasion.
Persuasion.
Persuasion, like suggestion, is a term of regrettably vague and
ambiguous character. It is used in the literature in two quite distinct
senses which may be fathered upon Dubois [2] and D6jerine [1]
respectively. For Dubois it is a purely logical process, for D6jerine it
is a logical process, but one in which affective factors play a necessary
and important part. These two conceptions must naturally be dealt
with separately. Dubois conceives persuasion as a process in which
certain effects are produced by chains of logical reasoning, and
distinguishes it sharply from suggestion. The latter is dependent upon
blind faith, while the former appeals to clear logical reason. Now, if
Section of Psychiatry
23
we bear in mind the analysis of the nature of suggestion which has
already been made, the relationship to it of Dubois’s conception of
persuasion is immediately apparent. This relationship is identical with
that which exists'between “rational thinking” and “complex thinking.”
In the former the stream of consciousness proceeds in a direction
determined entirely by the intrinsic values of its elements, each step
being the logical consequence of the preceding steps. Emotional
factors play no part, and the conclusion follows inevitably from the
premises just as a proposition of Euclid inevitably leads us along a road
fixed by the logical relationship of its terms. The conclusion can be
predicted with certainty by an observer who knows only the proposition
and nothing at all of the man who is thinking it. In “ complex
thinking,” on the other hand, the direction of the stream of consciousness
is conditioned by emotional factors which force it into a path which will
subserve the aim of the emotional system in question, and which distort
the logical relationship of its elements so that this aim may be achieved.
Here the conclusion cannot be predicted unless the observer knows not
only the proposition, but also the man who thinks it and the emotional
systems which dominate his mental activity.
If persuasion is identical with rational thinking then it is clear that
the superiority to suggestion which Dubois claims for it is based on
very solid grounds, for rational thinking leads to knowledge, whereas
suggestion leads only to beliefs erected upon an insecure foundation.
The sole question which arises is how far rational thinking can be
used for therapeutic ends and how far it is capable of destroying the
convictions responsible for psychoneurotic syn ptoms, for the impotence
of logic against the creations of an emotional system is a phenomenon
which is only too frequent and obvious. In practice, indeed, it will
be found that the utility of Dubois’s persuasion is severely limited on
account of this difficulty, but it is nevertheless indubitable that it has
utility.
The therapeutic employment of persuasion is dependent upon a
process which in its final stages is identical with that which occurs in
suggestion. We have seen that many of the symptoms of the psycho¬
neuroses are the result of beliefs held with conviction by the patient,
and that, however intricate the chain of causation may be, the pen¬
ultimate link is the conviction that certain symptoms are present.
Now the aim of persuasion, just as the aim of suggestion, is to implant
in the mind of the patient the opposite conviction, namely that the
symptoms have disappeared, or are about to disappear. This is
24
Hart: The Methods of Psychotherapy
explicitly stated by Dubois in the following words: “The nervous
patient is on the path to recovery as soon as he has the conviction that
he is going to be cured ; he is cured on the day when he believes
himself to be cured ” [2]. To take again the example formerly selected
to illustrate the action of suggestion, that of functional paralysis of
the arm. If this condition is treated by persuasion the aim, just as
before, is to destroy the conviction that the arm is paralysed, upon
which the actual paralysis is dependent, and to implant in its stead the
conviction that the arm is capable of normal movement. I3ut in this
case the conviction is achieved, not as the effect of an emotional process,
but as the logical result of a chain of reasoning. It is demonstrated to
the patient, for example, that all the tissues of his arm are healthy,
that none of the signs which inevitably belong to an organic lesion
are present, that the muscles of the arm are actually capable of work,
and so forth. From all these premises the conclusion that the arm is
not paralysed follows as an inevitable logical deduction.
Dejerine’s conception of persuasion cannot be so easily described and
placed in its relation to other methods. This difficulty arises, I believe,
because his conception does not correspond to any simple process, but is
made up of a variety of processes essentially different one from another.
In various passages in which he defines persuasion as he understands it,
he states, for example, that persuasion consists in explaining to the
patient the true reasons for his condition, in establishing the patient’s
confidence in himself, and in awakening the different elements of his
personality capable of becoming the starting point of the effort which
will enable him to regain his self-control; he says, further, that in
order for this to happen an element of feeling must intervene between
the doctor’s reasoning and the acceptance of this reasoning by the
patient, and that psychotherapy* depends wholly and exclusively upon
the beneficial influence of one person on another [1]. Now at least
three distinct processes are involved here. First, the explanation to
the patient of the nature of his condition is a reasoning process identical .
with the method of Dubois. Secondly, in so far as the effect is
dependent upon the beneficial influence of one person on another, it is
dependent upon an emotional relation existing between the two persons,
and is therefore clearly due to suggestion in the narrower sense.
Thirdly, the employment of the various elements of the patient’s
personality as weapons for achieving the therapeutic end consists
essentially in making use of those emotional forces in the patient which
do not necessarily involve a direct emotional relation to the doctor, and
Section of Psychiatry
25
is therefore identical with “ complex thinking ” in general. This third
process is the only one which we have-not already investigated. It will
be remembered that at the end of the section on suggestion we
postponed for later consideration the question how far and in what way
emotional or instinctive factors which do not involve a direct relation
between persons may be employed as therapeutic agents. This question
must now be examined, for it is evident that the third process con¬
tained in D6jerine’s method is an attempt to provide a practical
answer to it.
We have seen that most of the movements of our mental machinery
are due to the driving power exerted by emotional systems, that these
systems direct the stream of consciousness into channels which will
subserve their goal, and that a great part of our beliefs and opinions are
due to agencies of this character. Now it is clear that by suitable
stimulation and combination of the emotional systems existing in our
patients, effects can be obtained which will have a therapeutic value.
Thus, by making use of the religion, ambitions, affections and other
weapons which are available in the patient’s mind we may be able to
destroy or mould into other forms the mental processes responsible for
his symptoms. The effect here is due to the employment of emotional
factors, but it is not mainly due to the employment of an emotional
relation existing between the doctor and the patient. It is in other
words the result of “complex thinking,” but not the result of suggestion
in the narrow sense. The part played by the doctor here is comparable
to the action of an engine driver who merely directs the forces produced
in the engine.
This process constitutes one of the most powerful and efficient
weapons in our therapeutic armoury, and we shall subsequently see
that it is employed, to some extent at least, by all psychotherapists,
to whatever school they may profess to belong. Sometimes it is used
merely as a method of removing symptoms, the object being, just as in
the case of suggestion, to produce in the patient a conviction that the
symptoms have disappeared or are about to disappear. In other cases,
however, it is used as a means of readjusting the causes which are
ultimately responsible for the symptoms. Here the previous elucidation
of the causes by some analytical method is necessarily presupposed,
and we may now pass on to investigate the nature of these analytical
methods.
26
Hart: The Methods of Ptychotherapy
Analytical Methods.
The term “analysis ” is used in this paper to indicate any. method
whereby the nature and relationship of the causes responsible for the
patient’s condition are determined, and the condition removed by the
rearrangement and readjustment of these causes. "It is not meant to be
synonymous with psycho-analysis, a word which should only be applied
to the method devised by Freud and generally associated with his name.
Psycho-analysis is clearly analysis, but the latter is a wider term and
one applicable to all therapeutic procedures which satisfy the definition
given above. It is unquestionable, of course, that all modern analytical
methods owe a great debt to the work of Freud, and that in each and
every one of them many of his essential principles are incorporated.
Psycho-analysis, however, involves the acceptance of a particular theory
of causation, and should not be used to designate methods which are
not governed by this theory.
The employment of analysis as a therapeutic measure is based on
the assumption that certain disorders are pf psychogenic origin. If this
assumption is admitted, if it is agreed that some disorders are the result
of a chain of mental causes, then it is immediately obvious that treat¬
ment should aim at elucidating those causes, and then so altering or
rearranging them that their original effect is no longer produced.
This procedure is so evidently demanded by all the canons of scientific
medicine that the point is hardly worth labouring.
How many and what disorders are to be included in the psychogenic
group is a question which cannot be fully answered in the present state
of our knowledge. We are yet uncertain, for example, how far the
various types of insanity can be brought under this head. So far as
the psychoneuroses are concerned, however, the view that they are
essentially of psychogenic origin has steadily gained ground during
the past fifty years, and has been so confirmed and extended by the
experiences of the War, that it would be fair to say that it is now
accepted by almost every authority in every country. If this is so,
then clearly the analytical method of treatment is eminently applicable
to these disorders. Dispute can only arise as to the nature and action
of the causes responsible, and the relative merits of different methods of
ascertaining and removing them. It is upon diffeiences of opinion with
regard to these matters that the therapeutic procedures adopted by
various authorities are based, but the examination and criticism of
Section of Psychiatry
27
these differences would take us far beyond the limits of this paper,
which aims only at the consideration of broad general principles.
Relation op Suggestion, Persuasion and Analysis as
Therapeutic Methods.
We are now in a position to consider the relation between sugges¬
tion, persuasion and analysis as therapeutic methods. Analysis is
distinguished from the other two in that it is aimed at the causes
responsible for the condition, and seeks to remove the condition
by removing or rearranging those causes, whereas suggestion and
persuasion, in so far as they are not combined with analysis, are aimed
solely at the symptom, and seek to remove the symptoms without
reference to the causes which have produced them. This distinction
may be made clear with the aid of the following diagrams.
Fig. 1 represents the chain of causation responsible for the
appearance of certain symptoms, a, b, c, d, e indicating causal factors,
28
Hart: The Methods of Psychotherapy
and t indicating the symptoms produced by their interaction. 1 In a
large number of the symptoms of the psychoneuroses the penultimate
link ( e ) will consist in the conviction that a certain symptom is present,
and from this penultimate link the symptom itself follows directly in
the manner already described. Now if this condition is treated by
suggestion, attention is directed solely to the penultimate link, and
an endeavour is made to destroy this, and to substitute for it the
conviction that the symptom is not present (e 1 ). If the procedure is
successful the symptom promptly disappears, because the chain of
causation responsible for it is broken. The break is effected, however,
only at the penultimate link, the causes, a, b, c, d, are left in situ,
and the situation achieved is as represented in fig. 2. It will be
clear that, as the primary causes have not been attacked, there
is an obvious possibility either of relapse or of the development
of another similar symptom, a possibility notoriously borne out by
clinical experience.
If, next, the symptom is treated by pure persuasion a very similar
state of affairs is produced. The aim as before is to destroy the pen¬
ultimate link (e), and to substitute for it the conviction that the
symptom is not present. This is accomplished here, however, not by
implanting the conviction with the aid of an emotional factor, but
by collecting together trains of thought which will lead to the conviction
by their intrinsic logical force. The situation now is represented by
fig. 3, where f, g and h indicate the trains of thought in question
which have produced the conviction (e 1 ) that the symptom is not present.
The symptom disappears just as in the case of treatment by suggestion
and for the same reason; it will be observed, however, that the primary
causes are again left untouched. This similarity between the two
methods of treatment is evidently not always appreciated by the
exponents of pure persuasion, and suggests that the vaunted superiority
of persuasion is of doubtful validity. It may be.said, however, that it
is unquestionably superior to suggestion in that the removal of the
symptom is achieved by an integrating process presumably more
stable than the mere implantation of a belief without support or
foundation.
If, lastly, the symptom is treated by analysis, attention is directed,
not merely to the penultimate link, but to all the links in the chain of
1 The diagram is, of course, purely schematic aud unduly simplistic. The causes would
be represented more properly by a netwoik of circles than a line of circles, but this has been
omitted in order to avoid complicating the figure.
Section of Psychiatry
29
causation. When these have been ascertained an endeavour is made
to destroy or to rearrange them in such a manner that they are. no
longer capable of producing their original effect, namely the symptom.
If this is successful the symptom again disappears, but it disappears
now because the whole chain of causation has been fundamentally
altered. The situation thus attained is represented by fig. 4, where
a, b, c and d have been rearranged in a new pattern which no longer
leads to e or s.
h
■ Fio. 3.
6
The processes crudely illustrated by these diagrams will be rendered
more comprehensible by the consideration of an hypothetical case.
We will suppose that we are required to treat an hysterical monoplegia
of the right arm occurring in a soldier who has been buried by a shell
explosion. This symptom is not the result of a single cause, but of a
concatenation' of causes, amongst which the following may all have
played a part. The patient sustained a trifling injury to his arm in
childhood, which did not produce any noteworthy physical effect, but
• made a lasting impression on his mind. Secondly, he bad been assured
by his relatives, and possibly by bis doctor, that as a result of the injury
the right arm would always be weaker than the left. Thirdly, when the
shell burst a sandbag fell on the right arm. Fourthly, the soldier had
been suffering for some time previous to the final shell explosion from a
30
Hart: The Methods of Psychotherapy
gradually increasing “nervousness” and anxiety, due to the conflict
between the opposing forces of self-preservation and discipline, the
conflict which is the characteristic feature of the war neuroses. This
conflict had latterly become acute, and it was a biological necessity
that some solution of the situation should occur. Hence had arisen the
unconscious motive which is an integral factor in the causation of all
psychoneuroses, the motive which desires a disability as the only
solution whereby the conflict can be satisfactorily relieved. As a result
of the interaction of all these, and perhaps of other causes, the pen¬
ultimate link (e), the conviction that the arm was paralysed, was
produced, and the actual paralysis followed inevitably.
Now, if this condition is treated by suggestion, our object is to
produce the conviction that the arm is not paralysed. This is achieved
by hypnosis or other method of suggestion, and the paralysis promptly
disappears. No attention whatever is paid to the causes which produced
the symptom. Their original outlet is blocked, but they are left as a
pathogenic focus whence may develop similar or other symptoms.
If on the other hand, the condition is treated by persuasion, we seek to
prove to the patient by a logical demonstration that his arm is not
paralysed. We show him that all the tissues are healthy, that the signs
which should accompany a real paralysis are absent, that if we lift his
arm and then remove the support while his attention is diverted the*
arm does not drop immediately, and that therefore his muscles must
actually be functioning. By collecting together these and similar
arguments we shake and finally destroy the conviction on which the
paralysis is dependent, and when this aim has been attained the
paralysis inevitably disappears. But it will be observed that here again
the causes primarily responsible for the paralysis have not been
investigated or attacked, and the pathogenic focus is left untouched
just as in the case of suggestion. If, finally, the condition is treated by
analysis, all the causes mentioned above are first unearthed, and then
an attempt is made to destroy or rearrange them. This latter process
may consist, for example, in bringing the various factors into the
full light of consciousness, making their relationship and significance
apparent to the patient, and subjecting them to the solvent action of
the forces available in the patient’s mind, his ambitions, sell-respect,
religion, traditions, or whatever other weapon can be pressed into
service. It will be clear that we are employing here the process which
was found to form a part of D^jerine’s conception of persuasion, the
utilizing of the emotional factors existing in the patient’s mind as
Section of Psychiatry
31
weapons capable of readjusting and integrating the mental elements
responsible for the symptoms. Only in this case the method is applied
to the causes ultimately responsible, which have been elucidated by
analysis, and not merely to the symptoms themselves.
These considerations lead to the conclusion that analysis is obviously
superior to the other methods we have considered, and it might be sup¬
posed that it ought always to be used to the exclusion of the others.
This would be an erroneous deduction, however, because it is found in
practice that a considerable number of conditions can be dealt with
more rapidly and conveniently by the employment of suggestion or
persuasion. Certain hysterical symptoms, such, for example, as paralysis,
functional gaits, mutism and so forth can be removed with ease and
speed by suggestion or persuasion, which would involve a lengthy and
complicated procedure were they treated solely by analysis. It may be
said, nevertheless, that even in these cases treatment is far from being
adequate and complete unless the removal of the prominent symptoms
is followed by an analysis aimed at the elucidation and rearrangement
of the ultimate causes. Only in this way can a reasonable stability and
freedom from relapse be secured. Cases where the mere employment of
suggestion or persuasion has produced apparently solid cures are
frequent enough, but this is probably due to the fact that an altera¬
tion of the primary causes has been effected by some means independent
of the actual treatment. A war hysteric, for example, may have his
symptoms removed by suggestion, and may then be discharged from the
Army, so that the most important of the ultimate causes, the conflict
between self-preservation and duty, is rendered inert. Reasons of this
kind no doubt help to explain the fact that treatment by suggestion or
persuasion is often far more efficient and satisfactory in war psycho¬
neuroses than in the psychoneuroses of the civilian. In any case the
sphere of these methods is certainly limited, and fhey are only capable
of application to a comparatively small section of the great group of
the psychoneuroses. It would seem, indeed, that they are applicable
only to those cases in which the penultimate link in the chain of
causation consists in the conviction that a certain symptom is
present. Where this link is absent, and where psychical causes have
produced symptoms without its intervention, suggestion and per¬
suasion by themselves seem to be impotent. This holds for
example'in the anxiety-neuroses, which bulk largely amongst the
war cases, and in which analytical methods of one kind or another
are a necessity.
32
Hart: The Methods of Psychotherapy
Throughout this paper suggestion, persuasion, and analysis have
been sharply distinguished from one another, and regarded as inde¬
pendent methods of treatment. This has been necessary for the
purpose of investigating and correlating the basic principles involved.
It has already been indicated, however, that in actual practice no school
of thought relies exclusively on any one of the three, and that every
psychotherapist employs at least two and often all three principles.
The practitioner who confines himself to suggestion is impotent when
faced with many types of psychoneuroses, and crude and inadequate in
his treatment of all .types. Dubois employs a certain amount of
analysis and a considerable dose of suggestion. A perusal of D£jerine’s
work provides instance after instance of the use of analysis, and the
employment of affective factors is an integral part of his method. Some
Of these affective factors clearly belong to suggestion, however narrowly
we may define that term, and all of them come under that general con¬
ception of “complex thinking,’’ which is identified with suggestion by
many authorities, and is most certainly closely allied thereto. A
similar criticism applies to all the analytical schools. If it be agreed,
indeed, that the driving forces of the mind are all ultimately dependent
upon the interplay of instincts, then it is clear that without these
emotional factors the mind cannot do anything, and nothing can be done
to the mind.
Conclusion.
We may now attempt to sum up the conclusions reached in the
foregoing pages. It was originally stated that all methods of psycho¬
therapy are dependent upon the employment of one or more of three
basic principles, suggestion, persuasion, and analysis. Our investigation
has shown, however, that suggestion is a term of vague and indefinite
connotation, ranging in meaning from a conception identical with
“ complex thinking ” to a conception covering only the phenomena
observed in hypnosis, and closely allied phenomena. Under these
circumstances it would seem advisable to employ some other term to
indicate that wider conception of suggestion which includes within its
boundaries any employment of affective factors as curative agents, and
to limit suggestion to those instances where the affective factors are
those involving a direct affective relation between the doctor and the
patient. The wider term which would seem' the most appropriate for
this purpose is “affective therapeutics.” Our original statement would
then be modified so as to read that all methods of psychotherapy
Section of Psychiatry
33
are dependent upon the employment of one or more of three basic
principles, affective therapeutics, persuasion, and analysis. The
characters of these three principles may be described as follows.
Affective therapeutics consists in the employment of the various
emotional, or more properly instinctive, factors existing in the patient’s
mind as weapons whereby pathogenic mental processes may be destroyed
or altered. The method is dependent upon the property possessed by
these emotional factors of furthering tendencies in harmony with them
and inhibiting opposing tendencies. When the emotional factor
employed consists in an affective relationship between doctor and
patient the process becomes suggestion in the narrow sense. When
the factors employed do not involve this direct relationship, then we
have the process which is an integral part of D4jerine’s persuasion, as
it is indeed of all psychotherapeutic methods, but which is clearly
distinct from the persuasion of Dubois.
Persuasion, in the sense of Dubois, consists in an endeavour to
destroy a pathogenic mental process by reasoning, the effect being pro¬
duced not by any emotibnal factor but by the logical force of the
arguments presented to the patient. In itself this method is probably
almost impotent, but combined with affective therapeutics it becomes a
powerful and efficient weapon. .
Analysis consists in an investigation of the causes responsible for
the patient’s condition, and the removal of the condition by the
removal or alteration of the causes.
These three principles can be clearly distinguished theoretically,
but in actual practice more than one principle is almost inevitably
employed. Every psychotherapist, although he may style himself sug-
gestionist, persuasionist, or analyst, makes use of at least two and
often of all three principles. Suggestion and persuasion by themselves
have but a limited field of application; they are only capable of dealing,
with symptoms, and probably only with symptoms which are directly
dependent upon the existence in the patient’s mind of a certain con¬
viction. Affective therapeutics, other than suggestion in the narrow
sense, has a wider application, but its use as an accurate weapon pre¬
supposes a preliminary analysis. Analysis is clearly the ideal method,
but it is more properly a stage in treatment rather than a method
complete in itself. By its employment the various causal factors
responsible for the disordered condition are elucidated, but when this
has been achieved there remains the further task of rearranging or
D —10a
34
Hart: The Methods of Psychotherapy
eliminating these causal factors, and in this latter process persuasion
and affective therapeutics are probably invariably called into play.
Practical psychotherapy, therefore, necessarily involves an admixture
of principles, and this admixture will be there however the physician
may endeavour to exclude it. Suggestion, for example, is omnipresent,
and will obviously come into action wherever there is a doctor and a
patient. It is surely better then, that this action should be correctly
estimated and deliberately utilized rather than left to the vagaries of
chance. The task of the physician is to cure the patient, and in order
to achieve this end he should be prepared to make use of any and
every weapon which lies to his hand. Affective therapeutics, per¬
suasion and analysis all have their place, but treatment can only be
efficient if their nature and limitations are clearly understood, so that
the physician may choose and combine his weapons according to the
condition which has to be attacked.
REFERENCES.
[1] D6jerinb, J., and Gauckleb, E. “ The Psychoneuroses and their Treatment by Psycho¬
therapy,’’ Philad. and Lond., 1918.
[2] Dubois, P. 44 The Psychic Treatment of Nervous Disorders,’* New York and Lond., 1909.
[3] Jones, Ebnest. “The Aotion of Suggestion in Psychotherapy '* ( 44 Papers on Psycho¬
analysis **), 2nd ed., Lond., 1918.
[4] McDougall, W. “ Social Psychology,” 12th ed., Lond., 1917.
[5] Tbotter, W. “ Instincts of the Herd in Peace and War,” Lond., 1915.
Section of pa\>chiatr£.
President—Dr. William McDougall, F.R.S.
War Psychiatry . 1
By C. Stanford Read, M.D., Major R.A.M.C.
In dealing with psychiatry in relation to the Army, one must bear
in mind that we have to some extent different human material to con¬
sider than in civil life. There is somewhat of an age limit, mainly
from 18 to 40 years, and we have in the Service men who have been
through some sort of recruiting examination and so presumably a good
many mentally unfit have been thus eliminated. We have then, a large
body of the male sex only, who all have to adapt themselves more or
less to the same environment and experiences. In civilian life there is
a greater variety of age, individual, and environment. From this we
may surmise that some types of psychoses will not commonly be met
with in the Army, and that the special circumstances involved in war
will tend to bring about types of mental reactions not so frequently
seen in ordinary life. One must also bear in mind that the mere fact of
removing an individual from his civilian occupation, taking him out
of an existence, where within wide limits he had such great liberty of
thought and action, and placing him in such a different environment
in which he finds an unaccustomed iron discipline whereby he has
this freedom at once almost entirely curtailed, tends to engender
mental refections which may be abnormal, and especially so in those
who have a psychopathic constitution. Before the Commission which
1 At a meeting of the Section, held March 11, 1919.
ju —19
3fi
Read: War Psychiatry
sat to inquire into recruiting problems, in the evidence given by the
military authorities, the opinion was freely expressed that if a man was
fit enough to do any form of work in civil life, he was fit to do that work
in the Army. This is a great fallacy. Large numbers of cases which
have been returned from overseas with psychopathic symptoms freely
illustrate the falsity of.this statement. The mental factor has not had
anything like the consideration it should have had. One can formulate
few rules on such a point, and every case should be treated on its
individual merits. If there be any evidence of mental maladaptation
in civil life, how much greater will be the probability of such under
the complex conditions of military life, and still more so in actual
warfare?
One can readily understand that in discussing the aetiology of war
psychoses one has to take a very broad Outlook, for the various
factors which may predispose and be directly and indirectly causative,
are manifold and complex. War psychiatry is almost a new study.
During the years of modern medicine the soldiers taking part in active
warfare have been trained and picked men, and for the first time the
civilian population have been more or less suddenly called upon to fill
the ranks of large armies. The conditions of warfare have also
changed so much. Enormously high explosives, poisonous gases and
flame fire have been added to the Army’s armamentarium, while
bombing from the air and the peculiar methods of trench strategy
have added so greatly to the mental and physical strain of the
combatants.
Previous to the present war the only literature of any kind that
existed on war psychiatry emanated from the Russians, for during
the Russo-Japanese campaign for the first time mental diseases were
separately cared for by specialists from the firing line back to the
home country. The total number sent back is believed to have been
very nearly 2,000. Some detailed statistics thus came to hand which
I do not propose to discuss now, but only draw attention to the
surprising statement that psychoses showing the largest percentages
were epileptic psychoses, 22'5 per cent., and alcoholic psychoses, 19'5
per cent.
In considering the factors tending to bring about a mental break¬
down, one should first bear in mind the point I have already alluded
to—viz., that the necessary abnegation of free thought and conduct,
combined with the fact of becoming subject to an unaccustomed iron
Section of Psychiatry
37
discipline, is sufficient, especially in the psychopathically disposed, to
produce unhealthy mental reactions. Such reactions must, too, be
helped on to a great extent by associative factors, the leaving of home
and those near and dear and in many cases dependent on them, the
blighting of ambitious hopes in civil life, the fear of financial loss and
business ruin, and maybe the dread of future incapacity and loss of life.
Doubtless the herd instinct with the average man tends to overwhelm
these incapacitating thoughts and feelings, and the “ crowd emotion ”
gradually but surely begins to fill him with martial and patriotic
sentiments, so that before long he is striving hard to be an efficient
soldier, and even longing to come to grips with the foe. Nevertheless
many experiences may render him individualistic again, and it is then
that mental conflicts are set up which in the predisposed may result
in psychopathic reactions. Should he have had previous mental break¬
downs, his outlook in any circumstances is worse, but he is usually
ashamed to mention the fact at the time of medical examination, though
even when known to the authorities the fact is often ignored. I had a
man under my care upon whose history sheet was marked under the
heading of “ slight defect, but not sufficient to cause rejection ”—“ two
previous attacks of insanity.”
* Generally one hears of war psychoses as tending to be brought
about by the “stress and strain ” of warfare. Such a vague term would
supposedly comprise mainly the factors of mental and physical
exhaustion and climatic conditions, and these alone would not produce
a mental disturbance probably without other issues being involved.
In my opinion, the so-called “ exhaustion psychosis ” requires much
investigation. Intense physical exhaustion alone can produce no
psychosis.
The war correspondent of the Daily Chronicle on April 3, 1918,
wrote concerning the men who had fought for six days and nights as
follows:—
“ They were tired almost to death, and when called on to make one last
effort after six days and nights of fighting and marching, many of them stag¬
gered up like men who had been chloroformed, with dazed eyes and grey and
drawn faces, speechless, deaf to words spoken to them, blind to the menace
about them, seemingly at the last gasp of strength. Towards the end of this
fighting they had h 'drunken craving for sleep, and slept standing with their
heads falling against the parapet. In body and brain these men of ours were
tired to the point of death. They felt like old, old men. Yet after a few
days’ rest they were young and .fresh. It was almost impossible to believe
38
Read: War Psychiatry
they were the same men. They had washed off the dirt of battle and shaved,
and the tiredness had gone out of their eyes and their youth had come hack
to them.”
This graphic description pictures very vividly how, although the
extreme limit of exhaustion had been reached, with a few days’ rest
the normal state was regained without any ill-effect to body or mind.
If intense exhaustion produces chemical toxins, which, acting upon
the nervous system, are said to bring about a confusional psychotic
state, how can we explain the fact that the experience just spoken of
is quite frequent, and yet these men retain their normal mental health ?
It is very possible that some lowering of resistance may be left which
may predispose the men to a remote breakdown, but it is very
doubtful if even that would occur without some definite psychogenetic
factor.
Birnbaum has pointed out that pictures similar to the so-called
exhaustion states often occur “ solely in consequence of psychic shock, as
symptoms of frank psychogenetic disorders, and that there is much to
suggest the purely psychic origin of these disturbances in war.”
Bonhoeffer was unable to find evidence of exhaustion psychoses as
the result of warfare, and he states: “ a collective survey of war
observations demonstrates the great power of resistance of the
healthy brain and the insignificance of both exhaustion and emotional
factors in the development of actual mental disease.” With regard
to the exhaustion I certainly concur, though the question of the
emotional factor stands in a different category.
Aschaffenburg declares that he has seen no case in which any
psychic disturbance worth mentioning has resulted from exhaustion.
Clarence Farrar concludes from his observations on Canadian
soldiers that “ the factor of exhaustion may lead to collapse or to
acute transitory fatigue states, and if severe and protracted, to pro¬
gressive physical deterioration. War experience has not established
its setiologic importance in the neuroses or psychoses. I should say
that the majority of cases diagnosed as exhaustion psychoses are
psychopaths who are abnormally subject to over-fatigue, or persons in
whom exhaustion plays only a secondary part in a condition having
other ffitiologicalfactors.” The term “exhaustion psychosis” was added
of late to the official nomenclature of mental diseases. This I regard
as a mistake, in that it may lead many to use this term heedlessly
and encourage others not to look further for deeper and more
important factors.
Section of Psychiatry
39
The question of climate calls for no special mention as it is only
part and parcel of the general hardship that a soldier has to undergo,
except in the Eastern campaigns, where heatstroke, sunstroke and
allied conditions do undoubtedly tend to lower mental resistance.
Many of my cases with various psychopathic symptoms, but more
especially those who had been in confusional states, blamed the heat
largely for their breakdown. Whether or no this was a rationalization
I am not in a position to say, but I should be inclined to place
heat in the same category as exhaustion, that is as only being
contributory.
Acute illnesses were predisposing and contributory as well. In
the East there were many cases of nervous and mental trouble
brought on during or as a sequela to malaria ancj dysentery. The
toxin of malaria seems to have quite a predilection for the nervous
system, and amnesic and confusional states were quite frequent in its
train.
Physical traumata, such as head wounds and concussion, may lead
to the exhibition of mental symptoms through definite interference with
functioning or through destruction of cerebral tissue, and following on
such injuries, many anomalous mental states tend to occur, fugues,
amnesias, character changes and convulsive attacks being those mainly
seen.
Many authorities regard pre-existing syphilis as a marked pre¬
disposing cause of nervous and mental disease in times of war strain.
Whether this is so or not I am not in a position to say, and the point is
a very difficult one to decide. The mere presence of positive Wasser-
raann reactions in the blood does not prove that syphilis has any
definite relationship with the psychosis.
Alcohol is of more importance. Though I can only trace a very
small percentage—viz., 1'6 per cent.—to its definite influence, there are
some who take a very different view. Lepine, in his work “ Troubles
mentaux de la guerre,” makes the astounding statement that alcohol
was the primary or sole cause in one-third of his cases, and more than
half, perhaps two-thirds, were influenced by it. His observations were
founded on the study of 6,000 cases, but it is difficult to see how he
could come to such a conclusion. If his deductions are true, one can
safely say that the cases met with in the British Army are very
different. In the Russo-Japanese war the percentage was very high
and accounted, it is said, for one-third of all the cases, but in the last
40
Read: War Psychiatry
Russian campaign it -is claimed that not a single case of alcoholic
insanity had occurred.
From my point of view the question of alcohol in the causation of
mental diseases requires much reconsideration. Apart from the acute
intoxications and those chronic states induced by many years of
excessive drinking producing a demential condition, I regard alcohol
largely as only a contributory factor working with and aiding mental
conflict.. It tends to remove inhibitions, aids mental regression, and in
the end psychological mechanisms are set in action which mostly bring
about the result of having saved the individual mental pain. In more
or less superficial statistical work it is difficult to make sure as to the
absence or not of the alcoholic factor, but in my experience of war
psychoses it is not a glaring one, and when present is frequently found
• not to have been a main element. In so many cases precisely the same
syndrome may be met with, with or without alcohol as an adjuvant.
Mental conflict is the last but most important setiological factor in
the production of the war psychoses. Now that modern psychiatrists
are metre and more studying the psychology of mental diseases, they are
tending pari passu to regard mental conflict as the “ fons et origo.”
The mechanisms involved, the distortions and disguises which these
same mechanisms have brought about, and the end results in more
or less definite clinical types have been much studied and formu¬
lated in dementia prsecox, manic-depressive insanity and paranoidal
states.
Further research now reveals psychogenetic factors in many of the
so-called alcoholic psychoses, in epilepsy, hallucinatory deliriums and
prison psychoses. We understand now to some extent that the aim of
these psychological mechanisms is constructive, that the patients have
thereby defended themselves against internal warfare, have built a
world of their own in which they feel they can live, and have in many
instances obviated mental pain and self-reproach and gained their
compensations. In warfare we should not be surprised to find great
opportunities for mental conflicts. The battle within between the
highest desire to follow the dictates of duty and honour and the
individualistic wish for safety and to be out of it all, is a conflict that
must occur at any rate now and again to almost every combatant,
though probably not always in a fully conscious form. News from
home of a disturbing nature, the separation of loved ones and the
unfaithfulness of wives cause worries that one hears of in case after
Section of Psychiatry
41
case of mental trouble. Exhaustion and indisposition, rendering the
sufferer less able to work properly, tend to bring about morbid feelings
of incompetency, unworthiness and impotency, and thus perhaps arouse
past conflicts. Enforced sexual abstinence in some causes anxiety,
promiscuous intercourse self-reproach, and it is probable that the close
male companionship in some lights up a latent homo-sexuality which,
though perhaps never becoming conscious, produces a mental conflict
and may be in time a paranoidal state. Of course these mental conflicts
can produce no psychosis if resolution takes place normally, but through
repression and abnormal resolution havoc may be wrought, and especially
in those cases whose mental soil is fertile. It is probable that in many
instances alcohol is freely taken to narcotize these conflicts which might
or might not have produced psychopathic symptoms without its use.
Let me pass on to give you some facts about the psychoses of the
present war as deduced from the analysis of 3,000 consecutive cases of
N.C.O.’s and men who have passed through my hands in under twelve
months. At “ D ” Block, Netley, which is only a clearing hospital,
all expeditionary force officers and other ranks from every theatre
of war—France, Belgium, Italy, Salonica, Egypt, Mesopotamia, and
Palestine—are admitted, examined, and then drafted on with a report
of their case, to one or other of the British mental war hospitals, where
they remain if necessary for nine months before being certified as of
unsound mind and placed in an asylum as a special service patient.
Those sufficiently well, though not recovered, may be sent to relations
or friends if they will accept the responsibility. Since the outbreak of
war to March 1, 1919, 313 officers and 11,850 other ranks from the
Expeditionary Forces have been admitted. Of these, 8,361 had been
under fire and 3,489 had not been under fire; 814 had previously
been in asylums.
The average’ length of stay of each case in this hospital has only
been a few days, so that any deep study of the individual has been out
of the question, but what one has lacked here has been to some extent
•compensated for by the large numbers and wide though superficial
outlook gained. Though my leisure time for such work has been very
limited, I have made statistical notes on 3,000 consecutive cases, the
clinical careers of which I have since followed up in my visits to the
mental war hospitals. Officers have for more than one reason not been
included. Increased knowledge leads to improved diagnosis but greater
difficulty in labelling. I have therefore classified largely in terms of
42
Read: War Psychiatry
reaction types except in those cases where the clinical picture was such
that one could justly use a text-book heading.
My results show the following figures:—
Analysis op 3,000 Consecutive Cases.
Number
Pei cent.
Under fire ...
2,289
76-3
Not under fire
711
23*7
Recovered ...
1,376
45*8
Improved ...
387
12*9
No change ...
1,168
38 9
Died
41
1*3
Discharged from service
1,818
60*6
Returned to duty
215
7*1
Repatriated...
278
9*2
Sent to asylum
617
20*5
Still in hospital
23
0*7
Not traced ...
20
0*6
Previous attacks
293 (?) ...
9*7 (?)
Insane heredity
539 (?) ...
18*0 (?>
Had recent shell shock
123
4*0
Alcoholic history
393
130
Committed suicide ...
3
—
Attempted suicide
105
35
Escaped
5
—
Classification.
Number
Per cent.
Dementia prtecox
598
20*0
Manic-depressive —
Depressive phase ...
250
8*3
Manic phase
180
6*0
Simple depressed states
194
6*4
Confusional states
401
13*3
including
Acute confusion
116
3*8
Simple paranoid states
260
8*6
Acute hallucinatory paranoia ...
233
7*7
Pure paranoia
10
0*3
Mental deficiency
388
13 0
General paresis
. 142
4-7
Alcoholic psychoses
49
1*6
Anxiety hysteria
46
1*5
Epileptic psychoses
38
1*2
Psychopathic inferiority
40
1*3
Traumatic confusion ...
22
0*7
Amnesia and amnesic fugues ...
22
0*7
With organic brain disease
22
0*7
Associated with acute infective disease ...
24
0*8
Acute hallucinatory delirium ...
5
01
Unclassified ...
76
2*5
Section of Psychiatry
43
Dementia preecox, as might be supposed, accounts for the largest
percentage of these war psychoses—viz., 20 per cent. It is often
impossible to be certain that this condition exists until prolonged
observation has taken place, as so many of the other mental reactions
of war at first seem akin to it. So many show marked apathy as a
leading symptom that, in the absence of other diagnostic factors, time
often alone can be the test, and especially is this so as the previous
history of the patient is so frequently not obtainable. I have constantly
been deceived in this way and other psychiatrists have had similar
experience. The different types, hebephrenic, catatonic, and paranoid,
are met with as in civil practice. Nothing special is to be said of these
but naturally the content of their delusions and hallucinations often
have a military colouring.
The depressive reactions had a percentage of 14 7, of which 6 4
per cent, were more or less simple depressed states and 8'3 per cent,
conformed fairly typically to the depressed phase of the manic-depressive
psychosis. In all previous wars depressive states have been much in
evidence, and it seems natural that the circumstances of a soldier’s life
should tend in this direction. The loss or diminution of the herd
influence must arise at times when the individual feelings come to the
fore and introspection comes about with its morbid tendencies. Home
worries one finds a prevalent factor in the engendering of mental
breakdowns even in those who had shown no previous psychopathic
characteristics. The constant stern demands of duty, though hearts
are sore and souls in pain, must produce mental conflicts to which
rational adjustment is difficult. As the emotions in such an environ¬
ment must so largely be repressed, is it any wonder than many develop
morbid symptoms ? Depressive anxiety and morbid apprehension are
seen in the milder cases and intense depression in the more severe.
The feeling of diffuse anxiety is so frequently met with that Lepine
makes a definite class of these cases under the term “ anxious insanity,’'
which he thinks more fitly describes them than melancholia. Self¬
accusation and the symptoms of a morbid conscience are constantly in
evidence and not seldom can they be traced to auto-erotic associations
upon which many think their pathology depends. It is an interesting
and debatable point as to whether many of the anxiety conditiohs may
not be due to ungratified sexual desire according to the Freudian theory.
One sees no reason why this should not be in some an aetiological factor,
especially at those times when inaction prevents the drafting off of
44
Read: War Psychiatry
energy. A. very large number of depressions seem only secondary
to paranoid ideas. Some psychiatrists would not hesitate to place such
cases in the manic-depressive group though no retardation of thought is
shown, while others regard the paranoid reaction as essentially primary
and the depression only a natural sequence. The only British statistics
published at present are those by Hotchkiss, of the Dykebar War
Hospital, who found out of his nearly thousand cases about 14 per cent,
of the depressed manic-depressives, which agrees with my findings if
the simple depressed states are included.
Manic, types of reaction were comparatively infrequent—viz., 6 per
cent. They require no special mention.
The confusional states were extremely common and this is probably
why it has been superficially supposed that some exhaustive factor
must be the main causative agent. The percentage amounted to 17*5,
of which 13 per cent, were simple confusional states from stupor to
slight obfuscation; 3*8 per cent, belonged to the type of acute confusional
insanity; and 7 per cent, were traumatic. A certain number of these
cases were patently due to toxic influence and followed upon definite
bodily illnesses.
As I have already mentioned, the malarial poison was a common
offender and every convoy from the Eastern sphere contained some
patients suffering from a mild confusion with which usually a more
or less severe amnesia was shown. These generally had been acute or
subacute at the onset and had become somewhat chronic. A few
presented themselves in almost stuporose conditions.
The acute confusions differed in no way from those seen in civil life,
and without a more definite history it was often difficult or impossible
to say whether the cases would prove to be dementia prsecox when the
acute onset subsided. Acute hallucinatory states were brought about
more especially after psychic shocks, presenting the symptoms of an
acute hysterical dissociation of only a temporary nature. Traumatic
cases, such as the concussional, showed nothing special, but, with
nearly all psychotic symptoms, there would be a war colouring to the
picture. The pathology of many of these types of confusion is often
obscure, and the war psychiatric literature up to the present hardly
throws any light on the subject. The French writers either vaguely
speak of the effect of emotion, or state that there need be no astonish¬
ment at the different varieties of confusion seen in war patients because
of the prevalence of the alcoholic factor. Toxic factors are probably
Section of Psychiatry
46
accountable for many cases, but what these toxins may be is by no
means always obvious. Many confusions are undoubtedly purely
psychological in origin, such as those we see commonly associated
with the mental defects! Mal-adaptable mentalities when called upon
more or less suddenly to face new and difficult situations will often
naturally react in a confusional way from conflict of impulse. At
times what is taken for confusion is really a dream state resulting from
an inherent desire to negate reality.
Paranoid Reactions .—A pronounced feature of war mental reactions
is the great prevalence of a paranoid trend. It seems to permeate into
the clinical picture of a very large percentage of cases, even where the
outstanding features are widely different. It tends to colour the mental
defect and the manic-depressive types, while in the dementia prsecox
cases it is as usual a prominent early symptom. It is seen in full bloom
constantly in an acute and often temporary paranoid psychosis. Only
a vague feeling of suspicion may be present, or an indefinite sense that
everybody is against the patients, or it may develop still further into
■ a definite but often brief unsystematized persecutory state. In my
analysis I find 16'6 per cent, of paranoid cases, of which 8’6 per cent,
were simple paranoid states, 7'7 per cent, were somewhat acute and
hallucinatory, while only O'3 per cent, belonged to the pure paranoid
group, and these had mostly existed prior to enlistment. I think
that the soldiers’ environment and experience tend largely to bring
about this form of reaction.
The psychological mechanism of projection is common enough in
everyday life, but seems to be brought into use as a defence reaction
much more under the severe conditions of war. The mental defect
often has substantial grounds for his persecutory ideas. He is bullied,
made game of, and tends to lead an existence which brings about the
natural conclusion that everyone is against him. The whole trend of
iron discipline fosters in some the idea of persecution, which becomes
exaggerated in a mind that is morbidly disposed and that has become
individualistic. When duties are not performed satisfactorily the bad
workman blames his tools ; the soldier may take up a similar attitude.
Morbid introspection leads to the arousing of old self-reproaches,
conscious and unconscious, the resulting conflict ending in projection.
The history of a typical case is that the man is seen to become asocial,
avoids his comrades and gets depressed and sleepless. Casual remarks
elicit the fact that he thinks that everyone is against him, and after a
46
Bead: War Psychiatry
time he thinks he is persecuted by a definite group. He imagines he
is regarded as a spy and as an object of suspicion. Hallucinations may
or may not further complicate the picture. If they develop, the “ voices ”
threaten “ to do him in,” call him filthy and obscene names, and accuse
him of the most immoral acts. This clinical picture is by -no means a
new one, and is akin to the state of so-called alcoholic hallucinosis.
In many instances alcohol does enter into the history, and these states
are usually regarded as alcoholic, but precisely the same syndrome
is produced without this drug, and it is seldom that any real toxic signs
or symptoms are evinced. Out of my.233 cases of this type only
eighty-two had an alcoholic history as far as one could tell. I regard
alcohol here merely as a contributory factor, aiding mental regression,
helping to remove inhibition, and thus more fully precipitating the
symptoms. It is often easy to see that it was taken because of the mental
conflict as a refuge and narcotic. The prognosis is, I believe, fair,
recovery usually taking place with insight.
The pathology of these cases requires much more elucidation. The
Freudian school believe that homosexuality is a basic factor in paranoiac
states. It certainly must be patent to any observer that sexual matters
enter very largely into the hallucinatory content of these patients, and
we must from this presume that mental conflicts of a sexual nature
have an setiological relationship at any rate with the acute form- of this
psychosis. Considering that this kind of psychopathic reaction is as
common as it is on active service, it would be suggestive to investigate
the theory that the herding of men together in the army, where hetero¬
sexual desires are largely excluded from being gratified, tends to arouse
a latent homosexuality against which the personality defends itself by
projection. That this hypothesis has some grounds for support is not
improbable. As Shand has pointed out in a paper read before the
British Psychological Society last year, suspicion is an emotion which,
though so prevalent, has been enormously overlooked and neglected
by, psychologists in the past. There is much interesting material
on this point for investigation in war psychiatric work.
The more psychiatrists see of general paresis the more they find
that the correct diagnosis depends upon a study of a combination of
the mental symptoms and the organic nervous signs, plus the sero¬
logical findings. In my clearing hospital it was not therefore possible
to be by any means sure how many cases were passing through,
and, superficially one found that many wrong conjectures had been
Section of Psychiatry
47
made when the cases were afterwards followed up. As has been
pointed out by Major Eager of the Lord Derby War Hospital,
Warrington, many shell-shock cases have presented similar signs for
a time and were only differentiated by careful further investigation.
It is a very debatable question whether the stress and strain of war
does or does not tend to be a factor in hastening the advent of this
disease. One must bear in mind that in the Army we have a
lessened number of men between those ages in which general paresis
usually manifests itself—viz., from 35 to 45 years. In civil life
the percentage is about 11, whereas European armies show an
average of about 7 per cent, during peace time. During the Busso-
Japanese war the Bussians showed a percentage of 5'6 and in the
analysis of my much larger number the percentage is only 4‘7.
It seems, therefore that we have no ground for supposing that
active service increases the actual number of cases, but the age
incidence perhaps tends often to be somewhat earlier. Out of the
142 cases ten were under 30 years, the lowest being 27 years, twenty
were 35 or under, and thirty-one were under 40. The period between
the contraction of syphilis and the onset of paretic signs seems also to
be somewhat shortened in a good many instances, though what the
relationship is between this and war experiences is only pure conjecture.
Mental Deficiency .—Perhaps the first thing that would strike the
average observer if he saw a parade of my mental cases from overseas,
would be the large number who present the outward and visible signs
of mental deficiency upon their faces. Though facial expression and
features are but poor and superficial guides in ‘this direction, in the main
he would be right in his assumption that a large proportion of the
men had a subnormal mentality. It is true that the expression of
those who are confused and apathetic tends to lend the countenance an
appearance which is deceptive in this direction, and it is surprising how
when the confusion disappears and more interest is taken in the
environment, the previous impression of intellectual defect vanishes.
I am inclined to think that the question of mental deficiency—using
the term in its wide sense—is one of the most important with which
recruiting authorities have to deal. My statistics show a percentage of
13 of pure mental defects of all grades, mauy of whom had some
slight pathological symptoms temporarily superadded. It is astonishing
to note the length of service of some of these men who are sent home
with reports of their uselessness, and their having been a danger to
48
Read: War Psychiatry
themselves and others. But on tracing their history one so often finds
that they were never permitted to use a rifle and for a long period had
only been performing menial duties, and had only perhaps broken down
when the slightest responsibilities had been assigned them or some slight
strain encountered. A large number of such men were incorporated in
the Labour Battalions, where it was presumed that a mental defect
was of small account. We here see the idea carried out that if a man
can do any work in civil life, he can do that work in the army, and can
do it overseas. Practice, though, does not bear out any such theory, as
any psychopathologist would have predicted. Poor-witted farm labourers
who have lived in the most simple surroundings all their lives cannot
adapt themselves for long in the army organization, and still less so
when having to work under shell fire. With the games their comrades
play on them and the stern treatment meted out to therm by their
N.C.O.’s, is it any wonder that they develop some confusional symptoms,
that they get persecutory ideas, which often have some true basis, and
show stuporose and other psychopathic states ?
Mental adaptability is something that one cannot weigh in a
balance, measure in mathematical terms, and predict with certainty.
How hard it is to prognosticate in such a question is shown by the sur¬
prising number of mental defects who do somehow or other adapt them¬
selves normally for a really long time before breaking down. One can
therefore have some sympathy with the military authorities if they take
up the attitude that they require the service of every available man,
that no one can say with any certainty how long a mental defect may
be useful, and that it is* worth their while to risk the recruiting a
man on the chance of his being able to serve the State for some
fair period of time.. The psychiatrist tends only to see one side of
the picture, and that perhaps he also takes too academic a view is
possible.'
This has an important bearing on the swelling of an already
enormous pension list, which might have been to some extent obviated
with more care. Many of the cases were found to be purely mental
defects from fairly low grades to morons, while many others on this
basis have superimposed symptoms. Some amount of confusion with
memory defect, perhaps leading to fugues, was perhaps the commonest
type met with, but transient depression or excitement with or without
paranoidal ideas were met with as well. The medico-legal side of the
defect is of importance, for, as may easily be imagined, they are
Section of Psychiatry
49
constantly and fruitlessly punished for minor delinquencies, and only
later found to be partly responsible.
The true toxic alcoholic psychoses amounted to only 1'6 per cent.
In many of the paranoid states an alcoholic history was obtainable, and
ordinarily these are classed under this heading, but I do not think that
this is scientifically correct. Many modern psychiatrists are taking
this view, and regard alcohol as an setiological factor in the production
of mental disease as overrated, incidence being confused with cause.
Such a text-book type as alcoholic hallucination requires its pathology
remodelling in the light of modern psychopathological knowledge.
Important psychic factors are always present; alcohol is not a neces¬
sary factor in the production of the psychosis, usually the sensorium is
clear, and no definite toxic signs are observed. The acute intoxications,
chronic demented states and Korsakoff’s syndrome, stand in quite a
different category.
Psychoses associated with epilepsy —the only psychosis inquired for
by recruiting doctors—showed merely a percentage of 1*2. Epileptic
confusion was the main symptom seen. Many cases of epilepsy
transferred home were found on investigation to be really psycho¬
neurotic in origin.
Other abnormal states showing small percentages require no special
mention. A certain number were found to be purely psychoneurotic
and transferred at once to the neurological section of the hospital.
A few words may be said on the question of suicide as met with
under active service conditions. Of my 3,000 cases 105 attempted the
act and three were successful in thus ending their lives at the War
Mental Hospital to which they were transferred. First as to the means
employed. It is presumably true that different individuals tend to
choose the method according to their occupation, which may suggest
a certain mode, and that there are' good grounds for thinking {hat
definite psychic factors aid in this choice, and that mental analysis
would often reveal them. It has been stated that the soldier by
preference shoots himself, whereas among my cases this method was
quite exceptional and throat-cutting with a razor was almost universally
employed. It is a moot point whether the mechanical difficulties
involved in using the rifle is sufficient to explain why it is so seldom
chosen for this purpose. The majority of suicidal attempts were among
the manic-depressives, and others were acutely hallucinated paranoiacs,
who, driven to desperation through the continuous accusing voices,.
50
Read: War Psychiatry
sought an end to their existence. A few occurred in quite temporary
confusional states, in which one could trace no previous depression,
nor evidence of mental conflict. The act was sometimes premeditated,
and sometimes not, and amnesia for the act itself was extremely
frequent. Such memory gaps are common enough when certain
antisocial acts are performed, and they become necessarily of great
medico-legal interest.
Though the genuineness of these amnesias are often called in
question, there is no doubt that they do often truly exist, and doubtless
the memory could be recovered by special means. Through the
conscious personality, repression and dissociation take place as a result
of the mental conflict, and the suicidal act is performed while in this
dissociated state. The same pathological basis exists as in the amnesic
fugue. Suicide mainly involves the absolute negation of reality. It is
the furthermost limit of that flight from reality which in some degree
or other tends perhaps to be the most fundamental human trend.
The psychology of suicide requires more studying. It is much too
often taken at its surface value. Wholey has made some interesting
observations on this subject in discussing a case of an alcoholic toxic
psychosis of his. 1 He says:—
“ The regularity with which we find the alcoholic attempting suicide by
throat laceration lends confirmation to the theory that a ‘ birth phantasy'
determined the manner of suicide. Such an interpretation of the psychology
of the alcoholic is in keeping with the theory of his homosexual fixation. . . .
It is to be noted that it is not the affect-depression of the melancholic which
drives these patients to suicide but an overwhelming urge to escape from an
imminent death attended by the most hideous torture and mutilation. . . .
The alcoholic’s ‘ torture ’ practically always includes mutilation of the genital
organs.”
There is great reason to believe that in many, if not all suicides,
factors in the unconscious mind are mainly responsible, but I regret
I cannot follow Wholey’s meaning when he connects throat laceration
with the idea of “ birth phantasy,” which I find is also spoken of by no
less a psychiatric authority than William White, of Washington.
Ernest Jones, in speaking of the fear and desire for death in the
war psychoneuroses says*:—
'“Revelations of the Unconscious in a Toxic (Alcoholic) Psychosis,” Amer. Journ.
Insanity , 1918, lxxiv, pp. 437-444.
7 “ Papers on Psycho-analysis,” 1918, p. 580.
Section of Psychiatry
51
“ The conscious mind has difficulty enough in encompassing in the
imagination the conception of absolute annihilation and there is every reason
to think that the unconscious mind is totally incapable of such an idea.
When the idea of death reaches the unconscious mind, it is at once interpreted
in one of two ways, either as a reduction of essential vital activity, of which
castration is a typical form, or as a state of nirvana in which the ego survives,
but freed from the disturbances of the outer world.”
These ideas are very suggestive and mark a distinct advance in our
conception of the pathology of suicide.
Though 1 am in a position to give the ratio of the number of mental
cases admitted to D Block to the average number of troops on active
service during the year 1917, such a ratio would be quite valueless and
misleading, since because of wounds, death, illness and other reasons,
this population was a constantly changing one and no exact figures are
obtainable of the true number of men who visited abroad during that
time. Any comparison therefore with mental disease occurring in civil
life during the same period is out of the question and especially so as
separate statistics have not been made for the latter with regard to the
special age-period of 18 to 40 years, for with that period only is the
soldier mainly concerned.
The recovery-rate would probably be found to be somewhat higher
on further and later investigation as some of the cases had been
repatriated at an early stage and cannot now be traced. It should
be noted, too, that by eliminating the 388 mental defects the recovery-
rate is raised to 52'6 per cent. The organization for the transference,
housing and treatment of the mentally afflicted soldier has for a long
time run very smoothly and these patients can have little cause for
complaint. The gradually increasing numbers put a great strain on
the hospital accommodation and fresh institutions had to be taken over
for this purpose from time to time. Perhaps the main defect that has
existed was one difficult to ameliorate—viz., that we had not sufficient
trained psychiatrists to deal with the work efficiently.
I hope that in the near future we may in England be able to adopt
some such mental hygiene movement as now exists in the United States,
which already has borne such admirable and fruitful results. At
any rate, through this war, neuro-psychiatry has a more hopeful
outlook both for physician and patients.
ju—20
Section of po^cbiatr^.
President—Dr. William McDocgall, F.R.S.
War Neurosis: A Comparison of Early Cases seen in the
Field with those seen at the Base . 1
By William Brown, M.A., M.D.Oxon., D.Sc.Lond.
Reader in Psychology in the University of London , King's College; late Officer Commanding
Craiglockhart War Hospital , Edinburgh , and Major R.A.M.C ,
(ABSTRACT.)
[This paper was printed in extenso in the Lancet , May 17, 1919, p. 833.]
In a recent communication to a medical periodical 2 I have indi¬
cated the principal methods of treatment which I found useful in
dealing with early cases of war neurosis while acting as neurological
specialist to the Army of the Somme front. In the great majority of
these acute cases the method of rational persuasion sufficed to produce
a cure if preceded by a thorough physical examination and supported by
the arousal of feelings of confidence and enthusiastic expectation of a
favourable result. Where earlier emotional shocks and mental conflicts
had already weakened the patient’s powers of resistance to the stress
and strain of war the method of mental analysis was found helpful.
Finally, in cases showing extensive amnesia, involving dissociation of
intensely emotional psychic states, the method of light hypnosis , under
adequate safeguards , was invariably successful in restoring the lost
memories and freeing the patient from subconscious emotional obsession.
My experience with more chronic cases in neurological hospitals in
Great Britain has impressed me with the great difference produced by
lapse of time in these functional nervous disorders and in their reaction
1 At a meeting Of the Section, held April 8, 1919.
2 Lancet , 1918, ii, p. 197.
Section of Psychiatry
5S
to different forms of treatment. Several of my officer patients in France
were again my patients at Craiglocbhart, and notes on the further history
of many other of my patients of the Somme have come into my hands.
It seems, therefore, worth while to attempt a comparison of these
earlier and later cases. Their differences help somewhat to explain the
differences of opinion held by equally competent observers on diagnosis
and treatment.
Returns to Duty in the Field.
As regards the cases seen in the field the percentage of returns to
duty varied, as might naturally be expected, according to the nature of
the fighting. It was at the time of a push that this percentage became
highest. Thus, whereas my average percentage returns over a period
of sixteen months was 70, at the time of the Cambrai push in November
and December, 1917,1 was able to return 91 per cent, to duty. This
was due to the number of exceptionally light cases that are sent down
at the time of a push, to be out of the way. Neurologists in other
armies have no doubt obtained equally high percentages.
But these percentage returns to duty are of no help in deciding the
relative merits of different methods of treatment, for the simple reason
that the same method, apparently, was used by all of us with these
lighter cases—viz., the method of persuasion. For my own part, at any
rate, I reserved the other therapeutic methods mentioned above, almost
without exception, for cases whom I intended to send down the line. It
is a study of these cases which is the more helpful in contributing to a
scientific knowledge of our subject. But first let us consider the various
types of psychoneurosis as they arrive in an advanced neurological
centre at the time of a push.
Neurological Cases during a Push.
The majority of the nerve cases that came down during the first
forty-eight hours after our tanks and infantry went over at Cambrai in
November, 1917, were very light. They were either old cases of “ shell
shock ” who had lost their nerve again at the prospect of being heavily
shelled, or else men constitutionally weak of nerve and lacking the
power to pull themselves together in face of an emergency. They came
down in lorries as walking cases, and made a sorry show m the reception-
room, with their hanging heads and furtive looks. They gave the
impression of men who had, at least temporarily, lost their self-respect.
ju— 20a
54
Brown: War Neurosis
Many of them were keeping up, with obvious effort, rhythmical tremors
which had no doubt been involuntary and irrepressible some hours
before, but were now within the field of voluntary control. By distracting
these cases with a rapid sequence of questions as to the origin of their
disability, I was able to bring the tremors to an end, and by treatment
during the next few days made the cure a permanent one. These men
returned to the line within a week. Others suffered also from tachy¬
cardia and genuine headache and vertigo, and needed a more prolonged
rest in hospital.
On the following days more serious cases began to arrive, many of
them stretcher cases. These had been concussed or buried by the
explosion of shells quite close to them, and some of them had been
rendered unconscious for a longer or shorter period of time. A few
were still apparently unconscious of their surroundings, although their
minds were probably in a dream state rather than an absolute blank.
[Here were given descriptions of a few typical cases, of which the
following is one]:—
A Walking Case : Deafness, Mutism, and Amnesia.
Case C .—A walking case this, but unable to speak or hear. He is some¬
what lethargic, but on being given pencil and paper writes a description of the
origin of his injury. He has complete amnesia for events immediately
following upon the shell explosion up to the time when he reached the
advanced dressing-post. Slight tremulousness and occasional headaches
complete the list of his symptoms. I place him on a couch and'show him
written instructions to close his eyes and think of sleep. After an interval of
about two minutes I make a sudden noise by banging two books together. His
.eyelids flicker, and I find that his power of hearing has returned to him. I
then proceed to give him suggestions audibly, urging him to continue thinking
of sleep, to give himself up to sleep, and saying that I am about to put
my hand on his forehead, and that the moment I do so all the events of
his accident, which he has forgotten, will return to his mind with hallucinatory
vividness. The result is that the moment I touch his forehead he shouts out,
using the same words that he did while under fire, and giving evidence of the
same emotion of fear that he must have experienced at that time. After he
has worked off all this emotion I remind him of where he is (in hospital), who
is speaking to him (myself), &c., and after giving the suggestion that he will
continue to remember everything, I wake him up and find that his main
neurotic symptoms—deafness, mutism, and amnesia—have disappeared. I
send him back to the ward to have a good sleep. He makes an uninterrupted
and complete recovery during the next few days.
Section of Psychiatry
55
Causation : Dissociation op Psycho-physical Functions.
Treatment, in the form of vigorous counter-suggestion and rational
persuasion, was given to all the patients immediately upon their arrival
in hospital, and was continued unceasingly during their stay, with the
aid of the si6ter-in-charge. Consequently, in the majority of cases the
functional symptoms disappeared or became gradually of less severity
right from the beginning. But in a few of the more resistant cases I
was able to observe the tendency for more severe symptoms to make
their appearance after a “ period of meditation,” as Charcot called it,
and many of the other cases seem to have shown the same “ incubation
process ” during their passage from the line to the neurological centre.
It is particularly noticeable in the case of motor symptoms such as
paraplegia, hemiplegia, and loss of speech, and these are just the
symptoms the onset of which seems, at least on a superficial view, to
be completely explicable in terms of Babinski’s 1 theory of suggestion.
The idea of loss of power has been implanted in the patient’s mind at
the moment of mental confusion and loss of emotional control produced
by the shock of the shell explosion, and gradually realizes itself during
the following few hours or days.
But, as Myers 2 has pointed out, this theory cannot explain the loss
of memory which is so frequent a symptom in the war neuroses. Noj
does it explain the sudden or gradual onset of vaso-motor and secretory
symptoms which unless treated, and too often in spite of treatment,
persist for long periods, although there is often no wound present to
give one the excuse of classifying them under the heading “ reflex
nervous disorder.” And there is now a large and growing body of
scientific opinion which regards these “ reflex nervous disorders ” as
entirely functional in nature and curable by psychotherapy.
As regards loss of memory, it is a remarkable fact that Babinski
does not once mention this symptom in his recent book on hysteria.
Had he devoted more attention .to it and to other outstanding
psychological characteristics of functional nervous disorders, his final
theory might possibly have been less clear-cut but surely more
intellectually satisfying.
Viewed from the psychological point of view, hysterical disorders
all fall under one heading, as examples of dissociation of psycho-
1 Babinski and Froment, “ Hysteria or Pithiatism ” (Eng. trans.), p. 41.
- C. S. Myers, Lancet , January 11, 1919.
56
Brown: War Neurosis
physical functions (walking, speaking, hearing, remembering certain
experiences, &c.) following upon a diminution or loss of higher mental
control. One school of thought would explain this dissociation as
the result of conflict between opposing and incompatible emotional
tendencies and as characterized by repression of one of these
tendencies. Others consider that a strong emotional shock is
capable of bringing it about in those who are hereditarily predisposed,
and may even produce it in a normal individual, if sufficiently intense.
On the • other hand, Babinski holds that “ hysterical symptoms and
violent emotions are incompatible.” 1 It is perfectly true that an intense
emotion, such as anger, may overcome a functional dissociation. I have
made a functional paraplegic walk by the simple expedient of inducing
him to lose his temper with me. But this fact is in no real contradiction
with the theory of the emotional origin of the disease, especially if the
originating emotion was of such intensity as to produce a state of
stupor—a result often observed in this war.
[Here follow descriptions of cases showing delayed onset of
symptoms. The most satisfactory explanation of the “period of
incubation ” is that it corresponds to a period of subconscious emotional
development and not to the working merely of suggestion.]
Amnesia.
In 15 per cent, of all the cases seen by me in the field there was
pronounced loss of memory, combined with the different varieties of
physical functional symptoms (paralysis, mutism, deafness, contrac¬
ture, &c.). My method of dealing with these cases was to restore
the memory in a state of light hypnosis, taking care to encourage the
revival of the emotional elements of the forgotten experience in all
their original intensity. The result was that the accompanying
physical symptoms disappeared of themselves, with more or less
completeness according as the emotional accompaniments of the
recalled memories were more or less vividly re-experienced as a
present hallucinatory experience , without the need of making specific
suggestions that they should disappear.
In my first Lancet article I explained this on the theory that the
emotional memories were repressed memories, and that the physical
symptoms were their physical equivalents, the repressed emotion
having been “ converted ” into physical innervations in accordance
Babinski and Froment, Ibid., p. 43.
Section of Psychiatry
67
with Freud’s theory of “ conversion hysteria.” On again reading
through all my notes of these cases I feel inclined to suggest another
hypothesis for many o'f the cases—viz., that the reinstatement of
intense emotion acted physically in overcoming synaptic resistances
in specific parts of the nervous system, and so put the nervous system
into normal working order again. The effect is mdre potent than that
of, for example, an electric current would be, since it is selective and
occurs only in just those parts of the system concerned with the
production of the symptoms. (Cf. McDougall’s theory of the physio¬
logical factors of dissociation and hypnosis.) The theory of abreaction
would still apply to the cases where mental conflict and repression of
emotional tendencies had taken place at the time of the shock or
injury. But in many cases the conditions of the injury appear to have
excluded this mechanism.
This modification is one of theory only. In practice I still regard
the recall of lost emotional memories with hallucinatory vividness as
a most beneficial form of treatment for patients seen shortly after
the onset of their symptoms. It redintegrates the mind 1 and by
again linking up the physical manifestations of emotion with their
psychical counterpart enables the former to come to a natural end
when the emotion has been worked off, instead of persisting as the
relatively permanent physical manifestations of the neurosis.
Treatment of Amnesia in France and England.
In France I succeeded in clearing up every case of amnesia by
means of light hypnosis. Even caseB of obviously physical concussion
with retrograd,e. amnesia responded to this form of treatment. Thus,
an Australian soldier was brought into my ward with complete loss of
memory, his field medical card being marked “ Identity unknown.”
Through hypnosis I discovered that he had been pushed out of a motor
lorry by irresponsible companions, and rendered unconscious. He was
taken to Amiens, where he seemed to recover. Later on he was found
wandering and completely unable to give any account of himself.
He had previously been exposed to very heavy shelling and was of a
typically hysterical mentality. .
In England the results were very different. In only a small
proportion of cases could I recover lost memories by mild hypnotic
means. Like the other neurotic symptoms the amnesia appeared to
Cf. Myers : Op. cit.
58
Brown: War Neurosis
have become more fixed and intractable. In the few cases in which the
hypnotic state was induced and lost memories were recalled, it was
extremely rare to find the other neurotic symptoms greatly affected
thereby. Thus I hypnotized a deaf-mute suffering from extensive
amnesia, and eventually recovered all his lost memories, but he-
remained deaf and dumb throughout this time and eventually recovered
speech and hearing in a dream at night! In acute cases near the line
such failure never occurred.
What was lacking in my experiences in England was the emotional
abreaction, or the recall, with hallucinatory vividness, of the emotional
tone of the lost memories. At Craiglockhart I used a modified form
of the method, with three of the officer patients and succeeded in
producing the abreaction. In each of these three cases I had the
satisfaction of seeing the physical symptoms—paraplegia of old-
standing, with headache, painful contracture of right arm, and very
bad stammer, respectively—alter, increase, and then disappear. These
three officers all suffered from intractable insomnia. I therefore sent
them to sleep at night by means of light hypnosis—twice only—and
treated them by means of mental analysis during the day. In two out
of the three cases the “ emotional upheaval ” took place at night, the
patients re-experiencing their original shock in all its vividness and
the physical symptoms then disappearing. In the third case the
abreaction occurred during the day. They all made good recoveries,
although they were chronic cases of many months’ standing and every
other conceivable method had been used with them in vain.
Blood Pbessure : Disturbances of Endocrine Glands.
I made measurements of blood pressure in a series of 42 consecutive
cases of severe neurosis in the field, using the auscultatory method with
a Tycos sphygmomanometer. The frequency distribution of the systolic
pressures was as follows:—
Under 110 mm. 110 120 120-130 130-140 140-150 Above 150 Total
1 4 9 13 9 6 42
It will be seen that more than one-third of the cases had a blood
pressure > 140 mm., and much more than one half had a blood
pressure > 130 mm. The normal blood pressure of a healthy man
of about 30 years of age is generally given as 120 mm. to 130 mm.
I correlated these blood pressures with the corresponding pulse-rates
and obtained a zero correlation coefficient. These results may possibly
Section of Psychiatry
59
indicate a preliminary increase of adrenalin output in some of the
severer cases of war neurosis.
In like manner one might infer from the combination of tachycardia
with fine tremors of the outstretched hands found in so many cases
a disturbance of thyroid secretion. In two or three cases I also noticed
a tendency to exophthalmos and thyroid enlargement, but I was
surprised at its rarity, in view of the emotional aetiology assigned to
it in the text-books.
The importance which Sir Frederick Mott has attached to
disturbances of the endocrine glands in the symptomatology of the
war neuroses is likely to be more and more emphatically justified as
the results of observations made by different observers in this field
of research are accumulated and compared. The same holds good
of Mott’s views with regard to the rdle played by the physical
manifestations of the emotions in determining the form which the war
neuroses take. The far-reaching extent of the bodily changes, involving
cardiovascular and glandular activity in addition to that of the voluntary
and involuntary musculature, explains the intractableness of so many of
these cases, to which the diagnosis of hysteria in its ordinary sense
would hardly apply. Nevertheless, if the originating cause was a
mental disturbance, we may, theoretically, expect that psychotherapy
will help to readjust the balance once more even in such widespread
physiological disturbances, and practical success, although slow and
partial in many cases, seems to justify this expectation.
After-histories of Patients Treated ,in the Field.
I have a series of twenty-two completed after-histories of patients
whom I treated in France. I had used light hypnosis with all these
cases, which were severe, and cleared up their amnesias and other
pronounced hysterical symptoms (mutism, paralysis, spasmodic contrac¬
tures, &c.) by this means. In only one of these cases did relapse or the
appearance of other hysterical symptoms occur later on. This case
suffered from deaf-mutism, with extensive amnesia following upon
exposure to the explosion of a shell, all of which symptoms cleared
up completely. He eventually reached a neurological hospital in the
north of England suffering from weakness of the lower limbs. Mental
analysis brought to light earlier pre-war mental shocks, and when these
had been talked out all functional symptoms completely disappeared.
It was gratifying to find that fifteen of these cases (66 per cent.)
eventually returned to duty.
60
Brown: War Neurosis
One of them had been buried in a dug-out and suffered from amnesia
for the events of the accident, hyperesthesia of the right side of the neck
corresponding to the second and third cervical areas, and fixation of the head
owing to tonic contraction of the neck muscles.
Another had fallen into a shell hole full of mud, and had been dragged out
by traction on the left arm. Immediately thereafter his left arm became
completely paralysed, with anaesthesia, vasomotor disturbances, and exaggerated
tendon reflexes. There was evidently organic trouble, due to traction on the
brachial plexus, but this was overlaid by a considerable degree of “ functional ”
disturbance. The patient was very easily hypnotized, and then lived through
bis painful experiences once more, showing some movement of the arm while
doing so. This treatment, helped out by physical methods, produced a great
improvement in his powers of movement and sensation during the following
few days. Like the preceding case, this patient made a complete recovery
in England and returned to duty.
While working in a London hospital I saw a similar case of mono¬
plegia which had not been treated before reaching England. The
paralysis was still complete, and improvement under treatment' took
place much more slowly, although the final result was satisfactory.
The general conclusion which I would draw from these cases, and
from a few others whom I have myself treated at Craiglockhart after
having previously had them as my patients in France, is that the early
recall of submerged emotional memories by my method of modified
light hypnosis not only removes the accompanying functional symptoms
without danger of consequent relapse, but also greatly shortens the
period of convalescence which these severe cases need before final
discharge from hospital. If again subjected to great strain, no doubt
these patients would succumb more quickly than they would have done
had they not experienced their original shock. ,But this holds good of
all methods. One does not need to work long in the field to discover
this fact. Twenty-one per cent, of my Cambrai cases had been in
neurological hospitals (not my own) before. It should not be brought
forward aB a criticism of any method where severe nervous disorders are
concerned.
Mental Analysis : Autognosis.
Patients seen at a late stage of their illness show the well-known
fixation of symptoms so conspicuous by its absence at the front. But
more serious than the symptoms themselves is the patient’s state of
mind. A distorted view of his illness has developed and has become
linked up by numerous bonds of association with earlier emotional
Section of Psychiatry
61
incidents of his life equally misunderstood by him. We have here to
deal with the preoccupations of the neurasthenic rather than with the
dissociation, or, as it were, mental carelessness of the hysteric.
The method to be employed is that of long persuasive talks with the
patient, such as Dejerine advocates, and Rows, Rivers, and others have
adopted in England, in the course of which one enters into his past
mental conflicts and worries, explains fully the origin of his present
symptoms, and helps him to see both the past and the present expe¬
riences in their right proportions. This analytic method aims at giving
the patient a true insight into his mental condition, and I would therefore
call it the method of autognosis. Hypnosis may often be used as a
supplementary aid in the course of the analysis, to bring up earlier
emotional experiences with the requisite vividness.
Examples of the application of this method are only convincing
if reported in full, for which I have no space. It is only needed for the
more intractable chronic cases of war neurosis, when it may extend over
months. In the majority of acute and subacute cases these prolonged
analyses are certainly not necessary. "Nevertheless it is the most
complete of the purely psycho-therapeutic methods, and theoretically
the other methods (exclusive of mere suggestion) might be regarded
as abbreviations of it.
Section of psychiatry.
President—Dr. William McDougall, F.R.S.
On the Problem of Psychogenesis in Mental Diseases.'
By C. G. Jung, M.D., LL.D.
When I venture to discuss the problem of psychogenesis in mental
disease I am quite conscious of the fact that I am touching a question
that is not exactly popular. The great progress in the realm of brain
anatomy and in that of pathological physiology, and the general
prepossession in favour of natural science to-day, have taught us to look
out always and everywhere for material causes, and to rest content
having found them. The ancient metaphysical explanation of Nature
has become discredited on account of its manifold encroachments and
errors, so much so that the value of its psychological viewpoint was
lost. In psychiatry in the first decades of the nineteenth century the
metaphysical explanation of Nature ended in a moralistic aetiology.
This aetiological theory explained mental disease as a consequence of
moral faults. In the time of Esquirol psychiatry became a natural
science.
The development of natural science brought us a general view of the
world—viz., that of scientific materialism, which, considered from the
psychological standpoint, is a great over-valuation of the physical cause.
Thus scientific materialism as an axiomatic viewpoint refuses to
acknowledge any other causal connexion than the physical one. The
materialistic dogma in its psychiatric formulation runs as follows:
“Diseases of the mind are diseases of the brain.” This dogma still
prevails even to-day, although philosophic materialism is already
beginning to fade. The almost indisputable validity of the materialistic
dogma in psychiatry essentially depends upon the fact that medicine
au— 40
1 At a meeting of the Section, held July 11, 1919.
64
Jung: Psychogenesis in Mental Diseases
as a study is a natural science, and that the alienist as a physician
is a natural scientist. The medical student, being overburdened with
professional studies, cannot allow himself to make digressions into the
faculty of philosophy. Thus he is subjected exclusively to the influence
of materialistic axioms. As a natural consequence researches in
psychiatry are concerned mainly with anatomical problems, in so far
as they are not preoccupied by questions of diagnosis and classification.
Thus the alienist generally considers the physical aetiology to be of
primary importance and the psychological aetiology of secondary and
merely subsidiary importance ; and because of this attitude he keeps in
view only the causal connexions of the physical kind, and overlooks the
psychological determination. This is not a position in which one can
appreciate the importance of psychological determinants. Physicians
have often assured me that it was impossible to discover any trace of
psychological conflicts or of similar psychogenic matters. But just as
often I found they had noted carefully all the incidents of a physical
kind, and had failed to note all those of a psychological kind, not on
account of negligence, but because of a typical undervaluation of the
importance of the psychological factor. Once I was called in consultation
in a case in which two well known nerve specialists had diagnosed
sarcoma of the membranes of the spinal cord. The patient, a woman
aged about 50, suffered from a peculiar symmetrical rash in the lumbar
region, and from fits of crying. The physical examination made by the
doctors was exceedingly careful, as was the anamnesis. A piece of the
skin had been excised and examined histologically. But it had been
entirely overlooked that the patient was a human being with a human
psychology. Owing to this characteristic undervaluation of the psycho¬
logical viewpoint the conditions under which the disease originated
remained unexplored.
The patient was a widow. She lived with her eldest son, whom she
loved in spite of many mutual quarrels and difficulties. In a way he
replaced her husband. Life under these conditions became more and
more intolerable to the son so he decided to separate himself from his
mother and seek his residence elsewhere. On the day he left her, the
first fit of crying occurred. This was the beginning of a protracted
illness. The course of the disease, its improvements as well as its
exacerbations, all corresponded with changes in relation to the son,
as could be shown clearly by means of the psychological anamnesis.
The wrong diagnosis of course did not improve the symptoms; on the
contrary it worked by suggestion for the worse. It was an ordinary
Section of Psychiatry
65
case of hysteria, as was proved obviously by the later developments.
As both of the doctors were hypnotized by belief in the physical
causation and physical nature of the disease, it did not occur to them
to inquire into the psychological circumstances of the case. Therefore
they both could assure me that there was “ nothing psychic” in the case.
Such errors, however, are easily comprehensible, if one takes into
account the fact that neither alienists nor neurologists have any other
training than that of natural science. But for these branches of
medicine a knowledge of psychology is simply indispensable. The lack
of psychological training is frequently compensated later, especially
amongst general practitioners, by practical experience of life and its
fundamental emotions, but unfortunately even this is not general.
At all events the student hears little or nothing of abnormal psychology.
Even if time should allow him to follow a course of psychology, he
would only have the opportunity of learning a kind which has nothing
to do with the requirements of medical practice. This at least is the
situation on the Continent. As a rule psychologists are men of the
laboratory and not general practitioners, at all events not experienced
alienists or neurologists. Thus it is not astonishing that the psycho¬
logical point of view is omitted from the anamnesis, the diagnosis and
the treatment. And yet this view is of the greatest importance, not
only in the realm of the neuroses, where it has been increasingly
appreciated since Charcot’s day, but also in the realm of mental disease.
Speaking of the psychogenesis of mental disease I have chiefly in
mind those many forms lately labelled in a vague and misleading way
“ dementia prsecox.” Under this designation are gathered all those
hallucinatory, katatonic, hebephrenic and . paranoid conditions, not
showing the characteristic organic processes of cellular destruction
seen in general paralysis, senile dementia, epileptic dementia, chronic
intoxications, and not belonging to the manic-depressive group. As you
are aware there are certain cases belonging to the class of dementia
prsecox which do show cellular changes in the brain. But these changes
are not regularly present nor do they explain the special symptomatology.
If you compare the usual symptoms of dementia prsecox with the
disturbances which occur in organic brain disease you will find striking
differences. There is not a single usual symptom of dementia prsecox
which could be called an organic symptom. There is no justification
whatever for putting general paralysis, senile dementia and dementia
prsecox on the same level. The fact that occasional cellular destruction
occurs does not justify us in classifying dementia prsecox amongst organic
au —40a
66 Jung: Psychogenesis in Mental Diseases
diseases. I admit, however, that the denizens of the lunatic asylum
present such a degenerative picture that one can quite understand why
the term “ dementia pnecox ” has been invented. The general aspect
of a ward of the incurably insane, supports the materialistic bias of the
alienist. His clientele includes some of the worst cases possible. It is
therefore natural that traits of degeneration and destruction make most
impression on him. It is the same with hysteria; only the worst
hysterics are confined to an asylum, therefore alienists practically see
only the most hopeless and degenerated forms of the disease. Naturally
such a selection must lead to a prejudiced view. If one reads the
description of hysteria in a text-book on psychiatry and compares it
with real hysteria as it presents itself in the consulting room of the
general practitioner, you will have to acknowledge a considerable
difference. The alienist sees only a minimum of hysterics and a
selection of only the worst cases. But beside these there are numberless
mild cases which never come near an asylum, and these are the cases of
genuine hysteria. It is the same with dementia prsecox. There are
mild forms of this disease which very far outnumber the worst cases
which alone reach the asylum. The mild forms are never confined to
an asylum. They come under diagnoses as vague and mistaken as
dementia prsecox, such as “ neurasthenia ” or “ psychasthenia.” As a
rule the general practitioner never realizes that his neurasthenic case
is nothing but a mild form of that dreadful disease called dementia
prsecox with its almost hopeless prognosis. In the same way he would
never consider his hysterical niece to be the liar and impostor and
morally unreliable character of the text-books. Bad cases of hysteria
give a bad repute to the whole class, hence the public does not mind
confessing to nervousness, but will not confess to hysteria.
As regards the apparently destructive and degenerative traits of
dementia prsecox, I must call special attention to the fact that the
worst katatonic states and the most complete dementias are in many
cases products of the lunatic asylum, brought about by the psycho¬
logical influence of the milieu, and by no means always by a destructive
process independent of external conditions. It is a well known fact
that the very worst demented katatonics are to be encountered in
badly administered and overcrowded asylums. It is well known also
that removal to noisy or otherwise unfavourable wards often has an
unwholesome influence; the same applies to coercive measures or forced
inactivity. All the conditions which would reduce a normal individual
to psychical misery will have an equally baleful effect on the patient.
Section of Psychiatry
07
Bearing this fact in mind modern psychiatry tries as much at possible
to avoid the character of a convict settlement and to give the asylum
the aspect of a hospital. One makes the wards as home-like as possible,
the physicians deprecate coercion, and as much personal freedom is
granted to the patient as possible. Flowers at the curtained.windows
make a good impression not only on the normal but also on the sick.
It is a fact that in these days we seldom or never see the sad pictures of
demented and dirty insane persons sitting in rows along the asylum
walls. And why is this so? Because we realize that these patients
react to surrounding conditions just as much as the normal do. Senile
dementia, general paralysis, and epileptic insanity, run their course
whether they are placed side by side with similar cases or not. But
cases of dementia prsecox not infrequently improve or become worse
in response to psychological conditions, in a way that is sometimes
astonishing. Every alienist knows such cases; they prove the great
importance of the psychological factor. They clearly demonstrate
that dementia prsecox must not be one-sidedly regarded as organic
disease. Such ameliorations, or otherwise aggravations, could not occur
if dementia prsecox were only an organic disease.
I must also mention those frequent cases in which the beginning of
the disease, or a new outbreak of it, takes place under special emotional
conditions. I remember a case of my own in which a man, aged
about 35 was twice seized with a katatonic attack when he came into
the town in which he had lived as a student. He had a memorable
love adventure there. It came to an unhappy end. He avoided
returning to that town for several years, but as he had relatives there,
he finally could no longer refrain from visiting them. In the course of
six years he went there twice, and each time almost immediately fell
ill, on account of a fatal reanimation of his memories. Both times
katatonic excitement occurred. He had to be confined to an asylum.
Except for those periods of confinement he was successful in his work,
and apart from leading a somewhat solitary existence, did not show any
noticeable traces of mental derangement.
Cases are rather common in which, whenever an engagement to
marry or any similar emotional event is imminent, a renewed attack
occurs. The outbreak and the development of the disease are often
determined by psychological motives. I remember the case of a woman
who broke down after a quarrel with another woman. The patient’s
temperament always had been irritable and choleric. In this particular
qparrel she became violent against her partner, who in return called her
68
Jung: Psychogenesis in Mental Diseases
“ mad.” This reproach roused the patient still more, and she' said :
“ If you call me mad, you shall see what it means to be mad! ” With
these words she fell into a state of rage. As it caused a scandal in the
street the police intervened and took her to the clinic. There she soon
calmed down, only insisting somewhat too energetically upon her
immediate discharge. It did hot seem advisable however to allow her to
return after a few hours because she was still agitated. We sent her
from the consultation room to the observation ward. There she would
not obey the nurses, and tried violently to open the door. She feared
she would be kept permanently in the asylum. Her excitement became
so troublesome that she had to be placed in another ward. As soon as
she became aware of the character of the other patients there, she
began to cry out we had locked her up with crazy people in order
to make her mad. And again she said : “ If you like to have me
mad, you shall see what madness means.” Immediately afterwards
she fell into a katatonic dream state, with wild delusions and fits of
rage, which lasted uninterruptedly for about two months.
According to my view her katatonia was nothing but patho¬
logically exaggerated emotion, &ue to the fact of being confined to a
lunatic asylum. During the acute stage of her illness she behaved
just as the general public thinks that a mad person would behave.
It was a perfect demonstration of madness in every particular. How¬
ever it was certainly not hysteria, because there was a complete lack of
emotional rapport.
It is most unlikely that there was a primary brain disturbance of an
organic nature, and that the mental disorder, the violent emotions,
and the subsequent delusions and hallucinations were secondary.
Bather it is an instinctive reaction against deprivation of freedom.
Wild animals often show similarly violent reactions when they are
shut in. In spite of the manifest psychogenic causation, the case was
typically katatonic, with excitement, delusions, and hallucinations, not
to be distinguished from a case due to other than a psychological
cause. The patient had never had such an attack before. She was
always irritable, but her excitement was always due to a definite cause,
and each time quickly subsided. The only really katatonic attack was
the one in the asylum.
I remember another case of a similar kind. The patient was a
young school teacher, who began to be lazy, dreamy and unreliable.
Moreover he showed certain peculiarities in his behaviour. He was
confined to an asylum for the sake of observation. At first he was
Section of Psychiatry
69
quiet and accessible, and believed he would be discharged, as he was
convinced of his normality. He was in a quiet ward. But when we
told him that he would have to be kept under observation for some
weeks at least, he became angry, and said to the doctor : “If you like
to keep me here as insane, I will show you what it means to be mad.”
He immediately became very excited, and within a few days was com¬
pletely confused, and had many delusions and hallucinations. This
state lasted for some weeks.
The following case emphasizes my point: A young man had been
in the asylum for almost two months. He had been certified as morally
insane. This diagnosis was due to the fact that he had been proved to
be a cheat and a liar. He refused to work, and was excessively lazy.
It did not appear to us as if he were merely morally deficient. The
possibility of dementia prsecox occurred to us. There were no specific
symptoms however except great moral indifference. His behaviour was
disagreeably irritating, he was intriguing, and at times rough and violent.
He was out of place in the quiet ward. In spite of his troublesome
conduct I tried to keep him there, although many complaints were
received from nurses and patients. Once, during my absence from
the asylum, my substitute put him into the ward for excited patients,
on account of his troublesome behaviour. There he at once became
excited to such an extent that he had to be narcotized. He
then began to be afraid of being murdered or poisoned and had
hallucinations. Obviously the outbreak of a manifest psychosis was
due to the external conditions which influenced his mental state un¬
favourably. It would be an unsatisfactory explanation of such * a
case to attribute the psychosis to sudden aggravation of pre-existing
brain disease.
The exact opposite, namely marked improvement in a chronic
state on account of improved external conditions, is, as is well known,
rather frequent in occurrence.
If dementia praecox be essentially due to a process of organic
destruction, patients should behave like those with actual changes in
the brain. A patient suffering from general paralysis does not
improve nor become worse as the result of a change in the psycho¬
logical conditions, nor are such cases noticeably worse in bad asylums,
but cases of dementia prsecox are distinctly worse when the circum¬
stances are unfavourable.
Since it is evident that the psychological factor plays a decisive
r61e in the course of the dementia prsecox, it is not unlikely that the
70 Jung: Psychogenesis in Mental Diseases
first attack of the disease would be due to a psychological cause. It is
a matter of common knowledge that many cases originate in a psycho¬
logically important period, or following a shock or a violent moral
conflict. The alienist however is inclined to regard such conditions
rather as exciting causes or auxiliary factors, which bring a latent
organic disease to the surface. He thinks if such psychic experiences
were really efficient causes, they should exercise a pathological effect in
everybody. As this is obviously not the case, the psychic causes there¬
fore could only have the significance of auxiliary factors. This reasoning
is undoubtedly one-sided and materialistically prejudiced. Modern
medicine no longer speaks of one cause and one only of a disease.
Tuberculosis is no longer held to be caused only by the specific bacillus,
it owes its existence to a number of competitive causes. The modem
{etiological conception is no longer causalism, but conditionalism. Un¬
doubtedly a psychological cause hardly ever produces insanity, unless
it is supported by some specific predisposition. But on the other hand
a marked predisposition may exist, where a psychosis will not arise bo
long as serious conflicts and emotional shocks are avoided. It can be
stated however almost with certainty that psychological predisposition
leads to conflict, and thus by way of a vicious circle to psychosis. Such
a case looked at from an external standpoint might appear as deter¬
mined by a degenerative predisposition of the brain. In my view most
cases of dementia prsecox are brought by their congenital predisposition
into psychological conflicts ; but into such as are not essentially patho¬
logical, but common in human experience. Since the predisposition
consists in abnormal sensitiveness, the conflicts differ only in emotional
intensity from normal conflicts. Because of their intensity they are out
of all proportion with the other mental faculties of the individual.
They therefore cannot be dealt with by such usual means as diversion,
reason and self-control. It is only the impossibility of getting rid of an
overpowering conflict that leads to insanity. Only when the individual
becomes aware of the fact that he cannot help himself in his difficulties,
and that nobody else will help him, is he seized by panic, which pushes
him into a chaos of emotions and strange thoughts. This experience
belongs to the stage of incubation, and seldom comes before the alienist,
since it occurs a long time before anybody thinks of consulting a
physician. But such cases are not rare in the practice of nerve
specialists. When the physician succeeds in finding a solution to the
conflict the patient can be saved from the psychosis.
Of course it may be objected that it is impossible to prove such a
71
Section of Psychiatry
case to be the initial stage of a psychosis, and that no evidence coaid be
brought that a psychosis would have arisen if the conflict had not been
settled. Certainly X cannot supply proof of such a kind that my critics
would be immediately convinced by it. If a case of indubitable dementia
praecox could be brought back to normal adaptation in such a way that
a definite estimate could be made of the effect of the therapeutic
measures, it might be considered satisfactory evidence; but even such
evidence could easily be invalidated by the objection that the apparent
cure was only an accidental remission of symptoms. It is almost
impossible to produce satisfactory evidence, in spite of the fact that
there are not a few specialists who believe in the possible prevention of
psychoses.
It is still perhaps too early to speak of a psychotherapy of psychoses.
I am not altogether optimistic in this respect. For the time being, I
would lay stress on the importance of examining the role and significance
of the psychological factor in the aetiology and progress of psychoses.
Most of the psychoses I have explored are of an eminently complicated
nature, so that I could not describe them in the narrow space of a
lecture. But occasionally comparatively simple cases are met with,
the origin of which can be demonstrated. I remember for instance the
case of a young girl, a peasant’s daughter, who suddenly fell ill with
dementia praecox. Her physician, a general practitioner, told me that she
was always very quiet and retiring. Her symptoms came on suddenly
and unexpectedly, and nobody had suspected her of being mentally
abnormal. One night she suddenly heard the voice of God speaking to
her, about war and peace, and the sins of man. She had, as she said, a
long talk with God; The same night Jesus also appeared to her.
When I saw her, she was perfectly quiet, but absolutely without interest
in her surroundings. She stood erect all day long near the stove,
rocking to and fro, talking to nobody except when questioned. Her
answers were short and clear, but without feeling. She greeted me
without the slightest emotional reaction as if she saw me daily.
Though unprepared for my coming she did not seem in the least
astonished or curious to know who I was, and what the purpose of.
my coming was. I asked her to tell me of her experiences. In her
taciturn and emotionless way she remarked she had had long talks
with God. Apparently she had forgotten what the subject of her talks
was. Christ looked quite like an ordinary man with blue eyes. He
also talked with her, but she did not remember what He said. I told
her it would be a regrettable loss if those talks should be quite forgotten.
72 Jung: Psychogenesis in Mental Diseases
She should have taken note of them. She said she had taken note of
them, and she gave me the sheet of a calendar. But there was only
a cross upon it, which she had marked on the date when she heard the
voice of God for the first time. What she said was brief, somewhat
evasive and 1 indirect, and completely void of feeling. Her whole
attitude was absolutely indifferent. She was intelligent, a trained
teacher, but she betrayed not a trace of either intellectual or emotional
reaction. We might have been speaking of her stove rather than of
a most unusual phenomenon. It was impossible to get a coherent
history from her. I had to draw her out bit by bit, not against any
active resistance, as is the case in hysteria, bat against a complete lack
of interest. It was a matter of complete indifference to her whether
she was questioned or not, or whether her answer was satisfactory or
not. She had obviously no emotional rapport with her surroundings.
Her indifference was such that it produced the impression that there
was nothing in her that it was worth while to ask for. When I asked
whether she was troubled about something in her religions experience,
she calmly said that she was not. Nothing was troubling her, there
were no conflicts, neither with her relatives nor with other people. I
questioned her mother. She could only tell me that the evening before
the onset the patient went with her sister to a religious meeting. On
coming home she seemed excited, and spoke of having experienced a
complete conversion at the meeting. Her doctor, deeply interested in
her.case, had already tried to get more out of her, because his common-
sense conld not believe such a disturbance could arise out of nothing.
But he was confronted by her unfeigned indifference, and was forced
to believe there really was nothing below the surface. Her relatives
could say nothing more than that she had always been rather over
quiet, retiring and shy from her sixteenth year. In childhood she
was healthy, merry, and not in the least abnormal. There was no
pathological heredity in the family. The aetiology was quite
impenetrable.
She told me she did not actually hear any longer the voice of
God, but she was almost entirely sleepless, because her thoughts were
working uninterruptedly. She seemed to be quite unable to tell me
what she thought about, apparently because she did not know. She
made allusion to a constant movement in her head, and to the presence
of electric currents in her body. But she was not sure where they
came from, presumably they came from God.
There is probably no disagreement about the diagnosis of dementia
Section of Psychiatry
73
praecox. Hysteria is excluded, there are no specifically hysterical
symptoms, and moreover the main criterion of hysteria—viz., an
emotional rapport—is absolutely lacking.
When I was seeking to arrive at the aetiology of the case the
following discussion took place:—
E.: Before you heard the voice of God, did you experience a
religious conversion ?
Patient: Yes.
E.: If you were converted, you must have been sinful before ?
Patient: Yes.
E.: How have you sinned ?
Patient: I don’t know.
E. : Bat—I do not understand—surely you must know what your
sin was ?
Patient: Yes, I did wrong.
E.: What did you do V
Patient: I saw a man.
E.: Where ?
Patient: In the town.
E. : But do you believe it a sin to see a man ?
Patient: Nq.
E.: Who was thisman '?
Patient: Mr. M.
E.: What did you feel when you saw Mr. M. ?
Patient: I love him.
E.: Do you still love him *?
Patient: No.
E.: Why not ?
Patient: I don’t know.
I will not weary you with the literal reproduction of my attempts
to catch hold of the things behind the screen. They occupied about
two hours. The patient was steadily taciturn and indifferent, so that I
had to exert all my energy in order to continue our talk. One was
under the perpetual impression of the complete hopelessness of the
examination, and one almost felt the questions to be superfluous. I lay
particular stress upon the patient’s attitude, for it is just this attitude
that makes a psychological examination so toilsome and so very often
unfruitful. But it is an attitude only, and not in the least a real lack
of psychic contents. It is an attitude of self-defence, a mechanism
protecting against the overwhelming emotions connected with the
hidden conflict.
74
.Jung: Psychogenesis in Mental Diseases
Only the fact that the case was apparently simple gave me courage
and patience to continue questioning. In more complicated cases,
where it is often less a matter of realities than of phantasies, questions
become more difficult and even sometimes impossible, particularly when
a patient is not inclined to answer. It is quite comprehensible that
physicians in an asylum have no time as a rule to occupy themselves in
such a way with their cases. The exploration of a psychosis demands
almost limitless time. It is not astonishing therefore that the psycho¬
genic connexions are easily overlooked. I assure you that if the patient
had been admitted to an asylum you would not find more in her
anamnesis than I have already told you.
The result of my further examination was the following: Several
weeks before the outbreak of the illness the patient was in town with a
friend. There she became acquainted with Mr. M. When she fell in
love with him she became frightened by the extraordinary intensity of
her feeling. She thereupon became taciturn and shy. She did not
tell her friend of her feeling or her fear. She hoped Mr. M. would
return her love. Seeing no sign of this she almost immediately after¬
wards left the town, quite unexpectedly to her friend, and returned
to her home. She felt as if she had committed a great sin on
account of the intensity of her feeling, although, as she said, she
had never been particularly religious before. The feeling of guilt
kept on worrying her. A few weeks later her friend came to visit
her. As the friend was very religious she consented to go with her
to a religious meeting. There she was deeply.impressed and professed
conversion. She felt great relief, because the feeling of guilt disappeared,
and at the same time she found her love for Mr. M. completely
extinguished. I wondered why she thought her feeling of love to-
be sinful, and asked her why it appeared so to her. She replied
that owing to her conversion she understood such a feeling for a
man to be a sin against God. I called her attention to the fact that
such an attitude could not be natural, whereupon she confessed that
she always had felt a certain shyness of such feelings. She dated
that shyness to a sin she had committed in her sixteenth year. At
that time, whilst walking with a girl friend of the same age, they
met an elderly idiotic woman whom they provoked to obscene beha¬
viour. This fact became known to the girl’s parents and to the
school-teacher, and both punished her severely. Only afterwards she
realized the wickedness of her behaviour. She was much ashamed,
and promised solemnly to herself to lead a pure and irreproachable
Section of Psychiatry
75
life henceforth. From that time on she became retiring, not liking
to go out of the house, from fear that the neighbours would know
of her fault. It became her custom to stay at home and avoid all
worldly amusements.
The patient had as one might suppose been a morally good child
who remained, however, a child too long, a fact not rare with
sensitive characters. As a consequence of her childish irresponsibility
such an inadmissible deed could happen even as late as her sixteenth
year. Her subsequent insight led to profound regret. The experience
threw a certain shadow on the feeling of love itself, and she therefore
felt disagreeably stirred, as is quite comprehensible, by everything more
or less belonging to this episode. For this reason her sudden love for
Mr. M. was felt like guilt. By her immediate departure she prevented
the development of any further relationship and at the same time cut
off all hope.
Such reactions are not essentially morbid. They are often to be
observed in sensitive people in a lesser degree. In this case they were
of remarkable intensity. Her tendency to transfer her hopes to the
sphere of religion and to seek consolation there has nothing unusual in
it. The unexpected anc( complete conversion is perhaps exceptional,
though similar conversions, wherein there is no reason to think of a
psychosis, often occur at revivals.
The pathogenic impressions are not essentially morbid, they are only
particularly intense. The friend who took part in the same affair was
admonished and punished like herself, yet she did not become a prey to
profound regret and everlasting remorse, whereas the result of the
patient’s regret was that she excluded herself from intercourse with
other people. This resulted in a storing up of her desire for human
relations to such an extent that when she met Mr. M. she was simply
overwhelmed by the intensity of her feelings. Not meeting with an
immediately satisfactory response she was deeply disappointed and left
precipitately. Thus she fell into still deeper trouble, and her solitary
life at home became quite intolerable. Again her desire for human
companionship was stored up and at this time she attended the religious
meeting. The impressions made upon her turned her completely from
her former hopes and expectations. She even got rid of her love. By
this device she was saved indeed from her former worries, but her natural
desire to share the ordinary life of a woman of her class was also abolished.
Now that her hopes were turned away from the world, her “ fonction du
reel ” created a world in herself. When human beings lose hold on
au— 406
76 Jung: Psycliogenesis in Mental Diseases
the concrete values of life the unconscious contents assume reality.
Considered from the psychological standpoint, the psychosis is a mental
condition wherein a formerly unconscious element usurps the import¬
ance of real fact. The unconscious content replaces reality.
It depends, of course, upon the original disposition whether such a
conversion will lead to hysteria or to dementia prsecox. If the patient
can preserve his emotional rapport by means of dissociating himself
into two personalities, the one religious and apparently transcendental,
the other .perhaps all too human, he will become hysterical. But if on
the other hand he cuts off the emotional rapport with human beings
entirely, so that they make no impression on him, he will become a case
of dementia prsecox. In the case cited there is a striking lack of
emotional rapport, and in accordance with this fact there is no trace of
hysteria.
Can one speak of an organic process in our case at all ? I believe
it to be completely excluded, on account of the fact that the essential
experience was present in the sixteenth year, at which time there was
not the slightest trace of an organic lesion. There is not the faintest
evidence in favour of such an hypothesis, nor is there any reason to
explain the second traumatic experience with Mr. M. as having an
organic determination, or else all cases of this kind should be explained
in the same way. If we have to admit cellular destruction, it
certainly began after the shock of the religious conversion, in which
case the organic changes would be secondary only. More than ten
years ago I claimed that a great many cases of dementia prsecox
were in the first place psychogenic in origin, 1 the toxic or destructive
processes being secondary only. But in addition I do not deny that
there may be cases in which the organic processes are primary and the
disturbances of the psychic functions secondary.
It is a noteworthy fact that immediately after the consultation
in the foregoing case the patient’s mental state improved considerably.
I have repeatedly observed most striking reactions after such an
examination, either in the form of a marked improvement, or on the
contrary, of an exacerbation of symptoms, a fact strictly in keeping
with the important role played by the psychic factor.
I am aware my paper does not give a full account of the problem
of psychogenesis, but the point I wish to make is that in psychiatry we
have a field for psychological research which is wide and not yet
cultivated.
1 “ Psychology of Dementia Prsecox,” New York, 1909.
PROCEEDINGS
EDITED BY
MauAEISTER
Su: JOHN ¥
I'.SKKH T|FK bj.KRCT IO«} lip
EDITORIAL COMMITTEE
THE
VOLUME THE TWELFTH
8 E 8 S 10 N 1016-19
SECTION
SFRGERY
LONDON
*
LON<§MANS, GREEN A 00.. PATERNOSTER ROW
.
: ■ • ■:= I y i9 : v
Section of Surgery.
OFFICERS FOR THE SESSION 1918-19.
President —
Sir John Bland-Sutton, F.R.C.S.
Vice-Presidents —
Jambs Bbbby, F.R.C.S. Walter G. Spencer, M.8.
H J. Waring, M.S.
Hon. Secretaries —
V. Warren Low, C.B., F.R.C.S. Cyril A. R. Nitch, M.S.
Other Members of Council —
Sir Lbnthal Chbatle, K.C.B., J. Murray, F.R.C.S.
C.V.O., F.R.C.S. H. J. Paterson, F.R.C.S.
H. 8. Clogg, M.S. R. P- Rowlands, M.S.
Raymond Johnson, F.R.C.S. James Shbrrbn, F.R.C.S.
Wilfred Trotter, M.S.
Representative on Library Committee —James Berry, F.R.C.S.
Representative on Editorial Committee —Cyril A. R. Nitch, M S.
Sub-Section of ©rtbopa&ics.
President —
E. Muirhead Little, F.R.C.S.
Vice-Presidents —
Sir Robert Jones, C.B., F.R.C.S.Ed. T. H. Openshaw, C.B., C.M.G., M.S.
A. H. Tobby, C.B., C.M.G., M.S,
Hon. Secretaries —
A. S. Blundell Bankart, M.C. E. Rock Carling, F.R.C.S.
Other Members of Council —
J. Jackson Clarke, F.R.C.S.
Edrbd M. Corner, M.C.
R. C. Elm8lib, M.S.
E. Laming Evans, F.R.C.S,
H. A. T. Fairbank, M.S.
C. M. Page, M.S.
Paul Bernard Roth, F.R.C.S.
Sir James Purves Stewart, K.C.M.G.,
C.B., M.D.
C. Gordon Watson, C.M.G., F.R.C.S.
Sub-Section of proctoloos.
President —
F. Swinford Edwards, F.R.C.S.
Vice-President —
Percy Furnivall, F.R.C.S.
Hon. Secretaries —
P. Lockhart-Mummery, F.R.C.S. W. Sampson Handley, M.S.
Other Members of Council —
H. Graeme Anderson, F.R.C.S. Charles Ryall, F.R.C.S.
W. Ernb8T Miles, F.R.C.S. C. Gordon Watson, C.M.G., F.R.C.S
SECTION OF SURGERY
CONTENTS.
December 4, 1918.
Percy Sargent, Lieutenant-Colonel R.A.M.C.
Closure of Cavities in Bone (Abstract)
John Robert Lee, F.R.C.S., Major R.A.M.C.
Compound Fractures of the Femur in its Upper Third, with Demon¬
stration of New Pelvic-Femur Splint, also a Splint for Fractures of
the Upper Extremity
January 22, 1919.
C, W. Waldron, Major C.A.M.C., and E. F. Risdon, Captain C.A.M.C.
Mandibular Bone-grafts
DISCUSSION ON BONE-GRAFTING.
Captain W. E. Gallib, C.A.M.C. (Abstract) (p. 22); Major Nauohton Dunn,
R.A.M.C. (p. 28) ; Major Alwyn Smith, D.S.O., R.A.M.C. (p. 29).
Joseph E. Adams, F.R.C.S.
May 7, 1919.
Carcinoma of the Appendix
IV
Contents
SUB-SECTION OF PROCTOLOGY.
May 14, 1919.
J. I\ Lockhart-Mummkry, F.R.C.S. page
(1) Case of Complete Resection of the Large Rowel for Multiple
Adenomata ... ... ... ... ... ... 43
(2) Case of Mega-colon (Hirschsprung’s Disease) ... ... ... 44
(3) Case of Mega-colon (Hirschsprung’s Disease') with Secondary
Carcinoma... ... ... ... ... ... ... 44
(4) Case of Chronic X-ray Dermatitis of the Anal Region, excised
Eighteen Months ago ... ... ... ... ... 45
Percival P. Cole, F.R.C.S.
(1) Case showing Result of Resection of Rectum for Carcinoma ... 45
(2) Two Cases illustrating the Result of Resection in Complete Prolapse
of the Rectum ... ... ... ... ... ... 46
W. S. Handley, M.S.
Case of Recurrence in the Posterior Vaginal Wall Three Years after
Abdomino-perineal Excision for Carcinoma Recti ... ... 46
Arthur Keith, M.D., F.R.C.S., F.R.S.
Gunshot Wounds of the Great Bowel and Rectum ... ... ... 47
The Society does not hold itself in any way responsible for the statements made or
the views put forward in the various papers.
John Balk. Sons and Damelskoic, Ltd., S3-91, Great TitchfieJd Streat. London, W. I.
Section of Surgery.
President—Sir John Bland-Sutton, F.R.C.S.
Closure of Cavities in Bone.'
By Percy Sargent, Lieutenant-Colonel R.A.M.C.
(ABSTRACT.)
[This paper is printed in e.rtenso in the Journal of the Royal Army Medical Corps ,
February, 1919, p. 83.]
The processes of repair in bone are not different from those
occurring in other vascular tissues but are modified by the peculiar
and complex structure of bone. Cancellous bone is more adapted
for recovery than compact bone. The ■ healing of cavities in bone is
retarded or prevented by their walls not being collapsible. For the
sound healing of any abscess cavity, the walls must be approximated
until the granulations covering them are able to coalesce. In the case
of the soft parts, this is effected partly by the falling together of adjacent
structures, and partly by the pull of the contracting new fibrous tissue.
As these processes cannot occur in the case of bone, for mechanical
reasons, some operative procedure is necessary for the obliteration of
cavities in bone.
Various methods of obliterating bone cavities have been applied by
different surgeons. Professor A. Broca has converted the cavity into an
open trough by free removal of one of its walls; the overlying soft
parts being then encouraged to sink into and so gradually to obliterate
the cavity. The method adopted by the author is a modification of
Broca’s operation, and is best described as that of “ continuous
1 At a meeting of the Section, held December 4, 1918.
M— 11
2
Sargent : Closure of Cavities in Bone
muscle-grafting.” Before operation the bone is examined by stereo¬
scopic radiograms. The technique of the procedure is as follows:—
No tourniquet is employed, haemorrhage being controlled by the
frequent application of large pieces of gauze wrung out in hot saline.
The bone is thoroughly exposed above and below the site of the
cavity. The wall of the sinus leading down to the bone cavity is
widely excised. When there is more than one sinus the one giving
the most direct access to the bone is selected. The periosteum is next
incised to the extent of the whole length of the wound and stripped
from the bone both at the site of the cavity and for some distance above
and below it. Instead of the ordinary retractors Lane’s bone levers are
inserted between the periosteum and bone. Before attacking the bone
it is packed off by gauze pads, partly to avoid soiling the wound and
partly to prevent fragments of bone getting lost among the soft papts.
The stage of the operation which consists in preparing the cavity for
the graft is entirely subperiosteal. The part of the wall of the cavity
selected for removal should be that most conveniently related to the
muscle from which the graft is to be cut. The bone cavity is now
opened up, all granulation tissue and carious bone removed, and all
recesses cleansed; it is then washed out with hot saline solution and
plugged with gauze. This completes the first stage of the operation.
The second stage is not begun until after removal of the soiled
packing and re-sterilization of the instruments. This consists in filling
the cavity with a broad-pedicled muscle flap, to which an adequate
blood supply must be secured. The graft may be kept in position by a
few stitches of catgut. The skin is loosely sutured and small rolls of
rubber are inserted in the wound to provide for the escape of exudate,
one such drain being placed in the space from which the muscle graft
has been cut. The drains are generally removed at the end of forty-
eight hours, and the limb is splinted in such a way as to relax the
parent muscle. In some cases the wound heals by first intention, but
in many there is a considerable febrile reaction for a few days, with
local swelling and purulent discharge from the wound, which eventually
however heals soundly.
One advantage of the muscle-graft as compared with Broca’s
operation is that less bone need be removed, as the whole cavity need
not be converted into an open gutter. Hence the bone need not be
weakened to the same extent, with the risk of resulting fracture. If
the cavity extends into the articular end of the bone it cannot be
converted into an open trough in its whole extent. The obliteration
Section of Surgery
3
of the caVity by the falling in, or pressing in, of the overlying soft
parts may take some time or may be incomplete, but muscle-grafting
fills up the space immediately and entirely. In contrast with other
materials which have been used, muscle is a living vascular tissue.
Union between the raw bone and raw muscle may possibly take place
by first intention or the bone and muscle may each become covered
with granulations which will subsequently unite. In either case the
respective blood-vessels of bone and muscle coalesce.
We can but speculate as to the ultimate fate of the muscle graft;
we have no evidence that bone formation occurs, and ossification in the
graft would be difficult to demonstrate radiographically. The graft
retains its connexion with the parent muscle, and a specimen in the
Royal College of Surgeons Museum suggests that displaced muscle
retains at least a recognizable muscular structure. The fate of the
graft is a matter of secondary importance, for if the procedure has
successfully obliterated the cavity, sound and final healing will be
attained. It is immaterial from the point of view of strength whether
ossification ultimately takes place or not, for as the patient uses the
limb, and so subjects the bone to strains and stresses, compensatory
overgrowth occurs.
DISCUSSION.
Major Oswald Shields, R.A.M.C.: Colonel Sargent, in dealing with
bone cavities about to be treated with muscle-grafts, states that these cases
should be carefully selected. I consider that these carefully selected cases
should be those in which the cavity is comparatively small, and for preference
situated in such a bone as the humerus or the tibia. In cavities in the femur,
resulting from gunshot wounds, my experience with this operation has not been
encouraging, nor have I seen much better results with Broca's method ; these
results may be due to some fault in technique or, more probably, let us hope,
due to the cases being of a specially troublesome nature. The results of muscle¬
grafting in the above mentioned type of case have been more encouraging
where the treatment has not been hurried. Such a case has been treated as
one of osteomyelitis, and the wound has healed by granulations upon the
application of the Carrel-Dakin solution, followed by that of red lotion, the
zinc salt evidently stimulating growth. When deciding upon the adoption of
a correct surgical procedure, it is wise to view it both from the anatomical and
physiological standpoints, no less than the pathological. Thus I am not in
favour of a large cavity in bone being filled with a muscle-graft, for the constant
presence of such a graft will interfere with regeneration of bone, and the result
will not be so satisfactory in regard to strength, as in the case in which the
4
Sargent : Closure of Cavities in Bone
cavity is allowed to fill in with bone, in the way alreaidy mentioned. Such
filling up of a cavity with bone can be seen in radiographs every day, though
this is opposed to the experience of Colonel Sargent. The action of a muscle
from w T hich such a graft has been taken must necessarily be restricted and
interfered with, particularly in those cases in which a large graft is taken to
fill a cavity near a joint. Just as in those cases of fracture of the lower third
of the femur in which the quadriceps extensor becomes firmly bound down
about the seat of fracture, the free flexion of the knee-joint is interfered with.
Lastly, what really does become of this muscle-graft ? I cannot believe that a
functionless piece of muscle will remain as vascular as before separation. I
am sure that such a piece of muscle will become fibrosed and will gradually
atrophy. While this is taking place, what one may describe as an internal
blister is formed between the graft and the bone. This collection of fluid is
apt to become infected from germs conveyed into the blood through such
channels as the throat or bowel, or possibly from still infected tissues sur¬
rounding the old injury. This is the explanation of those sinuses that
sometimes develop after a bone wound has apparently well healed over for
months. My remarks are based not on results of exact experiment, but
purely on observations in the wards of a large military hospital.
Captain Z. MENNELD: The filling up of septic cavities in bone with living
muscle tissue is a war-timd innovation in surgery. Soon after Colonel Sargent’s
return from France, I asked him to see a Corporal J., with whose condition I
was not satisfied. I had, as usual, scraped out the cavity in the lower end of
his femur many times and excised the sinus, but could not get the wound to
heal: I had used many different antiseptics with no result, and when he sug¬
gested “ muscle-graft ” it was the first I had heard and seen of this operation,
which has since been so useful in dealing with bone cavities. Sincq that time,
now about a year ago, I have done I believe twenty-seven cases, but as I can
only trace twenty-three I shall confine myself to this number. Colonel Sargent
has finally elaborated an exacting technique for this operation, most of which
is necessary for the complete success which he is now obtaining. It shortens
the convalescence after what is often a very severe measure: certainly, the
later results are much better than the earlier ones. I will only emphasize
what I have found to be the important points of the operation in my
own cases:—
(1) Complete excision of the sinus which leads to the bone cavity and of
the surrounding scar tissue. It is essential, if primary union be aimed at,
that the incision should be through healthy skin, and that the wound
should lend itself to surface suture without the stitches being through scar
tissue or under any tension. I should prefer to make an incision wide of
the original scar, and content myself with local excision of the sinus in
any case in which these essentials were unobtainable, or even to leave the
wound open and allow the surface to granulate over. *
(2) The careful packing off of the wound to avoid bone chips being over-
Section of Surgery
5
looked. This seems an unnecessary point to emphasize, and I only do so as I
have taken out pieces from the wound in my own cases and seen several
surgeons do the same in theirs.
(3) The muscle tissue used as a graft must be muscle tissue only, and
without tendon or fascia attached to the surface which comes into contact with
the raw bone surface. It is often useful to have intermuscular or tendinous
tissue on the outer surface of the graft, as by this means the muscle can often
be sutured into position with catgut. The graft must have a good blood supply,
and can often be divided longitudinally turned over, and in this way lengthened
to fill an awkward cavity. It must be free at one end. I believe that if left
attached at both ends and allowed to fill the cavity laterally, muscular
contraction will very soon pull it out.
(4) Efficient drainage of the cavity from which the muscle has been taken,
through a separate wound in the most dependent position possible. It is not
necessary to drain the bone cavity, and it is a mistake to drain through the
original incision.
(5) Firm pressure over the muscle in the cavity when the dressing is
applied. I have often seen splintage employed, but it is- not always
necessary.
(6) Careful examination of each case for any interference with the blood
supply to the limb. In a tibia case of mine upon which Colonel Sargent
operated, the femoral artery was ligatured. It is healing now, but the result
is far from satisfactory. I do not think he would so treat such a casd again.
In another tibia case of my own, I found out afterwards that the man
had been warded for four months the year before with trench feet. I
certainly shall avoid such cases if possible in the future, and I look upon
this man as being the only case in which I have failed to fill the cavity
successfully.
With regard to after-results, as is to be expected, there is very considerable
oozing, and at first I was sent for on more than one occasion because the
patient was bleeding. This, however, if expected is not alarming, and only
necessitates packing the wound outside the original dressing, and at most a
firm bandage in addition. I do not undo the dressing for forty-eight hours or
rather more ; I then remove the drainage material—usually an old rubber
glove, or split drainage-tube—and have on two occasions closed the opening by
means of a suture, which has been left long for that purpose. There is often a
considerable reaction, and sometimes, in addition to constitutional symptoms
such as fever, an apparently severe local infection. This, however, only lasts
a short time, and if there is efficient drainage no ill effects appear. This local
reaction led me to pay much more attention to the drainage of the space from
which the muscle had been removed than to that of the bone cavity with the
muscle in situ , and also to the position of the drainage incision. I believe, as
in other cases, the position of the patient or of the limb will do much to assist
this drainage. In two or three cases I have had the wound irrigated with
saline through the drainage incision. There'has been an erysipelas-like
6
Lee: Compound Fractures of the Femur
appearance in two of my own cases and in two other cases known to me;
this does not seem to retard recovery or the ultimate result, but is somewhat
alarming at the time, being accompanied by severe constitutional disturbance.
The operation, from its description and when first seen, seems to be an un¬
necessarily severe one, but everyone who has dealt with these cases by other
means must be disappointed. I have given anaesthetics and seen several
operations in cases in which the full technique has not been carried out. I
have heard the most scathing remarks as to the results made both by the
surgeons who did the operation on its merits,,and by the sisters who had
to look after the patients. This was not the case, however, when the opera¬
tion was carried out on the lines suggested by Colonel Sargent. Recently
there have been cases ih which there has hardly been a rise of temperature.
In one humerus case I split the triceps, and curled the cut end up into the
large cavity, which it filled accurately. The boy was up three days after the
operation : the w T ound healed like a clean one, and has continued in good
condition since.
Compound Fractures of the Femur in its Upper Third, with
Demonstration of New Pelvic-Femur Splint, also a Splint
for Fractures of the Upper Extremity,
By John Robert Lee, F.R.C.S., Major R.A.M.C.
(Officer in Charge, Surgical Division , Fulham Military Hospital,
Ilammersm it h.)
At Fulham Military Hospital, London, we have had many
opportunities of treating fractured femurs and also of seeing the
results of treatment in other hospitals, as shown by cases which
have been transferred to us. The number of cases which come to
amputation from sepsis, or which join up in bad position with stiff
joints, is very great. For instance, during last June we had twenty
fractured femurs sent oyer to us from France, where they had been in
special hospitals from one to five months; of these some were in
fairly good position and not very septic, several of them were more or
less united in bad position, and most of them had sequestra, due to
trauma and inefficient drainage.
It is of the fractures of the femur in its upper third I wish especially
to speak. Ten of the twenty femur cases admitted in June were
At a meeting of the Section, held December 4, 1918 .
Section of Surgery
, 7
those of fractures in the upper third—of these three were in good
position and only slightly septic; two were in fairly good position
but septic ; five were in bad position, and of these three were very
septic. Therefore 50 per cent, were in bad position and 50 per cent,
were very septic. These results should be capable of improvement.
The position or displacement of the fragments in fractures of the
upper third as a rule is as follows:—
(1) The upper fragment is abducted and flexed by the glutei and
ilio-psoas muscles.
(2) The lower fragment is displaced backwards, upwards, and
inwards by the hamstrings, quadriceps and adductor muscles. The
powerful adductor magnus being an exceedingly important factor,
there is also some rotation. This deformity is typical; the main
causes producing it are:—
(a) The direction of the fracturing force.
(b) The action of the muscle groups.
The essentials of correct treatment rest on an adequate con¬
sideration of the anatomical factors and the principles of surgery, the
latter including arrest of hemorrhage, establishment of efficient
drainage, provision for antisepsis, general care of the patient, massage,
&c, I want, however, to draw special attention to the anatomical
factors. The fragments should be brought into correct alignment, the
muscle groups placed in a condition of physiological rest, and the
limb securely fixed in order that there may be no movement of the
fragments or spasm bf muscles; at the same time any interference
with the circulation of the limb should be avoided. Hitherto it has
been taught that in fractures of the upper third “ the upper fragment,
being short, cannot be controlled.” Therefore attempts have been made
to procure alignment by abducting the lower fragment. This method
is wrong in principle. I have taken measurements of a great many men
and find that the distance between the symphysis pubis and the
adductor tubercle is on an average two inches greater in the abducted
position than when the knees are side by side—hence in the abducted
position of the limb the adductor group of muscles have a greatly
increased pull, are in a condition of spasm instead of physiological rest
and, therefore, although the two fragments are brought parallel to one
another, an X-ray examination in many cases reveals the fact that the
upper end of the lower fragment has now moved upwards a distance of
about 2 in., and takes up a position near the lesser trochanter ; an
amount of extension that can be applied with safety fails to correct the
8
Lee : Compound Fractures of the Femur
shortening. Unless the two ends of the bone were impacted, what has
been accomplished is increased overlapping of the fragments, and not
an elongation of the adductor muscles. It occurred to me that if the
upper fragment could be controlled and the abduction overcome, the
fragments could be brought into proper alignment with the limb and
the muscles in a nearly normal position. With these principles in
view I designed a new* appliance which I have called. a pelvic-femur
splint. It consists of a grip with two pads, which fit the pelvis;
modified Thomas’s frames for both lower extremities are hinged on
to the pelvic grip. The pelvic grip can be adjusted to fit any pelvis
comfortably and securely. The pelvis and upper part of the femur on
each side are grasped by the pelvic pads. The'abducted upper fragment
Can be controlled and adducted to its normal position quite easily.
The amount of pressure required is regulated and the fragment kept in
position by a fly nut working on a screw. Both limbs can be put up
in the iron frames in the ordinary way. The upper fragment having
been* brought into proper position the lower one can be placed in
correct alignment by abducting or adducting, raising or lowering as
required while on the splint, the latter working on hinges or joints.
Any'backward displacement can be corrected by manipulating the
small wooden splint by means of screws. Adequate extension can
be applied. If much extension is found to be necessary an adjustable
piece similar to that used in the arm splint can be fitted from the
pelvic pad to the axilla on each side; hence the upward thrust of the
extending force will be partly taken by the axillte and trunk and the
pelvic calliper grip not displaced. All these manipulations should be
done on an X-ray couch (if necessary under an anaesthetic), so as to see
that the two ends of«the bone are in actual alignment, not merely sup¬
posed to be so. Having completed all manipulations necessary, the
binding screws are firmly adjusted. The pelvis and lower limbs can be
suspended by means of pulleys on a frame—the patient’s body raised as
needed for convenience of nursing, the prevention of bedsores, &c.
Many patients complain that splints fitted with a ring around the
thigh, as in a Thomas’s splint; cause much discomfort. With this
splint there are no bands encircling the limb, hence no interference
with the circulation occurs, which is a very important factor, especially
in septic cases.
The splint can be easily applied with a minimum of movement.
When it is applied the fragments of the bone are securely held in
proper anatomical position, the muscles are at rest, all necessary
Section of Surgery
9
dressings, nursing, &c., can be carried out, and if any movement of the
patient is necessary he is moved as a whole and not in parts.
The iron leg portion of the splint can be raised at right angles to
the operating table and thus be out of the way should any operative
procedure be necessary—the upper fragment being perfectly controlled
by the grip pad, the lower steadied by an assistant.
The splint is made double to ensure steadiness and to enable the
patieiit to be moved easily. The final result is that the patient lies with
the fractured thigh in its proper position comfortably beside the healthy
limb. In all cases skiagrams are.necessary—both antero-posterior and
lateral, in order to show whether the fragments are actually in correct
position.
While the splint is useful in all fractures below the great trochanter
where there is abduction of the upper fragment, its use i3 not limited to
compound fractures of the femur but it would be of great value in
treating fractured pelvis, intracapsular fractures,. and anterior polio¬
myelitis to give rest to paralysed muscles.
Arm Splint .—An efficient splint for the upper extremity should b6
firmly fixed to the patient’s body so as to. carry the limb, keep the
fracture in proper position - and at rest.
Usually the splint hangs on the limb instead of supporting it. The
splint for the upper extremity, which has been designed by me, consists
of two parts. One fits firmly on to the trunk. The other carries the
limb. The upright trunk part is fitted to the hip with an adjustable
piece which allows its upper forked end to be securely fitted into the
axilla. This part is fastened round the body by two straps. To the
upper end of the fork the part which carries the limb is attached by
joints which allow the arm to be adducted to any desired angle and
retained there; the centre of movement passes through the head of the
humerus. By releasing a set screw on the tubular piece the hip portion
can be turned round; the limb attachment is then turned completely over,
hence the splint can be Used for right or left limb equally effectively.
The splint can be adjusted so as to support the shoulder in any desired
position. The forearm can be placed in either the semi-prone or
supine position. Provision is made for any necessary extension. When
properly fitted the patient carries his upper extremity with the w.hole
weight supported by his body-—hence the limb is kept quite steady and
at rest. Dressing of wounds, massage, &c., can be carried out without
interfering with the splint.
After much careful observation of many cases, I have designed
10
Lee: Compound Fractures of the Femur
these two splints—one for each extremity, and have proved that both
appliances are efficient, easy to apply, and give great comfort to the
patient. 1 have taken this opportunity of demonstrating them in the
hope that their use in treatment of such cases may help to produce
better results in the future.
In conclusion, I desire to express my warmest thanks to my
colleagues, especially to Lieutenant-Colonel C. T. Parsons, for valuable
help and encouragement, to Dr. Florence Stoneyfor her great assistance
with the X-rays, to the staff of the Kensington War Hospital Supply
Depot, and to Messrs. Arnold and Sons who made the splints for me.
Section of SuiQen?.
President—Sir John Bland-Sutton, F.R.C.S.
Mandibular Bone-grafts . 1
By C. W. Waldron, Major C.A.M.C., and E. F. Risdon,
Captain C.A.M.C.
Bone transplantation in so far as the lower jaw is concerned is a
surgical procedure of long standing, yet when one looks back upon the
relative infrequency of this operation in civil practice, one realizes the
unexampled opportunities afforded us by the large number of cases of
war injuries of the mandible. During the past three years the surgeons
doing this work have made a carpful and uninterrupted study of all the
various phases of the problems arising in cases of severe fractures of
the lower jaw. Within a few days of being wounded most of these
cases have come to a special jaw injury centre for treatment. We are
all aware of the excellent results obtained by this policy of segregation,
for the large percentage of cases attaining bony union and good function
testify to the skilful splint treatment rendered by the dental surgeons
specializing in this work. In those cases in which X-ray and clinical
examinations would seem to show such an extensive bony loss that
unioh could not reasonably be expected, we are strongly of the opinion
that continued surgical supervision and close co-operation with the
dental surgeon are of prime importance.
Early Treatment.
Though not strictly within the scope of this paper, we feel that
some of the more important points should be considered. In the early
stages persistent efforts should be made to keep the mouth as clean as
1 At a meeting of the Section, held January 22, 1919.
12
Waldron and Risdon : Mandibular Bone-grafts
possible by frequent mouth-washes and irrigation of pockets and sinuses.
We are convinced that too much stress cannot be laid upon the evil
effects of curetting the fragments. Our policy has been to encourage
free drainage of the sinuses present without disturbing the comminuted
fragments, removing sequestra from time to time as they are found to
be separated. The increasing number of very severely comminuted
fractures resulting in *bony union confirms our belief in the merits of
such conservative treatment. Displacements of the fragments should
be corrected by dental splints as early as possible and when there is a
remote possibility of union taking place, it is advisable to secure
additional immobilization by the construction of a dental splint for the
upper jaw, to which the splinted lower jaw, in correct occlusion, may be
fixed, by means of an interlocking device. The prevention of displace¬
ment and the control of edentulous posterior fragments are of great
importance in the early stages and in many cases may be most difficult.
The usual methods employed are posterior extensions from the lower or
the upper splints. Other methods, of which we have had no experience,
are the malar-coronoid screw fixation, described by Major H. P.
Pickerill, N.Z.M.C., and that of Bruhn and Lindemann, who, by an
external operation, expose the posterior fragment, to which a wire is
fixed by means of washers and a nut. This wire is attached to the
mandibular splint by means of a bar extension. It is usually not advis¬
able to keep the mouth closed by splints for more than two months,
for after that time the careful exercise of function seems to promote
increased bone formation in those cases in which some degree of union
may take place. Where non-union is obvious, the early use of the
jaws is advantageous in that atrophy and extra-articular ankylosis are
prevented. In many cases this is accomplished by the insertion of a
small splint on one fragment with.a flange extension which maintains
correct occlusion yet allows free opening of the jaws. A careful examina¬
tion of the teeth should be made, extracting such as are sources of
infection, and those that are too close to the lines of fracture, and
preserving those that will be of service in the immobilization of the
parts when the bone-graft is performed. The latter point is of great
importance, and every care should be taken in the early treatment to
prevent undue strain upon the essential teeth. Careful examination
should be made at regular intervals, to ensure efficient drainage as
long as external or alveolar sinuses are existent, and, to determine as
accurately as possible, and record the date at which the external and
alveolar sinuses have finally become healed.
Section of Surgery 13
When to Operate.
Clinical and bacteriological evidence has shown that operations
should not be performed until at least six months have elapsed after
the complete disappearance of all inflammatory phenomena. Further
delay is of benefit in those cases in which the ununited fragments are
strong, easily controlled, and fair powers of mastication may be
obtained by means of dentures or splints. In the case of edentulous
or short posterior fragments that are controlled with difficulty, bone¬
grafting should be performed at the end of six months, in order to
prevent atrophy, displacement or fixation of the free fragment.
Without doubt some of the failures reported in the literature, may
be attributed to operating at too early a date.
The Transplantation of Bone.
The consensus of opinion appears to be that the transplanted bone
has varying, but extremely important, osteogenetic properties. Gallie
and Robertson [2] have shown that this is due to the osteoblasts
present on the periosteal and endosteal surfaces and in the open mouths
of the Haversian canals, which are in a position to absorb nutriment
from the bathing lymph. As osteoblasts are most numerous on the
endosteal surface, they recommend that grafts should include periosteal
and endosteal surfaces. Albee [1], for the same reason, advises a bone-
graft consisting of all its elements as it approaches more closely a
complete physiological unit—especially in reference to nutritional
distribution—which is obviously an advantage. With regard to the
osteo-conductive property of transplanted bone, Gallie and Robertson
state that the rapidity of absorption and replacement of the graft
depends on its size, density and the abundance of the supply of osteo¬
blasts that survive on the surface, the replacement being slower in very
thick grafts. With regard to the density of the graft, their experience
is that replacement is very rapid in open cancellous bone, such as the
rib, less rapid in grafts cut from the face of the tibia, and most
retarded in densely compact bone, such as the crest of the tibia.
The relative osteogenetic activity of the transplanted bone and of the
fragments must vary with the individual case, and therefore the
principles outlined should be applied surgically in such a way that
full advantage is taken of the osteogenetic properties of the fragments
and transplanted bone, and of the ostfeo-conductive properties of the
latter. This will be discussed when describing technique of the
operation.
14
Waldron and llisdon: Mandibular Bone-grafts
We have not had any experience with osteo-periosteal grafts but
have seen many excellent results in the hands of our colleagues at
the Queen’s Hospital, Sidcup. This method is best suited to cases
where the bony loss is slight, or where there is incomplete union.
Neither have we used the pedicled graft which Mr. Percival Cole so
strongly recommends, but we intend to use it before long. It might,
with advantage, be combined with free iliac crest or tibial grafts or
with osteo-periosteal grafts.
We have not had any experience in the use of boiled bone, having
confined our work to the use of autogenous free grafts.
Types of Fractures and Splints.
These may be conveniently classified according to the relative
difficulty in immobilizing one or both of the fragments. This is shown
diagrammatically in figs. 1, 2, and 3 (pp. 19, 20), showing the fracture
and the general plan of immobilization by dental splints.
Even when specially constructed, dental splints are only capable of
very limited modification at, or during the time of, operation. It is
preferable, therefore, in most cases to fix the fragments in good position
by means of strong dental splints not capable of adjustment, and to
carry out the operative technique accordingly.
We have not used the open-bite splint, but expect to do so in the
near future, in some cases with edentulous fragments.
The results obtained on this service are in a large measure due
to the excellent services rendered by our dental colleagues, Captain
B. Mendleson, attached R.A.M.C., and Captain A. H. L. Campbell,
C. A.D.C.
The Operation.
Fixation of the Fragments .—The necessary dental splints should be
cemented to the teeth at least one week before the operation, in order
that the mucous membrane of the buccal cavity may become accustomed
to them. We have found that frequently small ulcers occur, owing to
small irregularities in the splints, the projection of the interlocking
devices and the action of the free acid from the cement.
The Anaesthetic .—Rectal oil ether anaesthesia, supplemented when
necessary by intrapharyngeal ether administered through a nasal tube,
has been the method employed in eighteen of our cases. We have
adopted this method as a routine in bone-grafting, as one most
satisfactory in every way.
Section of Surgery
15
The Preparation of the Operative Field .—After a preliminary ether
and tincture of iodine preparation of the skin, we fix a square piece of
sterile dental rubber dam to the cheek and the lower lip, by means
of adhesive plaster. By turning this upwards, the mouth is walled off
from the overlying towels, which will be subsequently placed, and
soiling or contamination of them by mucus or saliva is prevented.
At the conclusion of the operation, the rubber dam is turned down,
covering and protecting the dressing from the fluids of the mouth.
The incision is made in accordance with the position of the bony defect,
keeping in mind the desirability of having the closure below the level
of the graft rather than directly over it. The non-touch technique
introduced by Sir Arbuthnot Lane is followed. As soon as the
subcutaneous tissues are freely exposed, the skin surface is walled off
from the wound. The ends of the fragments are exposed and the
periosteum is elevated from their external, inferior and internal surfaces
for a distance of 1*5 to 2 cm. on each side of the hiatus. Great care
must be taken, particularly on the internal surface, to avoid perforation
into the mouth cavity. The height to which the separation may be
carried safely may be determined by the previous examination of the
mucous membrane over the ends of the fragments and reference to
the X-ray plates.
Preparation of the Fragments .—The ends of the fragments should
be trimmed back from 1 to 1*5 cm. or more, until bleeding, healthy
bone is reached. Intervening cicatricial tissue should be excised and
discarded. After some experience with electric bone-grafting instru¬
ments, circular saws, &c., used in attempting to shape the fragments
and graft by the formation of steps, pegs, and dovetailing, &c., with a
view to obtaining auto-fixation of the graft, we have discarded these
more complicated methods and instruments, in favour of the most
simple. Since taking this step, our results have been better. We do
not like the peg and hole fixation on account of the fact that the
preparation of the hole in the fragments involves the reaming out of
the endosteal tissues, which arO of greatest osteogenetic importance.
Accurate dovetailing and the formation of steps in the fragments of the
lower jaw are quite difficult on account of the general contour and
variations in the planes of the fragments. When one realizes that but
little more than 1 cm. of the external surface of the jaw in a vertical
direction may be exposed with safety, the difficulties in the manipulation
of electrically driven saws in so small a space are readily appreciated.
These methods usually involve the use of the tibia, and we have observed
1(5 Waldron and Risdon: Mandibular Bone-grafts
that in order to secure a good mechanical fit the endosteal surfaces of
the grafts have been sacrificed. We therefore prepare the fragments by
the use of rongeur forceps, our choice being a Friesner mastoid rongeur
forceps and Lane’s gouge forceps. We attempt to square off the ends
as well as possible, and to leave a ledge above the graft which affords
additional surface contact between the fragments and the graft. This
is shown in fig. la (p. 19). This method puts a minimum of opera¬
tive stress upon the interdental splints, precluding any possibility
of displacing the fragments from the splints. In the case of gaps,
situated anteriorly, a square or butt joint may not be readily obtained
on account of the contour and planes of the two fragments.
A satisfactory overlapping plane joint, can, however, usually be
obtained without much difficulty. Similarly some special preparation
with overlapping or notching may be found necessary in the case of
free posterior fragments, which may, with advantage, be forced
backwards and slightly downwards by the graft. When the bed for
the graft is prepared, holes are drilled in the fragments through which
two short lengths of Belgian iron wire are passed and held by clamps.
Measurements are then taken for the graft.
The Graft.
In choosing bone for grafting purposes, we have heen guided by the
theory that the larger the area covered by osteoblasts in the Haversian
canals into which the blood-vessels may project, the better, and the
more cancellous the graft is, consistent with necessary strength,
the more rapid will be the change from the transformed section of
the transplant to the live bone forming bony union. We feel that the
bone that fulfils the above requirements best is the iliac crest. The
tibial crest, in our experience, has given good results, also the inner
surface of the same bone, but according to the theory, the grafting is
rather too compact when the tibial crest is used. Further, the patients
may be incapacitated for some time, and fractures of the leg at a later
date are by no means rare. The rib, in our cases, was not a success,
as it seemed to undergo an aseptic absorption, which resulted in a
springy mandible, where the graft was long. In these cases, a consider¬
able portion of the outer compact surfaces had been removed before
inserting, to allow the fluids of it$' bed to permeate it. This has also
been the reported experience of some German surgeons, and further, in
many cases of other surgeons we have examined, where the rib was
Section of Surgery
17
used, we have noted the same objection. The iliac crest graft is easily
obtained, is very cancellous, strong, and particularly adaptable, as any
surface may be used. The crest is easily exposed and the required
amotint removed by thin chisels and narrow saws. Haemorrhage may
be free, necessitating firm pressure and the insertion of a rubber-tube
drainage. The graft is readily trimmed and fitted to place. Holes are
then drilled in each end of the transplant, through which are threaded
the wires previously inserted in the ends of the fragments. These are
then tightened, fixing the graft firmly in position. The subcutaneous
tissues are then united with interrupted mattress catgut sutures, and
the skin closed with horsehair. It is important that all haemorrhage
should be controlled before closure. Should any slight oozing persist
a short drainage tube to the subcutaneous tissues may be left in
position for twenty-four hours. The technique we have employed
for incomplete alveolar union is similar, as shown in fig. 4a. For
incomplete basilar union, we have used the tibial inlay graft, as in
fig. 5 a (p. 21).
Post-operative Course—Treatment—Complications.
The patients are kept on a fluid diet for a few days, after which
ordinary minced diet may be ordered. It is advisable to keep the iliac
crest cases in bed for a period of ten days or two weeks, in order to
avoid the formation of hsematomata which may become infected. In
several of our cases slight infection occurred, which, under treatment,
healed nicely without any ill effects. The facial incisions healed per
primarn in fifteen out of our twenty-three bone-grafts of the lower jaw.
In two, slight suppuration necessitated the removal of the wires, and
the grafts were removed in four cases' The splints are left in position
keeping the mouth closed for two months. If both fragments are well
controlled by the lower splint, the mouth may then be left open and
function exercised carefully. If the posterior fragment is free, it seems
advisable to keep the mouth closed for three or four months. During
this period the splint-pins may be removed at intervals, and the mouth
opened for examination. We have been removing the splints about
four months after operation. In some of our cases splints have been
left on for a much longer period on account of the fact that the patients
were away on extended furlough. The time of removal of the splints
is more or less governed by the progress shown in the X-ray.
M —12
18
Waldron and Risdon : Mandibular Bone-grafts
Resume of Cases Shown.
Ten patients were shown. Two had some degree of alveolar union,
with slight but definite movement at the site of fracture after a*year
or more of observation, and the operations were performed with the
view of obtaining strong union. In one of them infection occurred,
necessitating the removal of the tibial graft. A large amount of new
bone was, however, laid down, resulting in strong bony union. The
second was an iliac crest graft, in which strong bony union was obtained.
In the remaining eight patients (nine grafts), separation of the fragments,
varying from 0*5 cm. to 6 c.m., was found at operation.'Both fragments
were well immobilized by the splints in three cases, and strong bony
union, with good function, was obtained (one tibial and two iliac crest
grafts). In one case the posterior fragment was displaced from the
splint at the time of operation. An iliac crest graft with hole and peg
fixation at one end was used. Union has progressed very slowly, but is
finally becoming bony. The functional result is good. In one patient,
immobilization was most difficult and imperfect on account of the few
remaining teeth being weak and the absence of upper teeth. The
connective tissue bed for the graft was thin, containing considerable
scar tissue. A bent, split, rib-graft was used. Following the operation
there was a recurrence of a salivary fistula, accompanied by slight
suppuration, necessitating removal of one of the wires. The parts are
now well healed and the graft is in position. The result is in doubt.
The posterior fragments were not controlled in three cases (four grafts).
In one (iliac crest), the functional result is good, but strong manipulation
reveals a definite spring between the graft and the anterior fragment.
In the remaining two cases (one double-graft tibial and one iliac crest),
union progressed very slowly, btit finally complete bony consolidation
took place.
Conclusions.
(1) Bone-grafting of the lower jaw is an operative procedure,
whereby union of the fracture and restoration of function may be
expected in a large percentage of cases.
(2) Complete co-operation and careful attention to every detail by
the dental surgeon and the surgeon concerned are essential from the
“ early treatment,” to the “ final ” stage.
(3) Full advantage should be taken of the osteogenetic activity of
the fragments, and of the transplanted bone, and also of the osteo-
Section of Surgery
19
conductive properties of the latter. The iliac crest is, in our experience,
best suited in most cases for the bridging of defects in the lower jaw.
(4) The operation should be made as simple as possible, the object
being to obtain good contact of the graft to fresh, healthy bone of the
fragments, maintaining the same firmly in position by wiring.
REFERENCES.
[1] Aubeb, F. H. “ Bone Graft Surgery,” Philad. and Lond., 1915.
[2] Gallie, W. E., and Robertson, D. E. “ Transplantation of Bone,” Joum. Amer . Med.
Assoc., 1918, lxx, p. 1134.
Fig. 1.—Non-union right premolar region.
Fig. la.—Fixation of fragments by dental splints. Preparation of fragments
for graft “G.”
Fig. 2.—Edentulous posterior fragment.
Fig. 2a.—Control of edentulous posterior fragment by dental splints. Fixation
of graft.
Inset.—Interlocking device.
m— 12a
Section of. iS lumen/
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21
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22
Gallie : Discussion on Bone-grafting
DISCUSSION ON BONE-GRAFTING.
Captain W. E. Gallie, C.A.M.C.
(ABSTRACT .) 1
Some of the old beliefs on this subject have been shaken as a result
of experience with war injuries. Many experiments on dogs have
been carried put in the clinic to which I am attached. When a piece
of living bone has been separated from its vascular supply and implanted
elsewhere in the body of the same patient the immediate result is a
coagulation of cells and vessels to which the surrounding lymph cannot
percolate. This leads to the death of all the cells in the lacunae and of
most of those in the Haversian canals. The absorption of these
structures takes from three to four weeks. On the open mouths of
the canals are osteoblasts, which possess the power of absorbing lymph.
Ten days after implantation the proliferation of the osteoblasts is well
established on both the endosteal and periosteal surfaces, and in a few
days new bone formation is visible on these surfaces. These pro¬
liferating osteoblasts attack the dead bone of the graft and rapidly
produce excavations. In the meantime a re-establishment of the
circulation has been taking place as a result of the ingrowth of new
blood-vessels into the mouths of the Haversian canals. This occurs in
about a fortnight. Ultimately the whole graft is seen to be permeated
by vessels and osteoblasts. The union of the graft is effected by the
deposit of new bone on the surface. If endosteal and periosteal surfaces
are removed from the graft, very little osteogenesis takes place from the
graft itself. The rapidity with which the changes take place depends
on three factors : the size of the graft, its density, and the abundance,
on the surface, of the osteoblasts which survive. In some cases it will
be months before replacement may be effected. When boiled bone is
employed for grafts the changes take place at a definitely slower rate.
Autogenous grafts alone guarantee success where there is a gap to be
bridged ; if boiled bone be used here the living elements will slowly
disappear. The great aim in grafting, as it is only on the surface that
1 The record of the work upon which this communication is based is published in extenso
in the Journal of the American Medical Association, 1918, lxx, pp. 1134-40, and the American
Journal of Orthopaedic Surgery , 1918, xvi, pp. 373-83.
23
Section of Surgery
*
living osteoblasts survive, is to have the largest osteoblast-bearing sur¬
face possible, therefore the width of the graft should be greater than its
thickness. Tibial bone should only be employed in cases where a strong
graft is essential; graft from the rib is better, as it is both more porous
and better supplied with lymph. It is advisable to split the graft into
several portions; in this way a large number of osteoblasts will be
afforded the chance of survival. Instead of Arbuthnot Lane’s metallic
plate boiled bone-graft plates have been used at the clinic to which I
am attached, and these have proved very satisfactory. There is no
likelihood of these becoming loose, and after the lapse of ten months the
only evidence of irregularity is a slight fusiform swelling. Even this
disappears after a still further interval of time.
Major Naughton Dunn, E.A.M.C. (Birmingham).
I propose to deal only with the function of the bone-graft from the
clinical side, -the selection of cases, the points in operative technique
and the after-treatment, which seem from my experience to be the most
essential for success.
Previous to the War, Albee’s operation of transplantation of bone
from the tibia to fix the spinous .processes of diseased vertebrae was
becoming popular. After seeing the results of over fifty cases I am
satisfied that this will in time be recognized as the routine treatment of
tubercle of the spine in children and adults. The operation, if under¬
taken before marked kyphosis is present, will result in a very large per¬
centage of cures without deformity. The essential of the operation is
insuring contact of the graft to the raw surfaces of the spinous pro¬
cesses of the two vertebrae above and of the two below the diseased
bodies, so that the transplanted bone may, by direct union with these,
give us a fixation which is not possible by external splintage.
In military surgery ununited fracture of the long bones is not un¬
common, and the chief value of the bone-graft has been, that it has
enabled us to restore continuity even when a considerable loss of sub¬
stance was present. Before resorting to bone-grafting two questions
arise: (i) Will re-establishment of continuity improve function ? and
(ii) is the use of the bone-graft the best means ? In the lower extremity
bone-grafting is seldom necessary, except for ununited fractures of the
tibia. For ununited fractures of the femur open operation to freshen
24
Dunn: . Discussion on Bone-grafting
the ends and reduce the fracture has, with efficient external fixation,
given excellent results. Non-union of the fibula has not in my experi¬
ence given rise to much disability; cases in which the middle two-thirds
of the bone have been deliberately removed seeming as regards function
to have perfectly normal limbs. In the bones of the upper extremity
non-union is more common, but the cases requiring the use of the
bone-graft call for careful selection.
The Humerus .—Moderate shortening in the case of the upper
extremity is no serious disability, so that direct apposition of the
fragments with a bone-graft, to ensure adequate fixation, will be used
where possible. Where either the upper or the lower fragment is too
short to allow adequate fixation of a graft, direct implantation of one
fragment into the other will usually be preferred. The result will then
depend largely on the efficiency of the external fixation applied. Where
a flail limb results in entire loss of the upper portion, direct fixation
of the shaft to the scapula will, as a rule, give better functional result
than the use of a graft.
Forearm. —Non-union of one of the bones of the forearm has been
remarkably frequent, and I have had three cases in which a flail limb
has resulted from non-union of both. In dealing with ununited frac¬
tures of the forearm bones, we must remember that where ankylosis
of the superior or inferior radio-ulnar joints is present, any move¬
ment of pronation and supination taking place at the site of the
fracture will be lost if union of the fragments is re-established.
Radius .—The hand articulates mainly with the radius, so that
loss of continuity of this bone is associated with radial deviation of
the hand and considerable weakness of grasp. This is especially so
in ununited fractures of the distal portion of the bone. A general rule
is that all cases of nnunited fracture of the lower two-thirds of the
radius require bone-grafting to give stability to the hand. In cases
of ununited fracture of the upper third this may not be necessary,
and if associated with ankylosis of the superior radio-ulnar joint should
not be undertaken, as reunion of the fragments will result in loss of
the movements of pronation and supination. Where the lower fragment
of the radius is less than 1 in. in length, shortening of the ulna to
correct the radial deviation and allow direct union of the radius gives
the best results.
Ulna .—In the case of non-union of the ulna, weakness of the hand
is less marked, and there is little deformity. Ununited fracture of the
lower third of the ulna or of the olecranon may as a rule be ignored.
25
Section of Surgery
Where the inferior radio-ulnar joint is ankylosed, loss of pronation and
supination will result from reunion of the fragments. Before operation
in these cases mobility of the hand should be restored, the radial
deviation of the hand corrected and the forearm fixed for a time in the
supine position. Unless this is first secured there will be strain on the
graft after operation or union will occur in the position of deformity,
which will necessitate further operation for the best result.
The Operation of Bone-grafting.
Success in bone-grafting depends on (1) asepsis; (‘2) adequate
contact of raw surfaces; and (3) efficient fixation.
If there has been severe sepsis, all wounds should be healed for
six months and scar tissue excised where possible, as a preliminary
to the major operation. The preliminary excision of scar tissue serves
three useful purposes: (i) It enables us to judge of the probability of
grafting bone without recrudescence of sepsis; (ii) it removes tissue
of low vitality, which would itself tend to slough after its blood
supply is further reduced; (iii) its removal allows healthy vascular
tissue to surround the bone-graft.
The graft should consist of periosteum, cortex and endosteum, and
be of sufficient strength itself to withstand the strain of function
when its union to the fragments is complete. Care should be taken
that the bed for the graft is cut on surfaces which will be in
continuity when the limb is in the desired position. In the case of
the forearm this will usually be supination, so that we should arrange
for this position to be maintained from the time the incision is made
until the fixation splints have been applied. The joints above and
below the fracture should be controlled, and no movement which might
disturb the position of the graft allowed. Movements of the digits
should be encouraged.
The source of the graft will usually be the inner surface of the tibia
or the fibula—either of these gives us a graft of adequate length and
strength—and, in order to ensure adequate contact of raw surfaces, it
should be as long as anatomical conditions in the receiving bone allow.
It should be just a little wider than the bed which has been cut for
it, so that when prised into place it is gripped firmly by the lips of the
fragments and further fixation is not necessary. Failing this, kangaroo
tendon suture will ensure adequate fixation. The graft should be
firmly held in its bed by hone forceps while these are tied. The
26
Dunn: Discussion on Bone-grafting
wound is closed by deep and superficial sutures, and two tubes, a
quarter of an inch in diameter, inserted for drainage. These are
removed at the end of forty-eight hours. This is a detail of some
importance, as loss of vitality of the graft has seemed to result from
the presence of a haematoma between the graft and the surrounding
structures on which it is dependent for its blood supply. The limb is
then encased in plaster of Paris, fixing the joints above and below the
fracture, and a window cut in the plaster so that the tubes may be removed
without disturbing the fixation. At the end of a month the plaster is
removed and a skiagram taken. It will usually be necessary to insure
adequate fixation for another two months. If the case is doing well,
the X-ray will show some absorption of lime salts in the graft, and
indications of fusion with the shaft will be apparent. Until the graft
has lost its individuality where it is in contact with the receiving
bone fixation should be maintained.
The Effect of the Removal of the Graft from the Tibia.
Of seventy-four cases of which I have personal experience, fracture
of the tibia from which the graft was removed occurred in two cases,
one six weeks and the other two months, after removal of the graft.
I do not think the injury would have resulted in fracture in. the normal
bone. X-rays taken three months after removal of a graft, as a rule
do not show any loss of density in the bone.
What is the Fate and Function of the Bone-graft.
My experience has been of the autogenous transplant only. I believe
that the transplanted bone lives and itself takes part in the formation of
a new shaft under favourable conditions. What it requires is an early
blood supply and adequate fixation to healthy bone. I have not seen
cases reported where ivory pegs or dead bone have been used success¬
fully to bridge a wide gap, and I have not had a case in which autogenous
bone was not available.
The following cases will illustrate the points to which I attach
importance in the selection of cases and the use of the bone-graft:—
(1) Disease of third and fourth lumbar vertebrae, showing graft used for
fixation.
(2) Showing correction of genu valgum by transplation of a wedge of bone
from the inner to the outer side.
Section of Surgery
27
(3) Showing removal of a portion of the shaft of the fibula to replace lost
substance in the ulna. This case demonstrates two points : First, that a
considerable portion of the middle two-thirds of the fibula can be removed
without loss of function, and that non-union was probably due to insufficient
contact with the receiving bone.
(4) Ununited fracture of the shaft of the humerus. In this case spon¬
taneous fracture of the graft two months after insertion indicates that its only
function was that of an internal temporary splint. Union resulted from
contact of the raw surfaces of the main fragments. The graft shows little
absorption of lime salts, and this usually indicates loss of vitality of the graft.
(5) Ununited fracture of the neck of the humerus; fourteen months’
duration. The upper fragment is too short to allow adequate fixation of graft.
Direct apposition obtained by wire and external splintage.
(6) This case illustrates the result obtained by early treatment in a case of
loss of the upper third of the humerus, and the result eighteen months after
injury. The arm is short but allows a fair range of movement.
(7) Result in a similar case which was not treated on these lines.
(8) Case of an old ununited fracture of the forearm, especially the radius,
one usually associated with fixed pronation of the forearm, radial deviation of
the hand, with limitation of movement in the wrist and fingers. These should
be corrected before operation to restore continuity of the bones. This avoids
strain of the graft.
(9) Ununited fracture of both bones of the forearm. Illustrates the length
of graft which should be used to insure adequate contact.
(10) Ununited fracture of both bones of the forearm. Preliminary opera¬
tion, dovetailing of ulna, followed by bone-graft of radius. Owing to extent of
scar tissue its preliminary excision was not possible, and the bone-graft of the
radius had to be removed six months later because of a persistent sinus. Last
X-ray taken twelve months after first operation shows strong union of ulna,
radius uniting.
(11) Ununited fracture of lower third of ulna with ankylosis of the radio¬
ulnar joint. Bone-grafting is contra-indicated in this case, as it would result in
loss of the movements of pronation and supination taking place at the site
of fracture.
(12) In a similar case of ununited fracture of the upper third of the radius
with ankylosis of the superior radio-ulnar joint re-establishment of continuity
would result in loss of these movements. In both these cases the fragments
are too short to allow of adequate fixation of a graft, and neither are associated
with much disability.
(13) Where the lower third of the radius is short, and there is radial
deviation of the hand, it is usually better to shorten the ulna and allow direct
apposition of the radial fragments, as was done in this case.
(14) Shows gradual absorption of a graft four months after operation. In
this case the Wassermann reaction was positive. This factor should have been
dealt with prior to operation.
Bnmi ; JJtimsmm on Bonz-grgfting.
(1A) Tiu> history of this nane is interesting*.. . On-lit!y 10, 191* h he sustained
u coin pound fracture of the n uiw*. Onr year later U in. of the ulna wore
femoyeul anil both hones plated. When I saw hire, in May, 1917, there waa
some union of the ulna, hut the radius was tin uni ted. The plates were
letnoveli, the pronution nl ih** arm corrected and later a graft inserted.
•iVJk
. Fig; % (Ca^c - ciondi^)^ at ter wo tin d ty,. ulna.
Fig. ’i (Oma -iTh—hon»vyraft from tibia five months after u^oHior. ‘N./w
tu*u;i» of |p&itU *h»?t tmd iossof rtensiiy iu gvttft.
Fig. ,>■ tirade If),-'^OQdjMrtri One .ya^-r and' eleven Th0#£<vMt$?- cj^gtibii.
Mn\H ,wvuiP.Mg'i4i^0 -bivpr- t>f. rc^ivimi bone. FarK upp^irjmt- nf u?f-
ft graft.
Section of Surgery
29
The last three cases are those which have convinced me that under
favourable conditions the graft lives and itself takes an active part in
the restoration of continuity.
(16) Ununited fracture of lower third of humerus, thirteen months’ duration.
During the operation the lower fragment was completely removed and then fixed
by kangaroo tendon to the shaft. Union resulted, and its previous form was
maintained.
(17) Shows 2^ in. gap in ulna, of nine months’ duration (fig. l). Bone-
graft, October, 1916. X-ray taken five months later shows fusion of graft with
shaft and new bone formation between graft and fragments (fig. 2). The next
X-ray, taken one year and eleven, months after the operation, shows firm
consolidation, the graft attaining the size and appearance of the normal shaft
(fig. 3). Note also the restoration of medulla in the middle of the graft.
(18) The last case is one of Sir Bobert Jones’s, illustrating a graft which
was itself the site of fracture three months after its insertion, and which united
by callus formation apparently like normal bone.
Major Alwyn Smith, D.S.O., K.A.M.C.
My experience of bone-grafting before the War was mainly limited
to the operative fixation of carious vertebrae and as such cases did
uncommonly well from the purely operative standpoint, one could not
learn much from them. Bone-grafting has a much wider field in
war surgery, but the risks and complications of the operation are
immeasurably greater. On account of disappointing results with
certain surgeons, the operation appears to be losing favour and
statements have been made in several quarters that it is hardly
justifiable. Although I have had disappointments and failures, I am
convinced as to the value of the procedure provided it be limited
to cases that do not display complications which we are accustomed to
associate with disastrous results. My war-time experience is limited
to cases of non-union in long bones, the result of simple or compound
fractures, and to cases of bone loss, with consequent hiatus—the result
of wounds.
General Considerations.
It is obvious that more consistent results are to be expected in the
young than in the middle aged, in ununited simple fractures than in
compound ones that have undergone septic processes. The latter type
of case, pn account of latent sepsis, damage to, and loss of, soft tissue,
30
Smith: Discussion on Bone-grafting
and its subsequent cicatrization is apt to end in failure. On account of
deformity and disability, a bone-graft is often imperative and the
patient is no worse off if failure results, whereas the improvement
in function that follows a successful issue is of inestimable value to him.
No septic cases should undergo operation—
(1) Unless discharging wounds have been healed for at least nine
or even twelve months.
The prolonged wait between wound healing and operation is of
great importance not only as a safeguard against sepsis but in order
to give Nature a chance. I have had cases of non-union of many
months’ standing, where one has despaired of union taking place
without bone-grafting, suddenly unite without apparent reason. The
period of waiting should be associated with treatment by immobilization,
massage, passive congestion and percussion : the latter by means of a
wooden hammer to the region of the fracture.
(2) Unless a preliminary operation for the removal of scar has been
carried out; or
(3) Unless a course of provocative massage of a month's duration
has been instituted which has not been followed by a “ flare up.”
A preliminary operation should always be undertaken where the
X-ray shows bone fragments that may be acting as foreign bodies.
In cases that have been fully healed for many months, I have found
small sequestra and encapsulated abscesses that obviously vetoed a
bone-graft.
(4) Unless the wound can be covered ivith healthy shin without
tension.
Where operation is contra-indicated on account of skin loss or large
adherent scars, pedunculated skin flaps may be taken from elsewhere as
a preliminary operation.
Function and Fate op the Graft.
I will now describe cases that exhibited features which may form
debatable points with regard to the function and fate of the graft.
In 1911 when the controversy as to the osteogenetic power of the
periosteum was much in vogue, I had under my charge in Western
Canada a small boy with morbus coxae. There was an abscess of the
joint which had not burst through the capsule, the type of case that
frequently bursts through the acetabulum into the pelvis. The child
had been immobilized for eighteen months when I saw him and there
Section of Surgery
31
were no signs of ankylosis taking place. The long rigorous Canadian
winter which debars open-air treatment was approaching and as the
child was losing ground I resolved to produce an arthrodesis of the hip.
On opening the hip-joint a pure tuberculous abscess was evacuated
and the head and neck of the bone came away as a sequestrum.
I resolved to fix the femur to the acetabulum by means of a bone-spike
taken from the tibia. After removing the bone-graft my assistant,
owing to misunderstanding, stripped the periosteum from the graft.
Having freely curetted the acetabulum and the femoral neck, I drove
the bone-peg from the great trochanter through the remains of the
neck and ran it into the ilium and thus fixed the femur to the pelvis.
Everything went well and firm bony ankylosis resulted. The track of
the graft was discernible in an X-ray picture twelve months later.
The result of this case seemed to point to the fact that the periosteum
is not all-important.
In 1912 I performed an Albee’s operation for low dorsal caries.
After six months’ immobilization the child was allowed up, but twelve
months later he was brought back to me with a lesion in the second
lumbar vertebra. The lower edge of the graft only extended to the
first lumbar vertebra. A second operation to immobilize the diseased
vertebra and the two below it was undertaken and it was found that
the previous graft had united firmly with the vertebral spines. The
point of marked interest lay in the fact that the graft was of stone-like
hardness and of a totally different consistency to that of twelve
months previously.
In April, 1916, I performed a bone-graft in the ulna, a series of
lantern slides of which I show you. Good union occurred, but about
ten weeks after operation an impromptu wrestling bout produced a
fracture. I knew that Sir Robert Jones had had a similar case
previously and the graft had thrown out callus and had re-united.
As you will see .from the subsequent slides, the very opposite occurred
here, the graft becoming disintegrated and finally disappearing, with
the exception of that in contact with the host bone. It will be noticed
that the gap is very much diminished but- that most of the bone
regeneration appears to have taken place in the endosteum of the host
bone adjacent to the graft and not in the graft itself. If the graft
be osteogenetic, why should union not take place and why should
disintegration have occurred? I am inclined to think that the graft
acts as a scaffolding and has little osteogenetic power of its own.
This opens up the argument as to the advantage of autogenous over
32
Smith: Discussion on Bone-grafting
heterogenous grafts. Possibly heterogenous grafts behave to some
extent as foreign bodies, although Clarence Starr, of Toronto, tells me
that in the experimental experience of Gallie and himself, open-mesh
animal bone, as a graft, thoroughly sterilized by boiling, has been
quite satisfactory. If we assume that the graft has no osteogenetic
power, we must assume that it receives its nutriment, and is finally
reconstructed, from the host bone at either end and also from the soft
parts that lie in contact with it, either directly through new vessels in
granulation tissue or through the medium of the periosteum that is
transplanted with it. It is thus necessary, if our premises are correct,
to make sure at the operation that whatever area of graft is in contact
with host bone must be in close contact with it and must be in contact
with healthy bone, which should, if possible, include the region of the
medullary cavity on account of its vascularity. From the practical
standpoint, the use of high speed circular saws may to some extent be
a disadvantageous factor in the early vascularization of the graft on
account of eburnation due to heat and the clogging of lacunae by fine
bone dust.
At the site of non-union in old septic bone injuries, the bone is
invariably devitalized; it is absolutely avascular and looks like com¬
pressed sawdust, but has a much harder consistency. I regard this as
quite inefficient for the production of union and I invariably remove,
by the aid of nibbling forceps, the ends of the bones, until vascular
healthy bone is reached; this preparation I consider of great importance.
The soft tissue bed in which the graft is to lie will aid in its nutrition;
it is thus necessary to make sure that scar tissue is freely removed and
that haemostasis is absolute. I once lost a very promising graft as the
result of the formation of a haematoma which was allowed to remain.
If we assume that a graft derives the majority of its nutrition from
the host bone, it would be interesting to know how long a period of
time elapses until the graft becomes totally revivified.
In the case quoted of Sir Robert Jones, of fracture of the graft, the
fracture took place seven months after the operation; in my case the
period of time between graft and fracture was only ten weeks. I have
never felt satisfied that a graft is safely reconstructed till after at
least three months and this period of time will obviously be increased
proportionately with the density of the graft and with the distance
between the ends of the host bone. I have thought that some grafts
become softened between the second and third month, especially if the
bridge be a long one, and from a practical standpoint it is unadvisable
Section of Surgery
33
to allow much latitude to.the patient for at least four months. The
photographs of a 4-in. gap in the ulna illustrate this point. The
patient played a game of tennis eight weeks after operation, but I
forbade a repetition for another two months for the reason I have given.
Where a graft partly fails and becomes united at one end only, the
question arises as to whether it will persist and become living bone in
whole or in part, and what factors will aid or diminish such chances.
The presence of mild sepsis or an unfavourable bed will certainly have
a deterrent action. The prints I show you are of a bone-graft of the
humerus performed in April last. Firm union took place at the lower
end, but the upper end came away as the result of faulty immobilization.
Seven months later a second operation was undertaken to freshen and
approximate the fragments, and it was found that the upper free end
was devitalized and sclerotic, and had become tapered in shape. The
bone was drilled in several places, and it was discovered that the graft
was only vascular for about one inch above its union with the lower
end of the humerus. The graft was mainly used as a fixation point for
the phosphor-bronze wire used at the second operation. Union has now
taken place, and the endosteum of the upper fragment of the humerus
appears to be growing round the sclerotic portion of the graft.
The question of unilateral fixation to host bone opens up a big
problem. The pretty operations that were devised to substitute the
head and shaft of the fibula for corresponding missing portions of the
humerus, in order to reconstruct the shoulder-joint, have not stood the
test of time. The same results are applicable to Lexer’s work in joint
transplantation. Failure is due to the inability of the host bone to
reconstruct the graft before it dies. The osteoblasts transplanted
with the graft can only prevent its death provided a new circulation
is rapidly established along its Whole extent.
The question as to what length of time may elapse before a bone-
graft that has apparently not “ taken ” at one end is capable of union
appears to be doubtful. The ununited portion is capable of union
after a prolonged period, provided the free end is in close contact with
host bone. The prints shown are those of a man who lost 3 in. of the
tibia in October, 1915. Two years later a slide inlay was performed in a
hospital in this country. Nine months later I saw him as a pensioner,
the graft ununited at one end, the limb flail-like, the patient walking
on crutches, never having put his foot to the ground. The bone
surfaces at the site of union were closely approximated, and no tapering
of the extremity was evident. It was decided to try the effect of
34
Smith: Discussion on Bone-grafting
function without weight bearing. A calliper splint was fitted, and
massage and percussion were instituted. The patient was told to walk
as much as possible in his appliance. After six months it was found
that the graft had become much thicker and that a large amount of
callus was being thrown out at the site of fracture. Union has now
taken place. What had happened during the first nine months? I
imagine that full vascularization and reconstruction of the graft had
occurred, and that with the added stimulus osteogenesis became
possible.
Statistics.
From my records I have collected thirty-one cases of war-time
grafting ; some of these were due to simple ununited fractures, but
the majority are old septic gunshot fractures. Of these cases there
were: Ulna nine, radius six, <humerus five, femur five, tibia four,
clavicle one, fibula one. Of the thirty-one—twenty-two were suc¬
cessful, four were partially so, that is to say, the graft united at
one end, the remaining five were failures all due to sepsis. The
graft was removed in three cases, and in two emergency amputation
was required ; there were no deaths.
The worst results were obtained in the humerus, mainly, I am
sure, due to' difficulty in immobilization. Five cases—no complete
successes, three partial successes and two failures. It is questionable
whether it is not advisable to sacrifice the length of the humerus
by means of step-cut operations rather than to attempt to preserve
length by means of bone-graft bridges. A shortened arm is a disability
of little moment. From the operative standpoint the following results
are of importance : (1) Perfect asepsis* (2) perfect haemostasis, (3) close
coaptation between host and graft, (41 rigid fixation of graft to host
bone, (5) rigid immobilization of the limb.
With regard to (5), in bone-grafts of the femur I obtain immobiliza¬
tion by means of a Thomas’s bed splint and have had no failures. For
fixation I use fine phosphor bronze wire cable—the so-called Vienna
silk. I have given up the use of kangaroo tendon and chromic catgut.
I use autogenous tibial grafts, consisting of the whole thickness of the
antero-internal surface of the bone, including the periosteum that
overlies the graft. A slide inlay of bone may be used, but if it has
become soft and atrophic, as the result of long disuse of the limb, it is
not satisfactory as it is apt to break with the slightest movement before
its reconstruction is complete. All grafts should be of sufficient length
Section of Surgery
35
to be in juxtaposition with each segment of the host for at least one
inch—two inches if possible. Where possible, comminution by a chisel
of the free ends of the host bone should be practised. I use a motor-
driven circular saw, but endeavour to prevent the bone becoming heated
by the use of saline drip. The limb should be immobilized for at least
twice as long as for an ordinary fracture, but, generally, massage and
active movement of the muscles that overlie the graft can be practised
at an early date. Forty-eight hour drainage by means of rubber tissue
is of advantage in most cases, especially where scar tissue remains and
post-operative oozing is to be expected.
The following communications have also been made before the
Section :—
President's Address :
Sir J. Bland-Sutton, F.ll.C.S.: “ Spolia Opima.” October ‘23,
1918. Printed in extenso in the British Medical Journal ,
November 30, 1918, p. 593.
Demonstration :
T. S. Kirk, M.B. (Belfast) : Demonstration of the P. K. Arm.
November 5, 1918.
Discussion :
Major Kobert Milne, Ii.A.M.C. : Contribution to “ Discussion
on Bone-grafting” (taken as read). January 22, 1919.
Section of Surgery
President—Sir John Bland-Sutton, F.B.C.S.
Carcinoma of the Appendix.'
By Joseph E. Adams, F.R.C.S.
Carcinoma of the appendix possesses a twofold interest in that it is
an nnusual manifestation of pathological change in an organ especially
prone to inflammatory disease, and that it may also throw some light
on the causation of an uncommon variety of intestinal cancer. Most
surgeons will agree as to the rarity of the condition, though some
American authors have stated that microscopical sections of large
numbers of appendices, examined as a routine practice, have proved its
occurrence in between 0'4 and 0'5 per cent, of the cases where operation
has been performed for attacks of appendicitis.
Deaver, 3 writing in 1914, states that the number of recorded cases
up to 1908 was 120, and he adds that with increasing microscopical
examination the condition has ceased to be a rarity. This may be so
in America, but in this country such cases are still far from common,
and 1 can only trace four in the last seventeen years at St. Thomas’s
Hospital, during which period over 7,000 appendicectomies must have
been performed. It is true that microscopical examination of the organ
is not undertaken as a routine practice, but such appendices do as a
rule present macroscopical abnormalities, and when these are noticed
the aid of a pathologist is usually invoked. One of these four cases
was classified as an endothelioma, but for purposes of description I
1 At a meeting of the Section, held May 7, 1919.
* John B. Deaver, “Appendicitis,” 1914.
AU— 41
38
Adams: Carcinoma of the Appendix
think other authors have included these among carcinomata, and this
is perhaps justified by the fact that the type which is most prevalent is
the spheroidal-celled—cancer occurring in young subjects, a large pro¬
portion even before puberty. I am indebted to Deaver’s work for many
of the following details:—
Age-incidence. —Fifty-four per cent, of Harte’s recorded cases were
under 30 years of age, the youngest being only 5. Obendorfer dis¬
covered this lesion in the appendix of a child only 7 days old. Numerous
cases have been recorded before puberty. Practically all these ap¬
pendices were removed for attacks diagnosed as appendicitis, and the
discovery of carcinoma was made by microscopical investigation.
Type of Cell .—The vast majority belong to the spheroidal, or to use
an American term, basal-celled, type of carcinoma. If columnar-celled
cancer is found, the average age is about 50. This observation accords
with thje incidence of columnar carcinoma in other parts of the
intestinal tract. The basal-celled growth is much less prone to produce
metastatic deposits. The growth is rarely large, and the classical type
is often located in the tip of the appendix (90 per cent, according to
MacCarty and McGrath). Other authors agree that 75 per cent, of
these growths occur in the distal half of the appendix. This condition
is slightly more common among females than males.
Deaver states that up to September, 1912, at the German Hospital,
Philadelphia, 6,327 appendices had been examined microscopically, and
sixteen instances of malignant neoplasm were found. This gives an
incidence of 0'25 per cent.
Malignancy .—This is a point of the greatest interest, and it is
stated that the majority of the cases are cured by appendicectomy alone.
This refers to what I have called the classical type—i.e., spheroidal-
celled carcinoma, occurring usually at the distal end and in young
subjects. It is characterized by slow growth, absence of early
metastases, and rarity of recurrence after removal. In this con¬
nexion it must be remembered that a certain proportion of endo-
theliomata have been included in the recorded cases, and these
characteristics apply essentially to this type of semi-malignant growth.
In those cases, occurring, like the common forms of intestinal
cancer, later in life the malignancy is that of ordinary columnar-
celled carcinoma.
The St. Thomas’s Hospital cases, all of which have been recorded
by my colleagues in the Lancet, I have endeavoured to trace in order
to ascertain the results of simple appendicectomy.
Section of Surgery
39
.Cullingworth and Corner 1 found a carcinomatous appendix at an
operation in 1901, and recorded it three years later, when the patient, a
woman aged 33, was perfectly well. This was a spheroidal-celled
carcinoma, and the patient had experienced two attacks of pain in the
right iliac fossa, in which a small solid tumour could be felt. Operation
revealed a fibromyoma of the right broad ligament, close to but not
connected with the uterus, with some adherent omentum, and an ap¬
pendix free from adhesions with a bulbous enlargement at the tip.
The lumen of the appendix was obliterated by this growth, which
was hard, but appeared caseous on section, and a suspicion of tuber¬
culosis was aroused. It was held that the fibromyoma rather than the
appendix was responsible for the symptoms and physical signs. Efforts
to trace this patient have been unsuccessful, so we can only include her
among the three year “ cures.”
In the same year, 1904, Battle 2 recorded a case, also in a female,
aged 14, in which the appendix was removed after six attacks occurring
at short intervals. No suspicion was entertained before operation that
the condition was other than chronic inflammation of the appendix,
but when removed it was thought to be tuberculous. There was a
bulbous tip, solid with growth, and a stricture in the lumen of the
appendix in its proximal half. Sections of this appendix conformed to
the spheroidal-celled type, and the growth showed 'an extreme degree of
invasion of the muscular coat. Correspondence with this patient has
elicited the satisfactory reply that she is now married and in perfect
health. She has one child, aged 5. Freedom from recurrence of
intestinal carcinoma after the lapse of fourteen years surely justifies
the use of the word “ cure.”
In 1905 Sargent 3 came across an appendix in an abscess due to what
was considered to be the first attack of appendicitis ; the appendix was
enlarged and caseous on section. A preliminary diagnosis of tubercle
was made here, but microscopical examination revealed the structure
of an endothelioma. The patient in this case was a girl, aged 12, and
she had been ill for nearly three weeks, with acute symptoms for fifty-
six hours before operation. There was a large inflammatory swelling
in the right iliac fossa, and the case was treated by incision and drainage
with immediate appendicectomy. Only the unusual appearance of the
1 Lancet , 1904, ii, p. 1340.
* “ Primary Carcinoma df the Vermiform Appendix,” Lancet , 1905, ii, p. 291.
* 44 Endothelioma of the Vermiform Appendix,” Lancet t 1905, ii, p. 889.
au —41a
42
Adams: Carcinoma of the Appendix
basal-celled tumours of Krompecher, of which multiple growths have been
recorded in the scalp. I know of four examples of primary carcinoma of the
vermiform appendix that have been detected microscopically in the routine
examination of appendices at St. George’s Hospital; the first published in 1900
had soon afterwards abdominal symptoms suggesting a recurrence, but the
patient was quite well in 1905.
The President, Sir John Bland-Sutton, F.R.C.S., delivered a
lecture entitled “Missiles as Emboli,” printed in extenso in the Lancet ,
May 10, 1919, p. 773 (with illustrations).
Section of Surgery
SUB-SECTION OF PROCTOLOGY.
President—Mr. F. Swinford Edwards, F.R.C.S.
Case of Complete Resection of the Large Bowel for
Multiple Adenomata . 1
By J. P. Lockhart-Mummery, F.R.C.S.
Patient, a young woman, aged 22. At the age of 16 she had begun
to suffer from diarrhoea with the passage of large quantities of blood
and mucus. She became very weak and anaemic. No treatment was
effectual in alleviating the condition, and she went on gradually getting
worse. In the early part of 1918 she came into St. Mark’s Hospital.
Examination with the sigmoidoscope showed numerous adenomata in
the rectum and sigmoid, the largest of which was about the size of a
walnut. They were very numerous and bled easily. The symptoms
pointed to there being adenomata throughout the large bowel.
Operation .—The abdomen was opened in the mid-line, and on
exploring the colon numerous large polypi could be felt as high up as
the caecum, and all through the transverse colon. The small intestine
was divided 6 in. from the caecum, and an end-to-side junction made
with the rectum. The whole of the large intestine was then removed
down to the point of union. The whole operation was done at one
sitting. The patient made a complete recovery, and has since been
earning her own living. Since the operation she has put on 2 st. in
weight, and the only inconvenience from which she suffers is that the
bowels act from three to four times a day, with semiformed stools. She
is also rather more thirsty than the ordinary individual.
1 At a meeting of the Section, held May 14, 1919.
44
Lookhart-Mummery : Case of Mega-colon
The specimen exhibited shows multiple adenomata of a simple
character throughout the entire large intestine.
Mr. IVOR Back : I am interested to see this ease, in which the colon has
been removed for a condition described as “ mega-colon,” a name which would
inclnde many disorders of the large bowel. I hope this case may provoke a
discussion upon (l) the indications for, and. (2) the technique of complete
colectomy. For example, is it a justifiable operation in a case of carcinoma
of the centre of the transverse colon ? It is certainly easier to perform than
an excision of the growth with end-to-end anastomosis of the colon in that
position; and it must surely diminish the liability to recurrence. Further,
is it indicated in cases of chronic intestinal stasis ? and if so to what degree
must the disease have advanced to justify it ?
Case of Mega-colon (Hirschsprung’s Disease).
By J. P. Lockhart-Mummery, F.R.C.S.
B. C., female, aged 26 ; has always been constipated. As a child she
frequently went three weeks without an action of the bowels. She has
had two children. During the last pregnancy the condition was much
aggravated, and at the time the child was born the bowels had not been
opened for two months. When admitted to hospital the patient’s
bowels had not been opened for twelve weeks in spite of aperients, and
she complained that during the last week or two she had suffered a good
deal of pain in the abdomen and back. Her general condition is good,
she does not feel ill, and she has not suffered from headaches. Lately
she has had a good deal of difficulty in passing urine. The abdomen is
enormously distended, about the size of an eight months’ pregnancy,
and well marked peristaltic waves can been seen through the abdominal
wall. The dilatation of the bowel appears to come right down to
the anus.
Case of Mega-colon (Hirschsprung’s Disease), with Secondary
Carcinoma.
By J. P. Lockhart-Mummery, F.R.C.S.
The patient is an ex-soldier, aged 54. According to his history the
bowels acted normally until seventeen years ago, when after an attack
of dysentery in Indid he began to suffer seriously from constipation.
Section of Surgery: Sub-section of Proctology 45
Since then the constipation has been very severe, and he has gone for
long periods without any action, and during these periods his abdomen
became tremendously distended. When admitted to hospital he had an
enormously distended abdomen with great waves of peristalsis passing
across it. Just within the anus there was an adeno-carcinoma which
appeared to be due to the irritation from the great weight of faecal
material above it. On exploring his abdomen I found that the dilatation
involved only the sigmoid flexure. This, however, occupied the entire
abdominal cavity, was over 6 in. in diameter, and its walls were
nearly £ in. thick. The dilatation extended right down to the anus,
and the rectum came right out to the pelvic walls all round.
Mr. LOCKHART-MUMMEBY (in reply to remarks made) : I think there can
be no doubt that a real muscle hypertrophy of the bowel wall is present
in these cases, and that most definite and powerful contraction can be
demonstrated. My own opinion is that the condition is due to some disease
of function, probably of the nature of reversed peristalsis in the affected
segment of bowel.
Case of Chronic X-ray Dermatitis of the Anal Region, excised
Eighteen Months ago.
By J. P. Lockhart-Mummery, F.R.C.S.
J. C., aged 48, was operated on at St. Thomas’s Hospital two years
ago for a fistula. He was subsequently treated for pruritus ani by
X-rays. Presumably he got a severe X-ray dermatitis which appears
to have been excised in the German Hospital about eighteen months
ago. There is now dense induration of the skin over the coccyx and
behind the anus with superficial cracks which refuse to heal.
Case showing Result of Resection of Rectum for Carcinoma.
By Percival P. Cole, F.R.C.S.
Patient, a male, aged 58. The abdomino-perineal operation was
performed on May 25, 1917. The patient was discharged from hospital
on July 19, 1917, and began work on August 1. He now complains of
pain in the lower sacral region. There is no evidence of recurrence.
46
Cole : Complete Prolapse of the Rectum
Two Cases illustrating the Result of Resection in Complete
Prolapse of the Rectum.
By Perciyal P. Cole, F.R.C.S.
(I) Patient, a male. From 6 in. to 8 in. of bowel became prolapsed
at the slightest strain. Two previous operations bad been performed
without in any way relieving the condition.
(II) The second patient, a female, is a case of a similar nature.
Case of Recurrence in the Posterior Vaginal Wall Three
Years after Abdomino-perineal Excision for Carcinoma
Recti.
By W. S. Handley, M.S. .
A. B., female, aged 46, was admitted to the Middlesex Hospital, in
February, 1916, for a growth on the anterior rectal wall. For two years
she had been troubled by prolapse of piles after defaecation, which she
used to reduce herself. Ever since this time she has had pain in the
rectum unaffected by defaecation. Examination under anaesthesia showed,
a firm nodular swelling, evidently a carcinoma, on the anterior rectal wall.
On February 17,1916, an abdomino-perineal excision of the rectum was
performed. Although the patient was a woman of frail physique, she
made a good recovery from the operation, and left the hospital on
March 22. She remained in good health, but on attending the hospital
for examination in November, 1918, a small recurrent nodule was found
in the posterior vaginal wall, opposite the point of origin of the primary
growth in the rectum. She was advised to come in immediately for its
removal, but for family reasons declined to do so. She was again seen
in March, 1919, and an ulcerated mass about li in. in diameter was now
found on the posterior vaginal wall. There were also some enlarged
glands in the inguinal region on hoth sides. About April 24 the re¬
current mass was excised and the vagina was restored by suture. A
50 mg. tube of radium was left in the post-vaginal tissues for twenty-
four hours. A few days later the glands in the groin were removed.
The patient is now convalescent.
Section of Surgery : Sub-section of Proctology 47
The case is shown because it is of interest to determine what
are the likely seats of recurrent growth after the abdomino-perineal
operation. It also illustrates the possibility of dealing operatively with
certain forms of recurrence after excision of the rectum.
Gunshot Wounds of the Great Bowel and Rectum.
By Arthur Keith, M.D., F.R.C.S., F.R.S.
Professor Arthur Keith exhibited a series of preparations, from
the War Office Collection of Pathological Specimens, illustrating wounds
of the great bowel and rectum, and a series of macerated pelves showing
the nature of the bone injuries which accompany wounds of the pelvic
viscera. A review of the histories relating to these specimens led him
to infer that injury and infection of the pelvic subperitoneal tissue were
just as fatal as penetration of the peritoneum and laceration of the
bowel. A study of the pelvic specimens also showed the widespread
effects of modern missiles of high velocity. In one case in which a
bullet passed through the pelvis from side to side, merely grazing the
margin of the ischium, the force of the missile had been so diffused
that the sacrum was broken transversely at the level of its third
vertebra, while in front the pubic ramus was broken on both sides.
In such cases the pelvic viscera were bruised and the subperitoneal
tissue pervaded by effused blood. An appendix was shown—the sole
viscus to be injured in a case in which the missile had entered the
abdominal cavity.
Sir GORDON Watson, C.M.G.: There is no doubt that as Professor Keith
surmises, injuries in this region are frequently followed by infection of
the pelvic cellular tissue and are then extremely fatal. For this reason,
quite early in the war, many of us realized that it was advisable to perform
colostomy for practically all wounds of the rectum irrespective of their severity.
The high mortality of rectal wounds was largely due to the fact that they were
complicated by wounds involving either the bony pelvic wall, the bladder,
the intestines, buttocks, hip joints, &c. It is convenient to classify wounds
of the rectum into intra- and extraperitoneal, but the combination of the
two is not infrequent. The treatment of these cases often presents great
difficulties. Small intraperitoneal wounds can sometimes be sutured, but even
when this is possible, colostomy is advisable. Large lacerated wounds are
more commonly met with. They are usually associated with perforations of
the small intestine and extensive injury to the pelvic wall. A long operation
48 Keith : Gunshot Wounds of Great Bowel and Rectum
becomes necessary in order to excise all damaged tissues, perform colostomy,
and pack and drain the pelvis. The mortality in these cases is so high that in
some instances an abdomino-perineal excision has been performed in the hope
of preventing acute sepsis. Major Gordon Taylor performed this operation
twice. In one case the patient did well for nine days, but unfortunately lost
his life under an anaesthetic given to dress the wound. The cases are so
desperate that such heroic measures are often justifiable. As regards colostomy,
it is often advisable, and indeed necessary, to perform transverse colostomy
because of damage to, or effusion of blood into, the pelvic mesocolon. The
purely extraperitoneal wounds require very free excision of soft parts, and very
liberal drainage of the damaged bowel, in addition to colostomy. In a few
favourable cases colostomy can be delayed and only be made use of as a
secondary operation if the primary operation of free excision and drainage does
not meet the situation. Occasionally in extraperitoneal wounds involving the
posterior part of the rectum, delayed primary suture has produced a satisfactory
result without colostomy. Whenever this line of treatment is contemplated,
a large tube should be passed through the sphincter. Through and through
wounds of the buttock usually call for free excision and are often suitable for
delayed primary suture. Some of these cases are complicated by injury to the
rectum, and unless this is recognized, the treatment of the buttock wound
will fail. Perineal wounds involving the anal canal without peritoneal injury
should be treated like fistulas by free excision and division of the sphincter.
In a previous communication to this Section I referred to the remarkable
explosive effect which may be produced by a bullet passing across the
perinaeum deep to the surface. The skin around the anal margin may
be completely torn from the margin of the sphincter round the entire
circumference, and the sphincter is then drawn upwards so that at first
sight it appears as if the lower part of the anal canal had been shot away.
I have seen several of these cases and they closely resemble one another.
PROCEEDINGS
EDITED BY
Sir JOHN Y. W. MacALISTER
UNHEH ran ,,,
THE EDITORIAL COMMITTEE
VOLUME THE TWELFTH
SESSION
SECTION OF THERAPEUTICS & ' PHARMA-COLOGA:
L 0 N t> O N
LONGMANS, OREEN k' CO., I'ATORNOSTER LOW
isis
Section of {Therapeutics ano pbarmacoloe\>
OFFICERS FOR THE SESSION 1918-19.
President —
W. Half. White, M.D.
Vice - Presid ents-
Robert Capes.
A. R. CtJSHNT, M.D., F.R.S.
H. H. Dale, M.D., F.R.S.
W. E. Dixon, M.D., F.R.S.
J. Gray Duncanson, M.B.
Harrington Sainsbury, M.D.
Ralph Stockman, M.D.
F. Parke s Weber, M.D.
R. B. Wild, M.D.
Hon. Secretaries —
W. Langdon Brown, M.D. Philip Hamill, M.D.
Other Members of Council —
William Bain, M.D.
A. J. Clark, M.D.
Douglas Cow, M.D.
George Graham, M.D.
Donald Hall, M.D.
P. P. Laiplaw, M.D.
R. W. Leftwich, M.D. (the late).
O. F. F. Leyton, M.D.
Walter Malden, M.D.
F. Ransom, M.D.
Representative on Library Committee —
J. Gray Duncanson, M.B.
Representative on Editorial Committee —
H. H. Dale, M.D., F.R.S.
SECTION OF THERAPEUTICS AND
PHARMACOLOGY.
CONTENTS.
April 15, 1919-
E. A. Bossan, M.D., and A. Balvay, M.D. page
A New Specific Antituberculous Medicament ... ... ... 1
The Society does not hold itself in any way responsible for the statements made or
the views put forward in the various papers.
London :
John Bale, Sons and Danielsson, Ltd.,
Oxford House,
Great Titchfield Street, Oxford Street, W. 1.
Section of fCberapcuttce ant> pbarmacoloo^.
President—Sir William Hale-White, K.B.E., M.D.
A New Specific Antituberculous Medicament.'
By E. A. Bossan, M.D., and A. Balvay, M.D.
The waxy envelope of the tubercle bacillus is an evident means of
protection to the bacillus. Experiment shows that the acid-fast bacilli
are neither reabsorbed nor destroyed by the phagocytes [1]. The
phagocyte disseminates the bacillus in the organism, but never destroys
it. Besistance to tuberculous infection is, therefore, the greater accord¬
ing as the blood contains a larger quantity of lipolytic ferments.
Carriere [3] and Clerc [2] have carried out interesting researches
dealing with the richness in lipase of the serums of many animals.
Carri&re [3] shows that the serum of the guinea-pig, the extreme
susceptibility of which to tuberculosis is well known, contains the
smallest quantity of this lipase.
Metalnikoff [4] proved that the mite attacking beehives is quite
refractory to the action of tuberculosis because of the very great lipolytic
power of its serum.
Noel Fiessinger and P. L. Marie [5], who repeated the experiments
of Metalnikoff, insist on the fact that the waxy or fatty envelope of the
tubercle bacillus is a true envelope of protection; the organism must,
therefore, lipolyse and then bacteriolyse those bacilli in order to defend
itself against penetration by microbes. The lipase “ sensitizes,” as we
may say, the tubercle bacillus by destroying its waxy envelope [6].
Those animals, the lipase of which is particularly active, phagocytose
and destroy the injected tuberculous bacilli very quickly. These authors
consider the lipase of the mite to be the cause of its immunity.
au —42
At a meeting of the Section, held April 15,1919.
2 Bossan and Balvay: New Antituberculous Medicament
E. Schulz [7], then one of us [8] mentioned by Grasset [9] state
that in the case of tuberculous subjects, whose defensive reaction is
sufficient, the bacilli which can be stained by Ziehl’s method become
fewer in number, and are replaced by the lipolysed granulous forms.
Therefore, “ we think that the increase of the local lipasic activity con¬
stitutes one of the most important means of defence for the tuberculous
lung” [10].
Metalnikoff [4], Deycke and Much [11], have isolated the bacillary
waxes by chemical means, and have tried, by dissolving them in oils
(nastin, tuberculo-nastin dissolved in olive oil) to manufacture a vaccine
which produces the appearance of that specific lipase.
Deycke [11], Citron, and Muller [12], showed that the injection of
the wax of the tubercle bacillus produced some lipolytic antibodies in
the bodily organism. But these authors could do no more than obtain
insufficient results in the treatment of tuberculosis.
But, as Metalnikoff rightly said [13], the tubercle bacillus wax,
though as in the case of the tuberculin, endowed with certain immuniz¬
ing powers, is quite unable, of itself, to confer perfect immunity.
In order, therefore, to confer that immunity, or at least to combat the
invasion by the bacillus successfully, we must immunize with the sum
total -of toxic substances contained both in the bacillus itself, in its waxy
envelope and in the medium in which it lives.
The organism must be able, not only to neutralize the toxins but
also to bacteriolyse the tubercle bacilli by first destroying their waxy
protective envelopes, that is by lipolysing them, thus making it possible
for them to be easily reabsorbed or destroyed by the phagocytes.
For many years we have done our best to fulfil those indications,
and to find out the way to extract directly from the tubercle bacilli, the
waxes and the substances that naturally adhere to those waxes [14]
without transforming them or destroying them by manipulation, or
by treatment with acids, ethers, chloroforms, xylol, heat, &c., which
neutralize the greater part of their antigenic powers.
Belying on the work of Professor A. Borrel, of the Pasteur Institute
(whose valuable and kindly help we gratefully acknowledge here) with
reference to the dissolution of waxes of the tubercle bacillus in oils
and animal fats [15] we have discovered a method which will not in
any way alter the treated bacilli that may afterwards be shown to be
alive by their culture in glycerinated bouillon. We, therefore, absolutely
respect the constitution of our antigen, thus preserving its powers in
the highest degree.
Section of Therapeutics and Pharmacology
3
Oar specific medicament contains, therefore, the bacillary waxes and
all that may be dissolved by that process out of the toxins and the
bacillary substances contained in the bacillus itself. Their presence is
proved by the local and general reactions which follow the subcutaneous
injections.
Waxes being, as Mac4 says [16], “the impregnated substrates of
true active products of tubercle bacilli,” their dissolution in our medium
and by our process, which does not alter them directly, embodies them
in the medicament. Our medicament is then really specific because it
both contains and sets in action the sum total of active principles. By
means of its use, we induce the organism to produce antibodies in
quantity and quality necessary and sufficient for preservation as a
therapeutic agent of a preceding infection.
The experiments carried out on animals have proved to us the
innocuousness of that product and the power acquired by the blood of
treated animals to lipolyse and to bacteriolyse the tubercle bacilli
in vitro [17]. In our first experiments we did our best to obtain a
vaccine producing only very little or better still, no local or general
reaction; this vaccine may be administered subcutaneously or intra¬
venously. We shall refer to this at a future date in a fresh series of
studies yet to be published relating to the preventive vaccination of
bovine animals; these studies and experiments appear, so far, to
have yielded excellent and encouraging results. But, being aware of
the difficulty of the passage of antibodies through the fibrous and not
very vascular strata that surround tubercular lesions, a difficulty which
Wright and Sahli have already emphasized, we carried out a fresh series
of experiments and endeavoured to inject our medicament directly at
the level of the tubercular lesions themselves, that is to say, in the
case of pulmonary tuberculosis we made the injections by the intra¬
tracheal route. We have been encouraged in our researches by the
works of La Jarrige [18], mentioning the experiments of C. Bernard,
the thesis of Delor [19], Guisez and Stodel [20], G. Rosenthal [21],
Berthelon [22].
One of us (Balvay), who introduced Forlanini’s method into France
[23], benefiting by that author’s great experience in the treatment of
cases of pulmonary tuberculosis, applied that method in the exhibition
of our specific medicament. He obtained positive results; the proof of
which is supplied by observations hereafter to be mentioned.
First of all, we made sure of the penetration of our medicament
into a healthy and into a tuberculous lung. We were then enabled to
4 Bossan and Balvay: New Antituberculous Medicament
demonstrate [24] with the assistance of our friend, Dr. Guieysse,
professor of histology, that not only are the fatty bodies which compose
it, the presence of which is easily made evident by the osmic acid,
found throughout the whole extent of the lung, but that they also
penetrate into the tubercular tissue.
(Section of the lungs of a tuberculous rabbit killed twenty-four
hours after an intratracheal injection of $ c.c. of medicament were
shown.)
We do not think there is any need to insist on the importance of
such a statement from the therapeutical standpoint. In the face of such
results, and with a view to making the injection by the intratracheal
route, which has been proved to be without danger in experiments on
tuberculous animals, we have modified the composition of our medica¬
ment, chiefly by increasing the quantity of waxes and toxins contained
in it. We have noticed that the subcutaneous injection of 1 c.c. has
always brought about general and local reactions (erythema, nodules,
distinct elevation of temperature); such reactions may supervene
after the first or after the third or fourth injection; this was shown
long ago to be the case by Levene [25]. On the contrary, when
subjects of pulmonary tuberculosis are treated by intratracheal injections,
we have never noticed any reaction no matter how great the dose
injected.
We must, therefore, seek to discover whether the vaccine is not
modified at the level of the broncho-pulmonary mucous membranes, or
whether the antibodies produced by the vaccine at the level of the
lesions themselves are immediately taken up by the antigens, and the
reaction fails to take place merely because they are not utilized. Rely¬
ing on that hypothesis, we injected 1 or 2 c.c. of our vaccine into the
trachea of six patients suffering from surgical tuberculosis, but whose
lungs were healthy. In each case the elevation of temperature was the
same as that which follows subcutaneous injections The reaction has
always been positive (Balvay, Godlewsky, Bouis). It was evident there¬
fore (1) that the vaccine did not undergo any modification at the level of
the broncho-pulmonary mucous membrane ; (2) that when the antibodies
produced in situ were immediately taken up by or fixed on the antigens
there was no reaction. The practical deduction is that the vaccine must
be injected directly to the level of the lesions. The method is applic¬
able also in the case of surgical tuberculosis. Breslauer [26] appears
to have had some idea of the application of this method.
These facts will perhaps enable us to supply the explanation long
Section of Therapeutics and Pharmacology
5
sought for, as to the absence of reaction when tuberculin is injected into
a healthy animal. We think this absence of reaction in healthy animals
can be explained by the fact that according to well established evidence
the healthy organism never produces tuberculous antibodies. The anti¬
bodies produced in a tuberculous person far from the lesions and, in
consequence, not immediately utilized, would be, on the contrary, the
cause of these reactions. Our experiments dealing with that question
will soon be published.
As many as eighty patients suffering from pulmonary tuberculosis
have been treated for more than thirteen months by intratracheal
injections of our specific medicament; their ages vary from 17 to 47.
We treated patients suffering from various lesions (fibrous cases,
exhibiting recent evolution of the lesions, fibro-caseous, caseous, those
in the cavity stage ; all of them with open lesions, and most of them in
the febrile stage). The result of treatment has shown that our specific
medicament produces its maximum effect in patients whose lesions are
entirely tuberculous and whose expectoration is very small. Hence the
necessity for getting rid of the microbic associations and of lessening, as
much as possible, the expectoration of certain patients. That result has
been obtained by the method of intratracheal injections of gomenol oil
at 5 per cent. In the case of patients whose expectorations are
abundant, we daily inject into their trachea 5, 10, or 20 c.c. of gomenol
oil. Those injections are made under the control of the laryngeal mirror,
and have never given rise to the least accident. During the days fol¬
lowing the first injections they usually set up an abundant expectora¬
tion, which diminishes rapidly in quantity until, after two or three
weeks of treatment, it ceases. That period of intratracheal injections
in reality constitutes a period of pulmonary cleansing.
Serial examinations of the sputum of these tuberculous persons
prove that the bacilli have first a tendency to lessen in number,
afterwards that their number diminishes but very little, and that the
bacilli never disappear entirely from the expectoration. When the
expectoration is greatly reduced, no matter whether the result has been
obtained by intratracheal, injections or by the fact of the sputum not
being originally abundant, we commence the intratracheal treatment
by our vaccine. Each patient is daily injected intratracheally with 2
or 4 c.c. of the medicament.
The observations noticed after those injections are the following :
Progressive diminution of the temperature, a better general stat4 of
health, regular increase of weight, and upon auscultation, a tendency
of the pulmonary lesions to a fibrous transformation.
6 Bossan and Balvay: New Antituberculous Medicament
The most striking result of these injections is that they are followed
by constant modifications supervening in the morphology and the number
of the bacilli of patients treated in that way. They consist in the fact
that nearly all the bacilli are lipolysed and bacteriolysed, and in the
usual and .transitory increase in the number of bacilli without any
increase in the expectoration.
Those modifications and that elimination are very quickly followed
by the disappearance of bacilli from the sputum.
The first modifications usually make their appearance after the third
week, and the disappearance of bacilli after six weeks or three months
of treatment.
Conclusions.
(1) In pulmonary tuberculosis our specific medicament must be
brought up to the level of the pulmonary lesions, into which we have
proved that it penetrates. That result is obtained by the method of
intratracheal injections. In the case of abundant expectorations,
preliminary cleansing of the lung is necessary.
(2) When introduced by the intratracheal route, the specific medica¬
ment seems to act very satisfactorily on the temperature, on the general
condition, the weight, and on the lungs. Invariably it produces changes
in the morphology of the tubercle bacilli (lipolysis and bacteriolysis), a
transitory increase in their number, and, after that, their elimination;
that is, the disappearance of the bacilli from the sputum after a treat¬
ment of from one to three months. This last stated fact indicates
the important part played by the medicament in the social struggle
against pulmonary tuberculosis.
(3) Its employment has never given rise to the slightest untoward
symptom. We would specially call attention to the fact that we have
had the opportunity of following the case histories of a certain number
of our patients for more than ten months. In all cases, the good
results noticed when they left the hospital have been maintained,
although they have started work again, and sometimes very hard work.
These results are recorded down to October, 1918. It is our intention
shortly to furnish a further account, with notes of observations, on many
other cases equally demonstrative of the value of our method of
treatment.
Section of Therapeutics and Pharmacology
7
REFERENCES.
[1] Boer el, A. “Bacilles tuberculeux et para-tuberculeux,” Bull. de VInst. Pasteur,
1904, ii, pp. 409, 457, 505.
[2] Clerc. “Contribution k l’etude de quelques ferments solublas,” These de Par., 1902.
[3] Carriers, C. R. Soc. de Biol ., 1899, ii, s4r. 1, p. 989.
[4] Metalnikoff. “ Contribution a l’£tude de Pimmunit^ contre 1’infection tuberculeuse,”
Arch, des Sci. Biol, de Petersbourg , 1907, xxiii, No. 2, November, et xii, Nos. 4 et 5.
[5] Fiessinger, Noel, et Marie, P. L. “ Les ferments digestifs des Leucocytes,” Par.,
1910, p. 134.
[6] Gilbert et Weinberg. “Traite du Sang,” 1913, p. 321.
[7] Schulz, E. “ Ueber die granulare Form des Tuberkulosevirus im Lungenauswurf,”
Deutsch. med. Wochenschr., 1909, xxxv, p. 1569.
[8] Bossan, E. A. “ Immunoth£rapie antituberculeuse,” Gaz. des H6p,, 1911, Ixxxiv,
pp. 123, 137.
[9] Gra8Set. “ Therapeutique gen6rale fondee sur la Phisio-pathologie,” p. 191.
{10] Fiessinger, Noel, et Marie, P. L. Loo. cit., p. 133.
[11] Deycke und Much. Milnch. med. Wochenschr ., 1909, lvi, p. 1885 ; 1913, lx, pp. 119-
190.
[12] MOller. “Ueber des antigenen Charakter des Tuberkelbazillenfette,” Wien. klin.
Wochenschr., 1917, No. 44.
[13] Metalnikoff. Loc. cit.
[14] Leber und Steinharter. Milnch. med. Wochenschr ., 1908, lv, p. 1324. Kleinsghmidt,
Berl. klin . Wochenschr ., 1910, xlvii, p. 59. Auclair, “Etude exp^rimentale sur le
poison du bacille tuberculeux humain,” Thise de Par., 1897, et Arch. de mid. experi¬
mental , 1897, ix, p. 1124. Auclair, “Les poisons du bacille tuberculeux humain :
la degenerescence casSeuse,” Rev. de la tuberculose , 1898, vi, p. 97. Auclair,
“Les poisons du bacille tuberculeux humain,” Arch, de mid. expir., 1899, xii,
p. 189.
[15] Borrel, A. Loc. cit.
[16] Mace. “ Traite pratique de Bact6riologie, ” i, p. 709.
[17] Bossan, E. A. ' “ Lipolyse et bacteriolyse du bacille tuberculeux,” Progres med., 1918,
March 23.
[18] La Jarrige. “Des injections intrapulmonaires,” Compt. rend, de la Soc. de Biol.,
1893, s£r. 9, v, p. 191.
[ 19] Delor. Thlse de Lyon.
[20] Guisez et Stodel. Compt. rend, de la Soc. de Biol., 1912, lxxii, p. 457.
[21] Rosenthal, G. “ L’injection intratracheale vraie ” (Consult, med. francaises), Poissat,
6diteur.
[22] Bebthelon. Province mid., July 20, 1912.
[23] Balvay et Arcelin. Congr^s pour PAvancement des Sciences,” Lille, August, 1909 ;
Soc. de mid. de Lyon, November 20, 1911.
[24] Bossan, E. A., et Guieysse. Compt. rend. Soc. de Biol., 22 f6vrier, 1919.
[25] Lbvene. “Bio-chemistrv of the Bacillus tuberculosis ,” Jonrn. of Med. Research ,
1904, xii, p. 256.
[26] Bre8Lauer. “ Die intravenose methode des localen Behandlung entzundlichen Pro-
zesse,” Centralbl. f. Chir., Leipz., 1918, xlv, p. 277.
8 Bossan and Balvay: Neiv Antituberculous Medicament
DISCUSSION.
Dr. Halliday Sutherland : The interest of the paper, to which we have
listened, is mostly a speculative interest, because the composition of the
medicament, for which considerable claims have been made, has not been
announced. It is claimed that the remedy is absorbed into diseased areas of
the lung, but I am bound to say that the photographs passed round fail to
demonstrate that assertion. In these photographs of sections of a tuberculous
lung, we see irregular masses of an oily substance, stained black with osmic
acid. Now if the medicament were absorbed, either by osmosis or by phago¬
cytosis into the diseased tissues, it ought to be evenly distributed and finely
subdivided. In reality it is not even within the pulmonary tissues, but lies
within the lumen of these bronchi or bronchioles which are not occluded by
disease. The same appearance could be reproduced by the intratracheal
injection of any vegetable or animal oil or fat. It is also claimed that the
remedy contains a portion of the waxy envelope of the tubercle bacillus in
solution. If that be so, the preparation of this substance marks a most
extraordinary advance in bacteriological chemistry. The exhaustive researches
of Bullock proved the difficulty of finding a suitable solvent for the protective
envelope of the tubercle bacilli. For my own part I have boiled tubercle
bacilli for six weeks continuously in chloroform, without obtaining complete
solution of the wax. On the other hand, we do know that tubercle bacilli can
be grown in oil, and presumably the oil in which they are grown will contain
some of the exotoxins. In an oily medium the bacilli revert to the strepto-
thrix form, and possibly the composition of the exotoxins might also undergo
alteration. If that be the nature of the medicament, as I speculate it may be,
then the results could be explained without difficulty. The patient's nutrition
would benefit by the absorption of a certain amount of a nutritive oil from the
respiratory tract; and his resistance would be increased by a reaction to the
tuberculin contained in the oil. I have used tuberculin for the past thirteen
years, and I still hold it to be our most valuable adjunct to general
treatment, when properly administered. That was also the view of Trudeau,
and is to-day the opinion of those who have used tuberculin most extensively.
So far as the medicament is concerned, all I have said is perforce sheer guess¬
ing, but if the guess be right then I think as good results could probably be
obtained by giving cod liver oil by the mouth, and tuberculin subcutaneously.
If it be an oil containing tuberculin, then intratracheal injection is a very crude
method of judging dosage, as this would depend on the absorbing power of
diseased tissue. Moreover, intratracheal injections, unless absolutely necessary,
are not advisable, as they certainly do not add to the patient’s comfort. In
conclusion, may I ask Dr. Bossan, who comes from a school to which we are
all indebted for much clinical inspiration, to forgive the critical nature of my
remarks, which are of necessity, speculative, and may I also support the
request from the chair that we might have more exact information about this
very interesting therapeutic experiment.
SmajJ cavity twenty-four boor* Hirer Ir.jMion. The »\h]^ avs to he
with the VitoeVui* mljK’od l y the cmmicr acid.
Fig. i. ;
Tubercular ooduiy t\v«iiiy-loiir ticfufs after injection. The vacant* Uj ho
reduced by the oetmc acid which has penetrated mif> the^nodule.
W~ 4 ( 2 a
Section of Therapeu tics ' and Pharmacoku/y 9
.
Dr. Boss AH. (in reply): UJ Thft f 3 mpaVution of the vaccine is not a secret.
It is common knowledge that wweW f&t substances and oils in cqinhi'rmfiee.
are mutually dissolve*!. iVoi>s*or .Furred..stated in ins puper, already quoted
from, that the waxes vd fluv tulw^fe- bacillus are dissolved in oils apd
animal fats. This fact is easily pr<vwd by, the loss of acid*fastness in the
treated bacilli. To prepare the vaccine* place the bacilli in well sterilized,
castor oil or poppy oil or olive bib. and; leave iho emulsion thirty days in the
incubator. Then filter .’it'Through a porcelain filter and the vaccine is ready
for use. Great care must be taken to prevent the access of any source of
cofttamin&tion. ( 2 ) it easy: to sec; from the photographs that the masses
K f
10 Bossan and Balvay : New Antituberculous Medicament
of oil are within the pulmonary tissues, some of them even in the epithelial
cells. And this will be still better seen from the examination of preparations
under the microscope. With the aid of my friend, Dr. Guieysse, I shall
shortly be enabled to demonstrate to the Fellows microscopic preparations
showing cells full of oily granulations. (3) The intratracheal injections are
easily carried out and well tolerated by the patients. (4) I must again repeat
that the administration of tuberculin alone is not sufficient, and that “in order
to confer perfect immunity, or at least to combat the invasion by the bacillus
successfully, we must immunize with the sum total of toxic substances con¬
tained both in the bacillus itself, in its waxy envelope and in the medium in
which it lives.”
proceedings of tbe TRo^al Society of medicine
SUPPLEMENT
(Vol. XII, No. 1 , November, 1918).
NOTES ON BOOKS.
[The purpose of these “Notes” is neither to praise nor to blame , but merely to drov
attention to some of the new books and new editions which have been added to the
Society's Library .— Ed.]
The Systematic Treatment op Gonorrhoea. By N. P. L. 'Lumb, Temporary Captain
JtA.M.C. Pp. viii -f 119. Price 4s. 6d. net. London : H. K. Lewis and Co., Ltd.,
1918.
In this book, which was inspired by the official campaign against venereal disease, the
author describes in clear language the course, symptoms, pathology and bacteriology of
gonorrhoea, and the routine examination necessary in every case of the disease. Concise
details are then given of the various complications of gonorrhoea, and the treatment—routine
and special (vaccine, electro-chemical, and*by mercury compounds). The last chapter is
devoted to the consideration of the gonorrhoea patient, his aspect of the disease, what pre¬
cautions should be observed, and various other points, including tbe methods of examination
which are necessary in order to ascertain when the patient can be pronounced cured.
Minor Maladies and their Treatment. By Leonard Wir liams, M.I). Fourth edition.
Pp. xi -f 402. Price 7s. 6d. net. London : Bailli^re, Tindall and Cox, 1918.
Under the present system of medical education the student has a natural tendency to
concentrate his mind on those organic diseases which are likely to form tbe basis of exam
ination questions. As a rosult when ho commences general practice he is apt to be discon¬
certingly ignorant of the proper treatment of the slighter ailments which will probably
constitute the bulk of his daily work—hence the importance of books such as the one under
review. In this, the fourth edition, tbe author has made considerable alterations. Among
others, the section on Constipation has been entirely re-written, the chapter on Change o
Air has been replaced by one on Minor Glandular Insufficiencies, and a short chapter on
Old Age has beeti added. The author rightly believes that, by the study of the whole field
of the internal secretions, we shall be able to detect and correct morbid tendencies far more
successfully than we have been able to do by means of the older methods. The book treats
of several points which are not usually emphasized in the larger text-books. It is written
in conversational style, the type is clear, and there is a comprehensive index.
N—7
o
A Handbook on Antiseptics. By Henry Drysdale Dakin, D.Sc., F.I.C., F.R.S., and
Edward Kellogg Dunham, M.D., Major M.O.R.C., U.S. Army. Pp. ix -f 129.
Price $1.25. New York : The Macmillan Co., 1917.
This handbook is intended for those who are concerned with the care of the wounded.
It gives a concise account of the methods of preparation and use of various new antiseptics
and modifications of old ones, which have been put to the test during the past four years
of the war. Although the authors disclaim any endeavour 41 to make a complete compen¬
dium of the innumerable antiseptics and disinfectants that have been proposed from time
to time,” there are few antiseptics of any note which are not commented upon. In
Chapter I are given a classification of antiseptics, the laws of disinfection, the influence of
media, the choice of antiseptics, and the modes of application. In the last chapter certain
special applications of antiseptics are described: the disinfection of carriers, the disinfection
of water, and the disinfection of hospital ships, &c., with electrolytic hypochlorite:
Aids to Rational Therapeutics, with U.S. A. Pharmacopoeia Equivalents. By Ralph
Winnington Leftwich, M.D., C.M., M.R.C.S.Eng. Pp. x + 233. Price 3s. Gd. net.
London : Bailliere, Tindall and Cox, 1918.
In the usual handbooks on treatment, diseases are, for the purpose of therapeutical
indications, either arranged alphabetically or according to the organ affected. In this book
the author has grouped together, without regard to the organ affected, diseases requiring
similar treatment, and diseases which are of allied pathology. On this double basis the
author has divided diseases into forty groups ; diseases which could not be so classified are
dealt with separately. The treatment common to each particular group is given, and is
supplemented by that treatment which is special to each member of the group where
modification is required. There are chapters on convalescent treatment and on doses. In
an appendix hints are given for students and for those newly qualified. The author is an
enthusiastic advocate of mental labour-saving. He has grouped diseases and methods of
treatment, and advocates the grouping of doses of drugs on a basis of uniformity. If he
could achieve the latter object he would earn the gratitude of every hard-working practi¬
tioner. In the British Pharmacopoeia there are only twenty-five liquors, but they have
sixteen different doses!
Clinical Disorders of the Heart Beat : a Handbook, for Practitioners and Students.
By Thomas Lewis* M.D., D.Sc., F.R.C.P. Fourth edition. Pp. xii -f 120. Price
6s. net. London : Shaw and Sons, 1918.
This edition follows the main lines of the three previous ones. It is compact and easier
to read than the larger works by the same author. Stress is again rightly laid on the fact
that recent knowledge of the heart and of its affections has been gathered largely by precise
graphic methods which have reformed our conceptions of cardiology, and Dr. Lewis has
incorporated the new information gathered from inquiry into the clinical histories of patients
and as to bedside methods, together with relatively simple tests by which the common
disorders of the heart may be recognized. The text has been revised and the graphic records
confined almost to such as illustrate what may be seen and felt. Hence those in active
practice can assess the value of subjective signs and symptoms on the part of their patients,
in the light of the most modern laboratory methods : the results of which are ably condensed
within the compass of this small volume.
Symptoms and their Interpretation. By Sir James Mackenzie, M.D., F.R.S., LL.D.Aberd.
and Edin., F.R.C.P., F.R.C.P.I. Third edition. Pp. xx -f 318. Price 8s. 6d. net.
London : Shaw and Sons, 1918.
In addition to various emendations in the text, the third edition of Sir James Mackenzie’s
book on “Symptoms” includes two new appendices. One is intended to demonstrate what
a great field of research lies ready to the hand of the surgeon, if he would use his oppor-
3
tunities ; the other gives some suggestions, the outcome of the author’s personal experience,
as to research in medicine. It is pointed out that investigation of the meaning of subjective
symptoms as a study of the earliest stages of disease offers a field for exploration unlimited
in extent. The various editions of this book, which has been translated into other languages,
afford indications that it is sought after by the growing number of those who strive after
precision in clinical methods.
The Life of Sophia Jkx-Blakk. By Margaret Todd, M.D. (Graham Travers). With
four full page portraits ; pp. xx + 574. Price 18s. net. London : Macmillan and Co.,
Ltd., 1918.
This is the life story, sympathetically told, of the “lion-hearted pioneer,” by whose
efforts and self-sacrifice the admission of women to the profession of medicine in this country
was in the main made possible. Sophia Jex-Blake plunged into medical affairs by acting,
quite suddenly, in 1866, as dispenser, general secretary, and “chaplain, with discretionary
powers,” to the hospital in Boston, U.S.A., whither she had gone on a tour of inspection of
women’s work. Here her friend, Dr. Lucy Sewall, was resident physician. She speedily
found herself “ getting desperately in love with medicine as a science and as an art.” Blessed
with natural gifts of persuasive oratory and an excellent memory, she shone as much upon
public platforms as when presiding at her own dinner-table. That she also possessed no
mean literary ability at this time is shown by the manner in which her book “ A Visit to
some American Schools and Colleges ” was received. She was enrolled as a medical student
and devoted herself to her medical pursuits, studying anatomy in New York under Dr.
Elizabeth Blackwell. The death of her father compelled her to forego her prospects in
America and to,live with her mother in Brighton. But she was destined, henceforth, to
seek out a means of medical education in this country. After having knocked in vain at the
portals of the University of Cambridge, she set to work to beard the professors of the Medical
Faculty at Edinburgh University. Her petition having passed this obstacle successfully in
due course, she was bitterly disappointed to learn that the judgment had been reversed by
the University Court. Unmoved by this decision she resolved to lodge a formal petition
with the latter body for the admission of women to the study of medicine in separate classes.
To the ultimate triumph of her cause the petition was granted and sanctioned by the Chan¬
cellor on November 12. 1869. Practical difficulties soon cropped up with regard to the mixed
classes which were inaugurated later, and opposition on technical grounds became so con¬
siderable that it threatened to imperil the whole women’s movement. The riot at Surgeon’s
Hall terminated in an action for libel brought against Miss Jex-Blake by Professor Christi-
son’s assistant, resulting in one farthing damage, but she had to pay in costs a bill of some
£900. This sum was gladly subscribed by friends and sympathizers. Another blow, in the
shape of the rescinding by the Senatus of the University of Edinburgh of the regulations for
the admission of women to the University, would have discouraged any but the stoutest
heart. Nothing baffled, we find Miss Jex-Blake instituting an Action of Declarator against
the Senatus to define the position of women, which terminated in the famous judgement of
Lord Gifford whereby the full rights of the women were vindicated, and the original enactment
of the University Court was found to be valid and binding in every respect. Other worries
crowded in upon her, not the least of which was the appeal of the University to the Inner
House against the Gifford judgement, with the scarcely surprising result that she failed in
her first professional examination t The battle was ended in Edinburgh by the reversal of
the Gifford judgement on appeal in 1873. In the following year the Cowper-Temple Bill was
introduced into Parliament “to remove doubts as to the powers of the Universities of
Scotland to admit women as students, aud to grant degrees to women,” but the que*tion
was shelved for a while. The opening, on October 12, 1874, of the London School of
Medicine for Women at 30, Handel Street, which she waa instrumental in founding, marked
a new epoch in the struggle. In 1876 the Russell Gurney Enabling Bill became law, and in
the same year Miss Jex-Blake qualified as M.D.Berne, and was placed upon the Register
through the portals of the Irish Colleges. Two years later the University of London
admitted women to all its degrees, and the Royal Free Hospital was thrown open to women.
N— la
4
Miss Jex-Blake practised in Edinburgh for twenty-one years, and by adding a few beds to
her Dispensary the nucleus of the Edinburgh Hospital for Women and Children was farmed,
ft was a source of much gratification to her that, in 1885, the Conjoint Colleges of Edinburgh
threw open their examinations to women, but it was not until 1891 that the University
followed suit. In her years of retirement at Windydene. the Sussex Mecca for young medical
women, Dr. Jex-Blake continued to exercise her ennobling influence upon all those with
whom sbe was brought into contact. The end came suddenly, but peacefully, on January 7,
1912. A family pedigree and some letters to the Times are placed in appendices, and there
are four portraits.
Etudes sub le Fonctionnement R*:nal dans les Nephrites chroniques. Par Pasteur
Vallery-Radot. Pp. 256. Paris : Masson et Cie, 1918.
This volume deals with the results obtained in a clinical investigation of chronic nephritis
carried on over a period of several years. The first chapter contains a full discussion of the
new functional tests utilized in the study of renal disease. In general, the author comes to
the conclusion that the majority of tests which depend on the eliminaiion of foreign bodies
are of little value, and concludes that it is necessary to use substances which occur normally
in the body, such as urea. Phenolsulphone phthalein, however, constitutes an exception,
since, according to the author, it closely follows the course of urea elimination. A good deal
of the volume is taken up with the problem of chloride retent’ou in nephritis. The statement
is made that the retarded elimination of chloride so often encountered in chronic renal
disease is but an exaggerated manifestation of what obtains in the healthy individual.
Normally, when excess of chloride is present in the organism, its elimination does not
proceed regularly, but its excretion may be represented by an irregular curve of staircase
form. This view is based on the results of many experiments on subjects with healthy
kidneys. In testing chloride excretion stress is laid on the nec< ssity for giving repeated
doses of sodium chloride on successive days: the usual method of giving one la»ge dose yields
little real information. The retention and consequent concentration of nitrogenous bodies
in the blood is fully dealt with. The opinion is expressed that, given certain conditions, the
most valuable information as to prognosis may be obtained by estimation of the amount of
urea present in the blood. If the urea content amounts to 100 mgr. per 100 c.c. blood the
prognosis is bad, and death will almost certainly take place within two yearn ; ii the amouut
of urea exceeds this, the prognosis become s coirespondingly more grave. With lower values
it is impossible to express a definite opinion, for in cases with from 50 to 100 mgr. the general
condition may improve or remain stationary for years. Definite kidney inad< quacy may be
present without any increase in blood urea content, but in these cases information may be
obtained by using Ambard’s formula. The concluding chapters deal fully with the arterial
and circulatory disturbances associated with Bright's disease. The book concludes with a
short chapter on observations made on rabbits suffering from artificially produced renal
lesions. There is a very full bibliography.
Elements op Folk Psychology : Outlines of a Psychological History of the
Development of Mankind. By Wilhelm Wundt. Authorized Translation by
Edward Leroy Schaub, Ph.D. Pp. xxiii -f 532. Price 15s. net. London : George
Alleu and Unwin, Ltd., 1916.
In recent years the problems with which psychology deals have begun to take their
natural place amongst the experimental sciences, and to all those interested in the neurones
and psychoses, with the development of the conception of psychological regression, the study
of the behaviour, thoughts, ideas and religions of primitive races has become of great
importance. It is now widely recognized that the principles of evolution are applicable both
to material and immaterial or spiritual processes. In ihe b< ck before us Wundt expounds
some of the common types and forms through which human social devehpment has passed
in relatively historical times. The forms of the folk-mind, as they express themselves at any
one instant of time, are here considered and portrayed in their reciprocal relations. Type-
5
specimens are described, then the rules or laws of mental development are deduced from the
inter-relations of these type-specimens. The aim of the book is synthetic rather than
analytical. The book is divided into an introduction and four chapters. Chapter I deals
with primitive man, and what men should be considered primitive; then in turn the
expressions of the culture of the t\pe, his marriage relations, his society, his language, his
thinkings, his beliefs in magic and demons, his art, intellect and morals are described. In
Chapter II the characteristics of man in the totemic stage are considered, and details are
given of the various cults and tribal organizations which at this stage have made their
appearance : then follow sub-chapters dealing with the origin of exogamy and its varieties,
and with polygamy. Various theories concerning the origin of the totemic ideas and the
laws of taboo are considered, and descriptions of the soul beliefs of the totemic age, with its
fetishes and animal and human ancestor-wo^hip, are given. This chapter ends with a
d^cus^ion of the totemic cults and the art of man at this stage of his development.
Chapter III is devoted to ibe age of heroes and gods, to the development of political society,
the origin of cities, of legal systems, of ideas of a Godhead and the Hero £aga, and the
correlated behaviour of mankind. In the final chapter the author discusses the development
of concepts towards humanity with its world-empires, world-cultures, world-religions, and
world-history.
The Hearts op Man. By R. M. Wilson, M.B. Pp. xx -f 182. Price 6s. net. London :
Henry Frowde, Hodder and Stoughton, 1918.
The purpose of this book, according to the author, is to discuss certain phenomena of the
circulation and of the nervous s\ stem, such as the relationship of the pulse to the respiration,
the mechanism of breathing in effort and at rest, and the meaning and effect upon the general
circulation of the great “ blood lakes ” of the skin, abdomen, and lungs. He has formed the
conception that there is a peristaltic wave in those arteries which join the blood lakes—
i.e., tlie arterial tree connecting the heart with the skin and with the mesenteric blood lake.
He has further arrived at the conclusion that there ar9 not two hearts but five, for the blood
lakes are propellers of the blood, and their activities are mutually interdependent. In the
elaboration of his theory the author discusses the action of the muscular system and the.
effect of the secretions of the ductless glands on the circulation. The r61e of the vagus
system and of the sympathetic nervous system is dwelt on. Many polygraph tracings of the
respiratory movements and of the pulse are shown to illustrate the various theories pro¬
pounded. The opinions of two distinguished critics of the book — namely, Sir James
Mackenzie and Professor Bayliss—are included in the preface.
Life and Letters op Sir Joseph Dalton Hooker, O.M., G.C.S.I. Based on Materials
collected and arranged by Lady Hooker. By Leonard Huxley. In two volumes.
With portraits and illustrations ; pp. xii-f 546 and viii + 569. Price 36s. net. London :
John Murray, 1918.
Sir Joseph Hooker’s life, written by Professor Huxley’s son, covers a most important era
of scientific advance, and contains much of the correspondence between Hooker and Darwin.
Hx>ker was Darwin’s lifelong friend, and for fifteen y*ars his sole confidant, and ro the story
of Hooker’s life’s woik is, in one aspect, the history of the share taken by botany in esta¬
blishing the theory of evolution and the effect pr< duced upon it by the acceptation of that
theory. H-oker had every opportunity and utilized each one to the utmost; like many
distinguished men he was a second s >n ; his father, Sir W. Hooker, was Professor of Botany
at Glasgow, and afterwards Director of the Royal Gardens at Kew, and h»s maternal grand¬
father, Dawson Turner, was a dn-tinguished botanist and a Fellow of the Royal Society.
Thus growing up in the atmospheie of botany he was educated at Glasgow, where he took
the M.D. degree in 1839, and after spend<ng some months under Sir John Richardson at
Haslar. he went as assistant surgeon find botanist in H.M.S. Erebus , under Captain Ross, in
the Antarctic expedition of 1839-43, and was thus able to advise Captain Scott with regard to
6
the voyage of the Discovery in 19Q1. In addition to botanical, he carried out valuable zoo¬
logical researches. On his return home he began to bring out the “Antarctic Flora,” and for a
time lectured at Edinburgh as substitute for the dying professor of botany, but failed to
obtain the chair. After refusing the corresponding chair at Glasgow, he returned to London
and was soon appointed botanist to the Geological Survey, in order to work out the British
flora, extant and fossil, in relation to geology. In 1847 he was elected a Fellow of the Royal
Society, and went to India, visiting the Himalayas, with exciting experiences in Sikkim and
Thibet; and after returning to England he married Frances Henslow, eldest daughter of
the. Cambridge Professor of Botany, and in 1855 became Assistant Director at Kew under
his father, whom, ten years later, he succeeded as Director. In the meanwhile, though
neither lecturing nor teaching in person, he examined in science for the medical services
and other bodies for twelve years, and thereby had a useful educational lever in his hands.
In setting questions, his object was to obtain answers requiring thought rather than memory ;
and he was convinced of the value of botany in medical education, not because it is of the
slightest direct advantage in practice, but because such elementary knowledge is essential to
a proper understanding of hygiene, the pharmacopoeia, therapeutics and materia medica,
and because the mental training of a good elementary botanical or natural history course
is the best means of becoming skilful in diagnosis and of expanding the mind. Though
brought up in the old school of a knowledge of plants, he fully appreciated the importance
of physiological botany which took shape under the inspiration of his friend Huxley, and
was taught by Sir Thiselton Dyer, his successor at Kew. The numerous letters to Darwin
and Huxley, his friend of forty-two years, form an attractive feature in this life of the great
botanist who died, full of honours, at the advanced age of 94 years in 1911. An apprecia¬
tion of Sir Joseph Hooker’s position as a botanist is contributed by Professor F. O. Bower.
Lipody&trophia Progressiva. By F. Parkes Weber, M.A., M.D., F.R.C.P.Lond. With
7 illustrations ; pp. 29. Price Is. net. London : Adlard and Son and West Newman,
Ltd., 1918.
This pamphlet, wilich is a reprint from the Clinical Jownal of June, 1918, contains an
account of four cases and a review of the literature. In spite of its title, the disease is not
always progressive. It usually commences in childhood, especially at 6 to 8 years of age. In
some cases the fat atrophy is preceded by increase of fat in the buttocks or legs. The
disease is not, as was at first supposed, confined to the female sex. Genuine examples have
been recorded among males, and probably some of the cases labelled “ bilateral atrophy of
the face ” are examples of this condition. The etiology is unknown, but is probably con¬
cerned with a disorder of the internal secretions. The condition, however disfiguring it
may be, and though it may give rise to a suspicion of tuberculosis, is not dangerous to life,
and is not usually accompanied by loss of strength or of general health.
A Text-book op Radiology (X-rays). By Edward Reginald Morton, M.D., C.M.Trin.
Tor., F.R.C.S.Ed. Second edition. With 36 plates and 93 illustrations; pp. xvi
+ 264. Price 10s. 6d. net. London : Henry Kimpton, 1918.
As is stated in the preface to the first edition, this text book does not aim at being in any
way comprehensive, but rather at forming a useful guide to those taking np radiology for the
first time, and to take them along the first steps in the application of the X-rays to the
investigation and treatment of disease. The fact that a second edition of the work was
called for within twelve months of its first appearance shows that it has filled a niche in the
literature of the subject. In this, the second edition, some parts have been revised, and
some new illustrations and new matter have been added. Among the latter may be men-
. tioned an instructive description of the X-ray appearances of some common disorders of the
stomach—the substance of a paper read before the West London Medico-Chirurgical Society
a few days after the publication of the first edition.
7
Baby Welfare : A Guide to its Acquisition and Maintenance. By W. E. Robinson,
M.D., B.Ch., B.A.Oxon. Pp. xiv + 206. Price 7s. 6d. net. London: T. Fisher
Unwin, Ltd., 1918.
The substance of lectures delivered by Dr. Robinson at the Infants’ Hospital, Vincent
Square, London, forms the basis of this work. The book sketches the “ Healthy Infant,”
about whom little is written, and then deals with the anatomy and physiology of the body :
the physical and chemical properties of milk, with a short chapter on its bacteriology.
Feeding of the infant, naturally, occupies a great part of the book, and the modification of
cow’s milk, as practised in the out-patient department of the Infants*. Hospital, is given in
detail. The following are interesting chapters: “ The Care of the Difficult Infant,”
“ Toxaemias,” “ Rickets,” “ Scorbutus,” and “The Care of Infants in Disease.”
Gymnastic Treatment for Joint and Muscle Disabilities. By Brevet Colonel H. E.
Deane, R.A.M.C. With Preface by Temporary Colonel A. Carless, A.M.S., and by
Brevet Lieutenant-Colonel F. W. Mott, F.R.S., R.A.M.C.(T.). With 26 illustrations ;
pp. 146. Price 5s. net. London : Henry Frowde, Hodder and Stoughton, 1918.
The author gives his experience of the good results in cases of joint and muscle disabilities
obtained in the War Hospital, Croydon, by simple gymnastic methods and inexpensive
apparatus, such as Indian clubs, the vertical rope, the sparred plank, parallel bars, Ac.
Colonel Deane has studied his subject practically, and therefore knows the effect of every
movement and each exercise from personal experience. This, without doubt, accounts for
the success of his methods, the underlying principle of which is that the patient must do
things himself, the “ will-to-do ” must be stimulated. “ A fraction of movement obtained
in that way,” says the author, “is infinitely more valuable than any greater amount of
movement obtained by passive methods.” The book concludes with a mention of the kind of
games which are a valuable adjuvant to the treatment by apparatus. These include the
ordinary games such as skittles, bowls, croquef, Ac., also two games—“cat and dog” and
“twos and threes ”—which, being reminiscent of childhood’s days, will doubtless be played
with avidity by the wounded sailor or soldier. There are two prefaces, by Colonel A. Carless
and by Brevet Lieutenant-Colonel F. W. Mott respectively, both of whom have seen the
results of the author’s methods of treatment.
War Neuroses. By John T. MacCurdy, M.D., Psychiatric Institute, New York. With
a Preface by W. H. R. Rivers, M.D.Lond. Pp. xii -f- 132. Price 7s. 6d. net.
Cambridge : The University Press, 1918.
This work is almost an exact reprint of an article published in the Psychiatric Bulletin
in July, 1917, and is a record of the author’s observations and study of cases of war neuroses
among the British Expeditionary Force which he made when on a visit to this country for
the purpose of gathering information on the subject which might be instructive to American
medical officers. Though such physical factors as concussion and internal secretions are
assigned their possible parts as causal agents, the aetiology of the war neuroses is shown by
the author to be mainly, if not entirely, of a psychological nature. Except for a chapter
devoted to a consideration of heart neuroses and one on the part concussion plays in the pro¬
duction of neurotic manifestations, the contents relate to the problems of the two hysterical
forms—viz., “anxiety hysteria,” most commonly seen in the officer, and “conversion
hysteria,” which is confined almost entirely to the private and non-commissioned officers.
MacCurdy’s point of view—now largely held by the more modern students of the subject—is
that the physical shock, which was and is by some still considered to be the causal agent of
war neuroses, is only the last straw in a series of factors producing the final breakdown, and
that a careful anamnesis will unearth a history of more or less protracted mental conflict
which is finally resolved by some accidental trauma, physical or psychical, into the now well-
recognized clinical picture of a fully-developed neurosis. The main psychological factor
involved is, he thinks, a failure of that sublimation which permitted a freeiilg of the
*
8
aggressive instincts through herd influence, so that the soldier tends to become individualistic
and to be appalled by the horrors of warfare, with the result that mental conflicts between
self and duty are set up, and these are necessarily complicated with a desire to get away from
the danger and horror of his environment. The private tends to long for a “ Blighty ” wound,
while the officer is allured by a desire for death. Wishes, fully conscious to the subject, are
found directly determining symptoms. Amidst the great strain of this modern warfare, a
previous neuropathic history is by no means a necessary factor, though if present the chance
of the development of a neurosis is much enhanced. The mental make-up of these patients is
discussed in detail, and the chain of symptoms from early fatigue, depression, insomnia, &c.,
until the breakdown is complete, is fully described. Under the heading of “ psychological
considerations,” all the psychic mechanisms in the production of the neurosis are explained,
and a chapter on “ prophylaxis ” concludes the volume. As Dr. W. H. R. Rivers points out
in his introductory preface, “Dr. MacCurdy was especially struck in tha neuroses of war by
their simplicity as compared with those of civil practice. He rightly ascribes this to the
fact that the war neuroses depend essentially on the coming into play of the relatively simple
instinct of self-preservation, while the neuroses of civil life largely hinge upon factors con¬
nected with the far more complicated set of instincts associated with sex.” The book i-
pregnant with interest.
The Influence of Joy. (Mind and Health Series, edited by H. Addington Beuce, A.M. )
By George Van Ness Dearborn. Pp. xviii -f- 223. Price 5s. net. Lcn>bu
William Heinemann, 1916.
Of late years special investigations have been made regarding the influence '•f * ,©
emotions upon the organic functions. Foremost among the investigators in ' is ikma’a is
Pavlov, who has so brilliantly shown the influence of the emotions, for good :.i t jvil, cn the
digestive functions. Pavlov's example has been followed by other 6< : m m in many
countries, and the effects of the emotions on the heart, arteries and lungs, l* ducy>, liver, Ac.,
have been carefully studied. The author of the present volume has mad< i in vestigation
on the influence of joy on the bodily functions, and his object in wri: i: is to show the
beneficial influence of joyful emotion on health.
if •
A Plea for the Insane: the Case for Reform in the Care and Treatment of
Mental Diseases. By L. A. Weatherly, M.D. Pp. 238. Price 10s. 6d. net.
London: Grant Richards, Ltd., 1918.
Dr. Weatherly presents the case for reform in the care and treatment of mental diseases
in a most direct and forcible manner. In his criticism of the Lunacy Act, based upon long ex¬
perience of its inadequacy to meet present-day requirements, and the too often injurious effectp
of its provisions on those whom it is formed to protect, and illustrated by numerous examples,
he will have the support of the great majority of the profession, and not least from those who
for years have been struggling against impossible conditions existing in many of the great
institutions for the insane. He has summarized most of the opinions of individuals and
societies expressed during the last quarter century, and he presents the case for reform
in a way no reader can fail to understand. It is addressed equally to the general public, and
should be widely read, especially by the members of municipal and governing bodies who are
responsible for asylums and mental hospitals; but it is the former whom the author rightly
blames for an inexplicable complacency towards the existing state of things. Dr. Weatherly
is fearless and unsparing in his criticism of the weakness of the provisions for dealing with
mental disease in this country, which compares so unfavourably with many others. The
author comments on the absence of careful clinical investigation into each individual case,
which asylum routine and the administration of the Lunacy Act, no less than the in¬
adequately small medical staffs, renders impossible, to the detriinent of the recovery-rate.
The case for voluntary boarders at County and Borough Asylums, for clinics and approved
homes is discussed, besides many other aspects of the question. There is also an instructive
chapter on criminal responsibility. The author supports his arguments by many quotations
9
of weighty opinions of well-known authorities; amongst others, Sir Frederick Needbam,
present senior member of the Board of Control, and Sir Thomas Clifford Allbutt, a late
Commissioner in Lunacy, from which it appears that the Board of Control is as little
sympathetic with many of the provisions of the Lunacy Act as it is powerless to remedy
them. In the last resort it is to the public he appeals. He says, in effect—if you want
adequate care and treatment for your mentally afflicted, borderline and insane, you must
agitate for it, and be willing to pay for it. Alienists themselves have been agitating in vain
for years. When disorder of mind comes to be regarded intelligently by a discerning and
educated public opinion, and when venereal disease can bo treated by notification and
prophylactically, as in the case of small-pox and scarlet fever, much of the difficulty will
have been overcome.
An Index op Prognosis and End-besults of Treatment. By Various Writers.
Edited by A. Rendle Short, M.D., B.S., B.Sc.Lond., F.R.C.S.Eng. Second
edition. Pp. xi -f 770. Price 30s. not. Bristol: John Wright and Sons, Ltd., 1918.
This volume is a companion to the Index of Treatment and Index of Differential
Diagnosis brought out by the same publishers. Its principal aims, as described in the
preface to the first edition, are to set out the end-results of different methods of treatment,
and, apart from that, to furnish data for prognosis in the individual case. The present
edition has been extensively revised and a number of new articles have been added, amongst
these being articles on tetanus, gas gangrene, septic peritonitis, and gunshot wounds. The
book is edited by a surgeon (Mr. Rendle Short) and a relatively large amount of space is
devoted to surgical subjects and the results of operative treatment. The articles are arranged
in alphabetical order, and there is a copious supplementary index.
Modern Urology. In Original Contributions by Amorican Authors, edited by Hugh
Cabot, M.D., F.A.C.S. In Two Volumes. Vol. I: General Considerations—Diseases
of Penis and Urethra—Diseases of Scrotum and Testicle—Diseases of Prostate and
Seminal Vessels. Vol. II : Diseases of Bladder—Diseases of Ureter— I seases of
Kidney. With 632 engravings and 17 plates ; pp. xiii -f 744 and viii + 708.' Price
$14.00. Philadelphia and New York : Lea and Febiger, 1918.
These two volumes comprise a series of articles by twenty-nine American surgeons
specializing in genito-urinary diseases. Volume I opens with an historical sketch of
genito-urinary surgery in America, by F. S. Watson, which includes brief sketches of
some of the more notable men in the field of urology, traces the evolution of urology
in America, and describes the contributions of American surgeons to the subject. Leo
Buerger contributes a chapter on the cystoscope and its use, and there are chapters
on the methods of diagnosis and X-ray examination written by Bransford, Lewis and
Dodd respectively. Syphilis of the genito-urinary organs is discussed by Corbus, who
has also contributed a chapter on genital ulcers. The anatomy, anomalies and injuries
of the penis are discussed shortly by H. A. Fowler, and Warren devotes a few pages
to diseases of the penis. Forty-nine pages are allotted to infection of the urethra and
prostate, the article being written by Barringer, while Osgood describes the diseases of the
urethra in the female in a similar number of pages. Stricture of the urethra is separately
considered by E. L. Keyes, jun. There is a section on disease of the scrotum and testicle,
which includes articles by George Gilbert Smith, A. Raymond Stevens, J. Dellinger
Barney, and Edwin Beer. The anatomy of the prostate is described by Quinby, and
Pilcher has a long article on prostatic obstruction. Young devotes a chapter to cancer of the
prostate, and another to sarcoma of the prostate. The second volume comprises a section
on the bladder, another on the ureter, and a third on the kidney. Kretschmer is responsible
for the anatomy and physiology of the bladder, Lower for diverticulum, and Hagner for
injuries of that organ. Caulk has an article of considerable length on infections of the
bladder. Stone in the bladder and the different methods of treatment are fully discussed by
10
Cabot, who also contributes the chapter on stone in the kidney in Section III. Tumours of
the bladder are described by Geraghty, and a full description of the tests of the renal func¬
tion is given by the same author in the kidney section. The section on the ureter occupies
sixty-six pages, and is written by Hunner. In the kidney section, in addition to those
already mentioned, there are articles on anatomy and physiology by Quinby ; hydro¬
nephrosis, moveable kidney and injuries by Squire ; bilharziosis and echinococcus, by-
Edward L. Young, jun.; tuberculosis, by O'Neil; and tumours, by Binney. The volumes
are profusely illustrated by photographs, drawings, and coloured plates, and some of the
articles possess a bibliography.
Vaccines and Sera: their Clinical Value in Military and Civilian Practice. By
A. Geoffrey Shera, B.A., M.D., B.C.Cantab., Hon. Captain R.A.M.C. With an
Introduction by Sir Clifford Allbutt, K.C.B., M.D., F.R.S. Pp. xxi-f 226.
Pjnce 7s. 6d. net. London : Henry Frowde and Hodder and Stoughton, 1918.
In the short space of some two hundred pages, Captain Shera gives briefly the results of
his experiences in vaccine and serum therapy in military hospitals. The book is divided into
four sections dealing respectively with (1) vaccines, (2) sera, (3) specific therapy, and (4) mis¬
cellaneous matters, such as auto-serum and normal serum therapy. The section dealing with
vaccines is the largest. Here the author adopts the method of treating each vaccine under .=
disease group—e.g., diseases of the genito-urinary tract, diseases of infected gunshot won
diseases of respiration, &c. The section closes with a short chapter on tuberculin, in -v 'uch
it is concluded “ that the therapeutic use of tuberculins is neither justified by use r ?. e-
the experimental evidence on which it is based bear repetition.” The second secti •
book deals with the filterable viruses, cerebro-spinal meningitis, tetanus, dipht n, .
anthrax. Sections three and four are very short, and treat only of certain aspec* r - ; uc
therapy, such as salvarsanized auto-serums, transfusion, &c. The book is c . -y a
glossary and a tabular classification of vaccines and sera arranged from the > r.ts of
both prophylaxis and curative treatment.
Blood Transfusion, Hemorrhage, and the Anemias. By Bertram M. i >li. faiM, A.B.,
M.D., F.A.C.S. With 18 illustrations; pp. xix -f 259. Price 18s. not. I hiladelphia
and London : J. B. Lippincott Co., 1917.
This is an expansion of the chapter devoted to the subject in the author’s earlier work on
the surgery of the vascular system. After an introductory historical note, preliminary
chapters are devoted to the phenomena of bleeding, the control of haemorrhage, and the
diagnosis of blood loss. Indications for transfusion are tabulated, including not only primary
anaemia but even the less-promising secondary forms. Dangers are discussed, but dismissed
with a caution that takes the form of an appendix on the technique of agglutination tests.
11 Methods ” are covered in about sixty pages, and though direct plans are fully described, the
“ citration ” system and a modification of the Kimpton instrument appeal most kindly to the
author. The rest of the book gives the writer’s experience of transfusion for acute hemor¬
rhage, for simple and pernicious anemia, for hemorrhagic diseases, for leukemia and splenic
anemia. There is a bibliography and an index.
Dr. John Radcliffe ; a Sketch of his Life, with an Account of his Fellows and
Foundations. By J. B. Nias, M.D., M.R.C.P., Radcliffe Travelling Fellow, 1882-85.
With 13 plates ; pp. 147. Price 12s. 6d. Oxford : The Clarendon Press, 1918.
The present work has been published in commemoration of the bicentenary of Radcliffo’s
death by Dr. Nias, who for many years has been collecting biographical data about his
predecessors in the Radcliffe Travelling Fellowship. The sketch of Radcliffe’s life contains
an account of his career at Oxford and in London, and of his friendship with Mead, who
probably gave him much help in settling the details of the Radcliffe Travelling Fellowships.
Dr. Nias is of opinion that these appointments were originally intended to benefit the
11
University directly by improving the raw material for appointments to University professor¬
ships, and not by any means to be the endowments for the benefit of the medical profession,
which they have since become. Biographical notices of the Radcliffe Fellows are given in
chronological order from 1715, when the first two fellows were elected, until the present time,
with the exception of Fellows still alive, in whose case merely a note as to their present
professional position is given. The history of the Radcliffe Foundations contains contribu¬
tions by Dr. Hatchett Jackson on the Radcliffe Library, by Dr. Rambaut on the Radcliffe
Observatory, and by Dr. Macan, Master of University College, on Radcliffe and University
College.
Organism and Environment as illustrated by the Physiology of Breathing
(Silliman Memorial Lecture). By John Scott Haldane, M.D., LL.D., F.R.S.
Pp. xi -f 138. Price $1.25. New Haven: Yale University Press; London:
Humphrey Milford, 1917.
In this volume are included four of the Silliman Lectures for 1915, delivered at Yale
University by Dr. J. S. Haldane. They are as follows: (I) The Regulation of Breathing.
(II) The Readjustments of Regulation in Acclimatization and Disease. (Ill) Regulation of
the Environment, Internal and External. (IV) Organic Regulation as the Essence of Life.
\ nadequacy of Mechanistic and Vitalistic Conceptions. The conflict between the mechanistic
h id vitalistic schools is viewed from a new angle and will thus appeal to the general biologist
y t 1 philosopher. For physiologists and physicians the book has an even more direct and
; tioal value, the recent important discoveries regarding the regulation of breathing, the
■I- t n of the blood and the phenomena of acidosis being briefly described in simple and
‘k u i ’’guage.
ft. ; w ftlEDiCAL ftlANUALS. .General Editor: Sir Alfred Keogh, G.C.B., M.D.,
- v\P. War Otitis and War Deafness: Diagnosis—Treatment—Medical
' s. By H. Bourgeois and M. Soubdille. Preface by ftl^decin-Inspecteur
: > ' English Translation edited by J. Dundab Grant, M.D., F.R.C.S. With
; \V. i itions and 6 plates; pp. xviii -f- 231. Price 6s. net. London : University of
L ; a -a Press, Ltd. ; Paris: ftlasson et Cie, 1918.
The pul -sliers of this series have done good service to those who have to deal with war
medicine and surgery and aurists have especially to thank them for this volume dealing with
military aspects of aural surgery. Drs. Bourgeois and Sourdilie’s work on war otitis and war
deafness is characterized by the minuteness of detail and the studious lucidity of French
writers, while the accuracy of the translation is vouched for by the English editor, Dr.
Dundas Grantr. The earlier chapters deal with the diseases of the ear as affected by the
circumstances of war. A modified radical mastoid operation is described in some detail,
supplying many hints for the military surgeon, whether at the Front or at the Base.
The traumatic lesions are more in the picture, and their consideration is very complete.
They are described as they occur in the various regions—auricle, tympanum, mastoid region,
neighbouring parts of the skull more or less remote and the intracranial structures as they
are related to the hearing and equilibrial functions. The various tests for hearing are
detailed and compared and the relatively few “bed-rock” tests are discussed not only in
the light of academical refinement, but also in that of common-sense and special experience.
Many difficulties in the diagnosis of organic, functional, perpetuated, exaggerated and
simulated deafness are simplified and to a great extent cleared up. The examination of
recruits and conditions of fitness for service, as well as the preparation of reports on the
disabilities leading to discharge and pensions or gratuities are very fully explained, in so far
as they concern the hearing functions. The later chapters are those which will appeal most
particularly to those who have to deal with troops, as, in view of the enormous incidence of
disease and injury of the ears and various disturbances of hearing in this war, questions
in connexion with them are constantly arising. Answers to most of them will be found in
this work.
12
Radiography and Radio-Therapeutics. By Robert Knox, M.D.Ed., M.R.C.S.Eng.,
L.R.C.P.Lond. Second edition, in two volumes. Vol. I: Radiography, with 78 plates
and 338 other illustrations ; pp. xxv + 384 xx. Price 30s. net. Vol. II: Radio-
therapeutics, with 15 plates and 100 other illustrations ; pp. x 222. Price 15s. net.
London : A. and C. Black, Ltd., 1917-18.
The first volume, dealing with radiography and diagnosis, has been considerably enlarged
and thoroughly revised. It deals with the whole subject from a full consideration of
sources of energy and appliances and their application in every class of diagnostic work to
which the X-rays are applicable. Separate chapters are devoted to such subjects as
localization of foreign bodies, the development of the bones, diseases of bones and joints, and
their differential diagnosis, and the examination of the principal systems of the body, thorax,
abdomen and pelvis. The illustrations are both clear and numerous, those of normal parts
being so complete as to take the place of an X-ray atlas. The radiography of the skull is a
branch that receives special attention, and here, as in many other parts of the work, the
influenoe of experience with cases arising out of the War shows itself unmistakably. The
volume closes with a chapter on congenital malformations and the usual glossary, biblio¬
graphy and index. Volume II is devoted to the consideration of tho therapeutic applications
of the X-rays and radium singly and combined. The changes in normal and diseased
tissues under radiation are dealt with at length and illustrated with microscopic slides.
Numerous cases are illustrated, both before and after treatment. Methods of measuring
•dosage, the use of filters, and appliances for treatment of special areas, are fully explained ;
those referring to the application of radium being specially complete. A chapter on the
physics of radium is contributed by C. E. S. Phillips, F.R.S.E., and others deal with the
application of radiations to injuries and diseases met with in military practice, and plastic
surgery of the face and jaws, the last being specially contributed by Mr. Percival P. Cole.
proceedings of tbe Ko^al Society of flDebtctne
SUPPLEMENT
(Vol. XII, No. 2, December, 1918).
NOTES ON BOOKS.
[The purpose of these “Notes” is neither to praise nor to blame , but merely to draw
attention to some of the new books*and new editions which have been added to the
Society's Library. —Ed.]
Pathologie de Guebre du Larynx et i>e la Trachee. Par E. J. Moure, G. Likbault
ot G. Canuyt. With 8 coloured plates and 128 other illustrations ; pp. 370. Price 25 fr.
Paris, F61ix Alcan, 1918.
This is a detailed description of the various lesions of the larynx and trachea resulting
from the War. The first chapter is devoted to pure functional lesions, mutism, aphonia and
stammering resulting from shock caused by the bursting of large shells near tbe victim.
The symptoms, signs and treatment of these lesions are described in detail, and it is pointed
out that the respiratory capacity of mutiUs is always deficient and that the prognosis depends
on the amount. It is claimed that with proper treatment a genuine aphonic ought to recover
his voice and that those who are cured can and ought to return to active service. The second
chapter treats of extralaryngeal lesions—namely, the injuries of nerves and neighbouring
organs, such as the oesophagus, pharynx, &c. The anatomy of the laryngeal, glossopharyngeal,
vagus, spinal accessory and hypoglossal nerves is discussed and tbe various disorders which
result from their paralysis both individually and in combination. The third chapter deals
with the injuries of the larynx and trachea themselves : the dangers such as haemorrhage,
asphyxia, emphysema; the causes of sudden death ; the complications that supervene, more
especially the different forms of stenosis which result. Treatment is very fully discussed and
the value of X-rays and bronchoscopy are emphasized. A short account of the lesions
resulting from “gassing” is also included. In the last chapter, which comprises more than
half the book, the technique of the various operations is minutely described. General
anesthetics are deprecated as a rule. “High” tracheotomy is preferred to the “low”
operation ; the trachea should always *be incised “sous le contrdle de la vue ” ; to prevent
blood entering the air-passages the tracheal opening should le as small as possible. The
methods of performing the thyrotomy are discussed and preference is given to the “ procGdc
de Moure” which, shortly stated, consists of local anaesthesia, absence of tracheotomy,
immediate and complete suture, the patient leaving the operating table breathing through
the normal passages. Lastly there is the treatment of traumatic stenosis of the larynx,
which occupies perhaps the most important part of the book. Moure is very strongly opposed
to all forms of internal dilatation and argues strongly in favour of tracbeo-laryngostomy.
His method consists in complete division of the stricture by laying it open freely from the
front so as to restore the normal calibre of the air-way. The new channel so formed is then
preserved by insertion into the wound of a roll of gauze (pansement en cigare) which is fixed
above a tracheotomy tube, the packing being changed every three or four days and replaced
by a vulcanite cannula after two months, when the wound is lined with epidermis. The
second stage consists in removing the tracheotomy tube and cannula and inserting a vulcanite
D—11
14
tube into the air passage, the ends of which project above and below the limits of. the wound
for several months. Thirdly, the tube is removed, and lastly after several weeks or months,
the fistula is closed by plastic flaps. Moure has treated twenty-four “ canulards *’ by this
method with eight complete cures, and sixteen of his patients are on the road to recovery.
As he says, the great majority of tracheotomized patients can and ought to be cured.
Rural Water Supplies and their Purification. By Alexander Cruikshank Houston,
M.B., D.Se., F.R.S.Ed. Illustrated; pp. xv -f 136. Price 7s. 6d. net. London:
John Bale, Sons and Danielsson, Ltd., 1918.
This is another book by the Director of Water Examination, Metropolitan Water Board,
and is written for the expert and non-expert reader who is interested in the problem of a safe
water supply in rural districts, many of which are served by water supplies not under the
direct control of a public authority. The first part of the book is devoted to rain water as a
source of supply, and its purification ; two chapters to well waters, springs, brooks, river and
lake waters. The methods of sterilization and purification of these waters are dealt with in
detail. Two further chapters give the results of actual experiments, and, lastly, a description
of apparatus required is given. At the commencement of each chapter there is a summary of
the matters discussed, and the conclusions arrived at are stated succinctly at the close. The
book Bhould prove of great value to those who are interested in the subject (and of rural
dwellers who is not ?), particularly from the offer of the author, Sir A. C. Houston, to explain
any difficulty to a reader who cares to communicate with him.
James Hinton : A Sketch. By Mrs. Havelock Ellis. With a Preface by Havelock
Ellis, and 8 full-page illustrations; pp. xxviii + 283. Price 10s. 6d. net. London :
Stanley Paul and Co., 1918.
The author has endeavoured to sketch the lifework of 41 one of the most remarkable
men in our profession,” as the late* Sir Samuel Wilks once wrote of James Hinton.
Bom at Reading in 1822, the third child of John Howard Hinton, M.A., a Baptist minister,
he qualified in 1847, and five years later he set up as a specialist in aural surgery in London.
As Mr. George Peard said of him, “ his heart was not in the work he had to do as a
professional man, but in the work he never had time to do ; his desire for human welfare
exceeded in its intensity the sum of all his other desires.*’ He soon began to write on
biological subjects, and after the publication of his “Life in Nature,” he earned the
praise of Thackeray, who remarked: “Whatever else this man can do, he can Write.**
In 1863 he was appointed aural surgeon to Guy’s Hospital, the post being specially created
for him, and he settled in practice in 18, Savile Row. Intimacy with James Hinton deepened
the belief in his greatness. This was the testimony of those who knew him well and in his
most trying moods. He always insisted on right motives for all actions, and he preached the
doctrine that our own goodness should never be allowed to stand in the way of our doing
good. His moral writings occupied four large volumes. He saw the necessity that exists for
all of us to “ understand the art of ceasing to make innocent things wrong.** Hinton’s views
on sexual matters were somewhat iconoclastic. He maintained that passionate desire should
make the body an instrument wherein the soul can express itself and be incapable of
anything else. The cure of prostitution is to be found in a great woman-sacrifice, nothing
else or less. It is to women that he looks as a saviour of women. We are too accustomed to
treat our sexuality as if it were the devil instead of the angel of our lives. The chief evil
in our modern life lies in our incapacity to realize that the sexual passion, frightful as it is as
a ruler, is sacred as a servant. The ideal relations of the sexes must be according to use, or
service, as well as pleasure, and according to reason and love with no self in them at all at
the basis. His attitude to women, whom he worshipped, was characteristic. He realized, as
few men have ever done, the inner tragedies of women’s lives, and this gave Hinton’s work
its value with regard to women’s problems. Speaking of marriage, he declares that, even in
its ideal form, it is not always complete in its beauty and usefulness. The marriage of the
future will combine, not only pleasure and the production of children, but will have for its
15
main object work for the world. “ Women are heroes,” he cries, “ and they should be treated
as such.” His gospel is that man’s needs ought never to mean woman’s sacrifice, but the
needs of woman should alone constitute man’s pleasure. His ideas respecting monogamy
and polygamy are in many senses revolutionary, but they provide much fo6d for serious
reflection. “ It should be possible,” he declares, “ for a woman to devote her life to a work,
and yet to have a husband. This would be placing her on a par with men. It must be a
depressing influence for women to know that, if they marry, they must be absorbed in house¬
work ; that is, they are being used up for the man.” From the point of view of a lover, a
doctor and a, redeemer, he probed into the evils with which, as yet, neither religion nor
legislation seem able to cope. Hinton was a true seer in that he was one of the first to
recognize that woman’s need is man’s opportunity, instead of man’s need demanding her
sacrifice. His views on “The Mystery of Pleasure and Pain,” and on “ Art and Morals,**
are typical of his teaching. He died in 1875 in a hospital at St. Michael’s, in the Azores, of a
cerebral tumour. There is a full index and several photographs.
Surgery in War. By Alfred J. Hull, F.R.C.S., Lieutenant-Colonel R.A.M.C. With
a Preface by Lieutenant-General T. H. J. C. Goodwin, C.B., C.M.G., D.S.O.,
Director-General, A.M.S. Second edition. With 210 illustrations ; pp. xv + 624.
Price 25s. net. London : J. apd A. Churchill, 1918.
This is the second edition of the work, which contains a full account of its subject—
surgery in war—whilst it presupposes a knowledge of surgery in general. It is profusely
illustrated both by reproduction of photographs and by coloured illustrations. There is a
full index. The Director-General, Lieutenant-General Goodwin, has written the preface,
in which he notes a more detailed description of the primary treatment of wounds by excision
and suture, as well as concerning shock and trench feet. Colonel Hull has been assisted by :
Colonel E. M. Pilcher, who contributes the introduction ; Captain W. Miller, a chapter on
gunshot wounds of the chest; Dr. C. H. Browning, that on tetanus; Captain A. A. W. Petrie,
on wound infection and anaerobic infection ; Colonel Owen W. Richards, on wounds of the
abdomen ; Major Jocelyn Swan, on gunshot injuries of peripheral nerves, and on the later
treatment of bone injuries; and Captain H. E. H; Tracy, on gunshot wounds of the jaw
and face. The work commences with the bacteriology of gunshot wounds, followed by the
various methods of treatment; next comes the removal of foreign bodies, aided by radio-
graphical localization ; then chapters on tetanus, on anaerobic infection, and on gas gangrene.
Then follow chapters on special regional surgery, gunshot wounds of the head, spine and
blood-vessels, with separate chapters on haemorrhage and transfusion of blood; gunshot
wounds of joints, of the abdomen, of the chest, of the peripheral nerves, of the limbs in
genera], and amputation of the jaw and face; on compound fractures, shock, and trench feet.
A final chapter of some forty pages on the later treatment of gunshot injuries of bone, deals
with questions which will be of continued interest for many years.
War Surgery of the Abdomen. By Cuthbert Wallace, C.M.G., F.R.C.S.Eng., M.B.,
B.S.Lond. With 26 ^illustrations ; pp. viii + 152. Price 10s. 6d net. London :
J. and A. Churchill, 1918.
To quote the author in his preface: This book contains the experience in abdominal
surgery of a sector of the battle line over a period of thirty months. It is founded on the
practice of many surgeons, working under different conditions and in different hospitals. The
personal equation and influence of locality have thus been largely eliminated. It is hoped
that the figures quoted may present a standard with which other surgeons may compare their
results.” The figures quoted will certainly do this, but the book is very much more than an
array of figures ; it is full of interest and rich with information. “ In South Africa we learnt
to treat many wounds with little respect. Wounds were allowed to scab over, and did
remarkably well. Many surgeons were convinced that rest, starvation and morphia were the
right treatment of abdominal wounds. This war, fought on infected soil, has proved that
dirty wounds must be cleaned. It has also shown that penetrating abdominal wounds should
16
be explored.”. The collection and evacuation of the wounded to the regimental aid posts,
the advanced dressing stations, and so to the casualty clearing station or advanced
operating centre is then described, and a tribute is paid to the magnificent work of the
regimental medical officer and his stretcher bearers. A general review of abdominal wounds
follows, in which amongst others the following points are dealt with : The relative frequenc}*
of abdominal wounds, the nature of the projectiles, the relative mortality of the different
projectiles, the influence of the position and the direction of wounds $s affecting prognosis,
and the comparative frequency of wounds in the different viscera. A table is given showing
the effect on the mortality-rate produced by the time which has elapsed between the receipt
of the wound and the operation, from which it is seen that up to six hours the chances are
in favour of the patient, and after that period are always against him. It follows from this
that the sooner a man is operated upon the better, provided he can be kept quiet and well
nursed, so that the casualty clearing station if reasonably far forward (from 10,000 to 15,000
yards from the line) is the best place for the operation. The mobile operating van is con¬
sidered, and rejected as impracticable. The diagnosis of penetration of the peritoneal cavity
is then considered. “ It may be said that the wound of a hollow viscus has in itself no
symptoms; it is haemorrhage or peritonitiawhich gives the danger signal.” “ Experience
has shown that one has to be very careful in making a negative diagnosis, and it has also
shown the wisdom of operating in doubtful cases.” The next fifty pages are devoted to
wounds of particular organs : their diagnosis, treatnfent and prognosis. Many interesting
cases are quoted to illustrate the conditions found at operation. A chapter is devoted to
abdomino-thoracic wounds and diaphragmatic hernia', and this is followed by a chapter on
the “causes of failure.”
Thk Statics op the Female Pelvic Viscera. By R. H. Paramore, M.D.Lond.,
F.R.C.8.Eng. Volume I, with 26 illustrations; pp. xviii -f 383. Price 18s. net.
London : H. K. Lewis and Co., Ltd., 1918. '
In fourteen chapters and 354 pages the author has exhaustively completed his subject
from the academic standpoint he has adapted. The acceptable accomplishment of his aim
has been attained by study, research; experiment, resource, judgment and compilation,
reminding the render of the similar, subtle and serious, studies of John Hunter. It is a
laborious method, in which the sieve is used with effect and discrimination. What are the
materials? They are revivals, opinions and efforts concerning the constituents of the pelvic
floor. A connexion of first importance ought to be recalled. The pioneer movement was
established in 1884 by Dr. David Berry Hart in his “Atlas of Female Pelvic Anatomy” ;
his description of the pelvic floor as a whole, and of its behaviour under various influences,
including the genu-pectoral position, has been followed by discussion betraying interminable
ingenuity, restlessness, and rivalry. During the summer of 1907, the author of this volume
was attracted to the subject, now so deservedly his own. He is the sponsor for the muscu¬
lature : he has written often upon it: he has done justice to the muscles and their tendinous
fasciae: he liberally discusses the connective tissues: he is generally sceptical as to liga¬
mentary and other hangings or supports of the uterus. Details, otherwise wearisome, have
been laboriously investigated in chapter after chapter, terminating with the sufficiency of the
pelvic floor. Surgery—abdominal and pelvic not excepted—has banished in abundance old
views and absurd teachings, and has established realities where superstitions had lagged
behind. When the pelvic floor is more conveniently and rightly regarded as the perinaeum
and as the continuation of the anterior abdominal wall, conservative and operative surgery
will look back on the enduring merit of the original lead of Dr. David Berry Hart and on the
selective achievements of Dr. R. H. Paramore in the elaboration and adjustment of details.
This glaring need Dr. R. H. Paramore, by his text, illustrations and bibliography, has
fulfilled in a highly creditable manner. The volume is a most welcome and permanent
addition to the special literature.
17
A Text-book of Pharmocology and Therapeutics, or the Action of Drugs in Health
and Disease. By Arthur R. Cushny, M.A., M.D., LL.D., F.R.S. Seventh
edition. With 71 illustrations : pp. viii 712. Price 18s. net. London : J. and A.
Churchill, 1918.
Professor Cushny’s text-book is already too well known to need detailed notice. The
present volume marks the seventh edition of this useful work, and the opportunity has been
taken thoroughly to revise the whole of it and to bring it up to date*. The hsue of the
ninth revision of the United States Pharmacopoeia has made it necessary to review the
description of many drugs. The section on disinfectants has been revised in the light of war
experiences ; the treatment of dysentery with the ipecacuanha alkaloids has now been firmly
established ; a reconciliation of clinical and experimental results with digitalis is attempted,
and the action of certain of the opium alkaloids has been further developed. The general
arrangement of the book into an introduction and four parts is maintained. Part 1 deals
with substances characterized chiefly by their local action ; Part II with substances
characterized chiefly by action after absorption ; Part III with the heavier metals; Part IV
with cod-liver oil, hypophosphites and glycerophosphates, together with various mechanical
remedies; whilst a classification of drugs according to their therapeutic uses, and a
clear index, complete the book.
War Wounds of the Lung : Notes on their Surgical Treatment ^t the Front. By
Pierre Duval. Authorized English translation. With 27 plates and illustrations ;
pp. viii -f- 99. Price 8s. 6d. net. Bristol: John Wright and Sons, Ltd., 1918.
Duval rightly contends that the practice which obtained for rather more than the first
two years of the war of treating wounds of the chest on lines different from those of other
parts of the body has no logical basis. That this is true is now universally recognized, and
to no one is greater credit due for the elucidation of this fact than to Duval himself. Deaths
from chest wounds are due to causes which produce the same results in other wounds, and
which in relation to their ill-effects on other wounded tissues have for some time been appre¬
ciated and overcome—viz., hfemorrhage and infection. Duval advocates more general and
earlier operative interference with the object of dealing with the haemorrhage directly, and of
preventing infection by excision of the damaged tissues and removal of foroign bodies. From
the purely surgical standpoint the argument is most convincingly presented, and its validity
must be admitted ; but fhe practicability of routine early operation on chest cases in fully
equipped surgical centres near the line on an active front hinges so much on military con¬
siderations, transport, Ac., that such questions cannot be decided solely on surgical
grounds.
Studies in Forensic Psychiatry. By Bernard Glueck, M.D. From the Criminal
Department, Government Hospital for the Insane (U.S.A.). Pp. viii + 269. Price
10s. 6d. net. London : William Heinemann, 1916.
This is one of a series of monograph supplements to the Journal of Criminal Law aiul
Criminology , the publication of which is authorized by the American Institute of Criminal
Law and Criminology. In a series of papers, rather than in a connected survey, the author
has endeavoured to apply the recent methods of psycho-pathology to an intensive study of
the criminal classes. In the first paper on psychogenesis, the author points out that the
psychoses of criminals can be established far more clearly in prisoners awaiting a trial than
in those already in jail, since the deleterious effect of confinement on physical health can
be eliminated. He brings forward reasons for believing that the important setiological
factor in a large number of cases is the emotional shock which the commission of crime and
its attendant consequences provoke. He supports his view by detailed accounts of condi-
tionst such as stupor, amnesia, headaches, delusions, &c., which develop after the com¬
mission of offence, in prisoners apparently normal during their previous life. The next
paper, on the psychoses of prisoners, carries this theme further, and contains a strong plea
for the establishment of a psychiatric department in prisons for the special treatment of
d— 11a
18
these cases. A chapter on litigious paranoia gives an account of two persistent litigants
who, after bringing numerous actions against their supposed persecutors, were finally recog¬
nized as insane when charged with criminal offences. Both cases illustrate the need for
closer co-operation between the lawyer and the physician in the administration of the law.
The final chapters in this book deal with malingering and kleptomania.
Diseases of the* Heart and Aobta. By Abthub Douglass Hikschfelder, M.D.
With an Introductory Note by Lewellys F. Barker, M.D., LL.D. Third edition.
With 20 plates and 325 illustrations by the author; pp. xxviii + 732. Price 80s. net.
Philadelphia and London : J. B. Lippincott Co., 1918.
To the student of cardiology, Dr. Hirschfelder’s book offers a compendium of phenomena
observed at the bedside with facts learned in the laboratory in order to show how each
supplements the other in observation of the patient and in direction of treatment. At the
end of each section a full bibliography is published, so that the totality forms one of the most
useful text-books and works of reference in any language on this special subject. The
numerous and excellent illustrations lend added value to the letterpress. The presont edition
records in the main changes of evolution. Graphic methods, which have now become
routine are carefully dealt with, so that it is possible, even without firsthand acquaintance,
to assess the precise diagnostic value of each. Studies with the volume pulse demonstrate
the importance of back-flow in the peripheral arteries, and give a new meaning to pulse
curves. Additional evidence is afforded for the contention of the author in 1908, and of
Dr. Thomas Lewis in 1909, that extrasystoles, auricular tachycardia and fibrillation are
closely related phenomena which represent an ascending scale of increased irritability of the
heart muscle. Other new matter comprises studies of cardiac overstrain in soldiers, cardiac
dyspnea, the total volume of the blood in cardiac disease, hyperthyroidism, and the use of
digitalis in large doses, various observers being quoted to show that the beneficial action of
this drug is often greatest when the pulse-rate is slowed down to fifty to sixty beats per
minute. Dr. Hirschfelder states that in order to obtain this result large doses may have to
be administered for a considerable period of time, and the patient may entirely miss the
benefit if half-hearted therapy is resorted to.
The Life and Letters of Joseph Black, M.D. By Sir William Ramsay, K.C.B.,
F.R.S. With an Introduction dealing with the Life atid Work of Sir William
Ramsay, by F. G. Donnan, F.R.S. With 7 illustrations; pp. xix + 148. Price
6s. 6d. net. London : Constable and Co., Ltd., 1918.
For many years Sir William Ramsay devoted one lecture a week during the summer term
to the history of chemistry. Black originated the quantitative study of chemical reaction,
and though chemical science has travelled far in the interval between “fixed air ” and argon,
the mantle so greatly and honourably worn by Ramsay was none other than that of Black.
As he was, like Black, an alumnus of Glasgow University, it is most appropriate that he
should have brought out this life and letters. At Glasgow, Black was a pupil of Cullen's
and succeeded him there as lecturer on chemistry and again in Edinburgh as professor of
chemistry (1766). As is not infrequently the case, Black’s best work, that on latent heat
and that on gases, was done at an early age, before he migrated to Edinburgh, where he
passed an uneventful life in teaching his students and helping forward the cause of science
-and industry. His calm and attractive personality is well brought out in extracts from
letters written by himself and by his friends; Lord Brougham describes him as “ a person
whose opinions on every subject were marked by calmness and sagacity, wholly free from
passion and prejudice, while affectation was only known to him from the comedies he might
have read.” Five out of the seven illustrations are successful reproductions from the series
of original portraits and caricature etchings made by John Kay and published in 1837, and
special attention may be directed to “The Philosophers,” Black and Hutton, whose intimate
•friendship is told in Chapter VII. Professor F. G. Donnan contributes as tho introduction
a sympathetic account of Sir William Ramsay’s life and personality.
proceedings of the 'Ko\>al Society of flbebtcine.
SUPPLEMENT
(Vol. XII, No. 3, January, 1919).
NOTES ON BOOKS.
[The purpose of hese “Notes” is neither to praise nor to blame , but merely to draio
attention to some of the new books and new editions which have been added to the
Society's Library .— Ed.]
The Chemical Constitution of the Proteins. By R. H. A. Plimmer, D.3c. In three
parts. Parti: Analysis. Third edition. Pp. xii -f 174. Price6s.net. London:
Longmans, Green and Co., 1917.
The third edition of Dr. Plimmer’s monograph on the chemical constitution of the
proteins has been divided into three parts. As most of the new work done since the last
edition appeared has been connected with analyses it has been thought advisable to devote
the first part entirely to a consideration of the methods employed in protein analysis and
their results. After an introductory description of the naturally occurring proteins, the
author considers the effects of hydrolysis by different methods. He then passes on to the
isolation and estimation of the amino-acids, and describes the composition of various
proteins in amino-acids as obtained by different observers. Finally, the analysis of proteins
by determination of the distribution of the various kinds of nitrogen is dealt with. A full
bibliography is appended, and the former omission of references in the text to the papers
quoted in the bibliography has been remedied.
Chemistry of Food and Nutrition. By Henry C. Sherman, Ph.D. Second edition,
re-written and enlarged. Pp. xiii -f 454. Price $2. New York : The Macmillan Co.,
1918.
The science of dietetics and nutrition has been much neglected in this country, and,
although British workers have contributed in some degree to the advances recently made
in the subject, the bulk of the work has emanated from American laboratories. It is not
surprising, therefore, that most of the current text-books dealing with the chemistry of food
and metabolism also come from across the Atlantic. Some of them are highly technical and
are suited more to the specialist than to the student or general practitioner, but the work under
review, by the Professor of Food Chemistry in Columbia University, compiled as the result
of several years’ experience in teaching, does not belong to that class, and furnishes a concise
yet sufficient summary of the subject for all who are interested in food as a factor in health
and disease. The first edition, published in 1911, has now been re-written and enlarged.
The scientific foundations on which our present views of food and nutrition are built are
JA-11
20
adequately described, and particular attention has been paid to the difficult task of presenting
the striking results of some of the most recent investigations of the effects of various food
constituents on growth and disease in such a manner as to make clear their importance
without giving an exaggerated impression, and with due emphasis upon the fact that on
many significant points any interpretation now offered is necessarily tentative. It should bo
pointed out that this book is concerned only with the chemistry of the subject with which it
deals, and is especially concerned with the food requirements of man and those considerations,
which should guide our judgment of the nutritive value of foods. A detailed description of
the individual articles of dietr has appeared in another volume by the same author, entitled
“ Food Products.” The two together form a useful introduction to the science of dietetics,
and for those who wish to study any particular branch of the subject more deeply the
references at the end of each chapter will afford a satisfactory guide.
The Operative Treatment op Chronic Intestinal Stasis. By Sir W. Arbuthnot
Lane, Bt., C.B. Fourth edition. With 133 illustrations; pp. xii-f 328. Price 20s.
net. London : Henry Frowde and Hodder and Stoughton, 1918.
In the fourth edition of Sir Arbuthnot Lane’s well-known work the views of several
authorities on special branches of medical science have been included as separate chapters.
Professor J. G. Adami, who, in 1914, rather vigorously criticized the doctrine that seventeen
symptoms and nine diseases were indirectly due to intestinal stasis, contributes an interesting
and broad-minded essay on “Intestinal Stasis, Intoxication and Subinfection,” and from
further consideration finds how slight now is the difference of opinion between his and Sir
Arbuthnot Lane’s views. He agrees that strain brought to bear upon the mesenteries and
main areas of suspension of the bowels results in the production of non-inflammatory bands,
but, though he pays passing tribute to Dr. Mutch’s work, originally published in the Quarterly
Journal of MediciTie (1914) and now reproduced in this volume, he shows reason for his belief
that the diverse symptoms are not solely due to intoxication, but #lso depend on the escape of
bacteria into the tissues and organs of the body. In support of the bacterial factor he quotes
Rosenow’s experimental production of fibrositis by streptococci of a low grade of virulence, and
Mutch’s conclusion that Still’s disease is due to the growth in the intestine and passage into
the circulation of the Micrococcus citreus. He, however, admits the existence of a considerable
number of conditions both acute and chronic, of infectious origin—of non-specific morbid states
—which may be produced, not by a single species of pathogenic microbe, but indifferently by
several species, such as may be present in the alimentary canal. In his contribution on “ The
Great Bowel from an Anatomist’s Point of View,” Professor Arthur Keith concludes that
the real cause of intestinal stasis is a lesion of the neuro-muscular system of the intestine*
which in the first instance may be functional, though later structural changes may follow,
the peritoneal bands and adhesions being not the cause but in most instances a mere accom¬
paniment of stasis. Dr. Mutch’s two papers contain the results oi much laboratory research ;
the first, on the bacterio-chemistry of the small intestine, has already been mentioned ; the
second, on “ Chronic Streptococcal Infection of the Alimentary Canal,” is based on the
examination of cultures secured at operation or from the colon immediately after its removal
by Sir Arbuthnot Lane. Local delay is the primary, and deficient assimilation of food in
the upper parts of the digestive tract the second, essential factor favouring streptococcal
growth in the intestines, a rich nitrogenous diet being requisite for streptococcal growth, and
for streptococcal predominance in the presence of Bacillus coli , which exerts an inhibitory
influence, a generous carbohydrate admixture. The results of infection with Streptococcus
longus —pain, diarrhoea, pyrexia, arthritis -are aggravated by excess of carbohydrates, and,
clinically, benefit may result from diets either carbohydrate-free or protein-free. Dr. Jordan
also has two well-illustrated articles—one at the beginning, the other at the end of the
volume—on the skiagraphy of chronic intestinal stasis. The influence of intestinal stasis
in hastening presbyopia by inducing sclerosis of the lens is whole-heartedly emphasized by
Mr. Ernest Clarke. Sir James Mackenzie’s chapter on “ X-disease ” from his well-known
work is included, though at the time when it was written he had not yet come to the con¬
clusion that he now has, that the condition he called X-disease and chronic intestinal stasis
21
were identical. Major A. White Robertson describes the blood picture, and Dr. Leonard
Williams the medical aspects of intestinal stasis. The main part of the volume is, of course,
Sir Arbuthnot Lane’s full account of the disease with which readers are in the main familiar.
The evolution of his views is shown by the inclusion of articles—for example, “ The Anatomy
and Physiology of the Shoemaker ” - written thirty years ago, on the effect of strain in
producing changes in the skeleton, for a similar crystallization of resistance in the abdomen
leads to the formation of bands which, at first serving a useful purpose, eventually become
of pathological importance.
Typhoid Fever considered as a Problem of Scientific Medicine. By Frederick P.
Gay. Pp. xi -f 286. Price $2.60. New York : The Macmillan Co., 1918.
The author’s purpose is to point out the relations of the laboratory and'clinic in
connexion with the problem of typhoid fever ; he also aims at striking a balance between the
clinical treatises of Curschmann and others on the one hand, and the many excellent
laboratory and public health works on the other. It is the life-history of the typhoid bacillus
that has been followed up in this book, rather than the manifestations of the disease it
produces, and the book gives a very clear insight into the nature of the problem. The modes
of infection, the diagnosis and sequelae, occupy four chapters, and an excellent account of our
present-day knowledge of the “ carrier” state is found in Chapter VII. The author discusses
at some length the questions of the general measures of prevention, the artificial immuniza¬
tion against typhoid fever, and also the protective value of vaccination against typhoid.
A chapter is devoted to the paratyphoidal infections. In the chapter on treatment the
author states that “ the book is in no way designed to serve as a clinical manual . . . our
consideration of the treatment of typhoid fever logically limits itself to a consideration of
certain types of therapy which may be regarded as really efficacious in modifying the course
of the disease or as specific in nature.” The chapter on “ Suggested Methods of Advance in
solving the Typhoid Problem” is interesting. An exhaustive bibliography has been added,
but there is no index.^
The Chemistry of Synthetic Drugs. Second revised edition. By Percy May, D.Sc.Lond.
Pp. 250. Price 10s. 6d. net. London : Longmans, Green and Co., 1918.
This is more than a mere description of the chemical nature and mode of preparation of
synthetic drugs ; attention is paid to the reactions between the drugs and the living organism,
and as regards the relation between the chemical characters and pharmacological actions of
drugs it is shown that wide generalizations cannot be drawn and that it is only in the case
of closely related compounds that relationships can be traced. Valuable information can
often be obtained by studying the changes that a drug undergoes in the animal body, for by
this means light may be thrown on the action of the drug and guidance provided as to the
preparation of fresh synthetic products of a less toxic nature, the usual alteration of drugs
brought about by thS metabolism of the body being in the direction of the conversion of an
active and poisonous drug into one less active and less poisonous. Compared with foodstuffs,
most drugs are destroyed with difficulty by the body, and owe their activity to this property,
but if they are absolutely resistant they are quite inactive ; substances with a specific action
must be fairly resistant, otherwise they would react with all protoplasm. After three
introductory chapters dealing with the theory and action of synthetic drugs, the effect of
various elements and radicles, and the chemical changes of drugs in the organism, successive
chapters are devoted to various groups of drugs, the narcotics and general anaesthetics,
antipyretics and analgesics, the alkaloids, atropine’ and the tropeins, the morphine and
isoquinoline groups of alkaloids, adrenalin and other derivatives of ethylanline, the
derivatives of phenol, antiseptics, the purin derivatives (diuretics) and purgatives. In
the chapter on the arsenic and antimony compounds a good description is given of the
salvarsan preparations and reference is made to Danysz’s luargol. The last chapter, “ on
various other compounds of interest ” deals with the glucosides, camphor, and, among
the sulphur compounds, with ichthyol, ichthalbine, and intramine or di-o-aminophenyl-
disulphide. There is a useful index and the book is of a convenient size and get-up.
22
Hygiene op the Eye. By Wm. Campbell Posey, A.B., M.D. With 120 illustrations ;
pp. x -f- 344. Price 18s. net. Philadelphia and London : J. B. Lippincott Co., 1918.
The main object of this work is an appeal to the general public in respect of matters
concerned in the preservation of the eyesight. Thus from the educational point of view the
subject is fully discussed, in relation to errors of refraction, spectacles, strabismus, artificial
lighting, and school life generally, and the daylight illumination of rooms and buildings.
A review follows of the more common diseases of the eye, and observations are added upon
the manner in which the eye is affected by the general health. Blindness and the diseases
and conditions leading fco it are discussfed together with the national movements which are
being made towards its prevention. Particular attention is given to ocular injuries, arising
from the risks incurred in the course of industrial occupations, and the means of preventing
such injuries. A good deal of elementary knowledge of the subject is contained in the
twenty chapters, and the language employed by the author is as free from technicalities
as his subject permits. A full index completes the volume.
A Histoby of the Bristol Royal Infirmary. By G. Munro Smith, M.D., L.R.C.P.Lond.,
M.R.C.S. With 87 illustrations; pp. xiii + 507. Price 12s. 6d. net. Bristol :
J. W. Arrowsmith, Ltd., 1917.
The author of this work did not#live to see the completion of his labours, but a large
portion of it was in type, and the proofs were corrected by him before he passed away, on
January 13, 1917. Some quaintly worded memoranda of the early part of the eighteenth
century show that the Bristol Royal Infirmary was founded in or about the year 1735.
This book is the history of the institution from that date down to June 28, 1912, when the
new surgical wing was opened by Their Majesties the King and Queen. But while the
historical object is rigidly adhered to in the narrative, at the same time that only forms
the basis for an extraordinary number of anecdotes, for the most part humorous, relating to
the old medical worthies of Bristol and to the patients under their care. The sidelight which
these anecdotes throw upon medical practice in the eighteenth century is not only very
entertaining, but instructive. The book is a storehouse of medical stories, unfamiliar, and
worthy of the telling.
Diseases of the Eye. By J. Herbert Parsons, D.Sc., M.B., B.S., F.R.C.S. Third
edition. With 18 plates and 319 text figures; pp. viii + 667. Price 16s. net.
London : J. and A. Churchill, 1918.
The author has made considerable additions to the text in this new edition. There is a
new section devoted to symptomatic diseases of the eye, inclusive of the ocular manipulations
of nervous and other diseases ; more space has been given to operative treatment, especially
in relation to the complications of cataract extraction and the more modern methods of
dealing with glaucoma, by means of trephining. An exhaustive index is another feature
worthy of notice. Although much new matter has been added the author has contrived to
reduce somewhat the size of the volume in comparison with the last edition.
Clinical Cardiology. By Selian Neuhof, B.S., M.D. With 20 plates and numerous
other illustrations; pp. xix + 302. Price #4.00. New York: The Macmillan Co.,
1917.
At a time when the subject of heart disease is being copiously written about in this
country, English readers will be interested in learning how the problems are viewed from the
American standpoint. The author describes the various mechanical aids to the study of
heart disease, and shows how the information gained through them may be applied clinically.
The polygraph and electrocardiograph and orthodiascope are fully described and the tracings
made by them are explained. An important section on the “ arrhythmias r follows, in which
the author explains in detail the significance of the various forms of irregular cardiac action,
their recognition by ordinary bedside methods, and their differential diagnosis. Endocarditis
23
and valvular murmurs are described after the method of the older writers. The thorny
subject of blood-pressure is fully dealt with and the conclusions of the writer may be-
commended to those who pin their faith to the value of sphygmomanometric readings.
As regards therapy in circulatory diseases, he deals only with those drugs which upon careful
clinical and pharmacological investigation have proved of real value. About digitalis he
notes the interesting fact that before the appearance of symptoms of overdosage the patient
may complain of “extreme hunger and hunger pangs.” He regards this symptom as
^indicating that sufficient digitalis has been taken, and considers it due to the stimulating
effect of the drug on the vagus nerve. The author’s intention of emphasizing the clinical
side of cardiology is certainly carried out. He gives'a number of clinical records of cases to
illustrate the various conditions dealt with. The personal note runs all through the book,
the author presenting the subject from his own point of view and from his own experience.
A final chapter on the therapy of pneumonia from the circulatory standpoint is not
encouraging to the therapeutist who indulges freely in “cardiac stimulants” in this
disease.
Studies in Electro-physiology (Animal and Vegetable). By Arthur E. Baines,
Consulting Electrician. With 10 coloured plates and 146 other illustrations ; pp. xxix
+ 291. Price 12s. 6d. net. London : George Routledge and Sons, Ltd., 1918.
Studies in Electro-pathology. By A. White Robertson, L.R.C.P. <fc S.E., Temporary
Major, R.A.M.C. With 2 coloured plates atid other illustrations ; pp. viii -f 304.
Price 12s. 6d. net. London: George Routledge and Sons, Ltd., 1918.
Mr. Baines lays emphasis on three points : the oneness of life, the part electricity plays
in vegetable and animal life, and the suggestion that the electromotive force should be made
a factor in the diagnosis and treatment of disease. The oneness of life so ably demonstrated
by Darwin, Wallace and others in the nineteenth century finds fresh evidence in the twentieth
in such scientific works as those under review. Professor Bose, of Calcutta, has already
familiarized us with the fact that plants respond to mechanical, chemical and electric stimuli.
Mr. Baines here shows that a similarity exists in vegetable and animal life not only in loco¬
motion and sensitiveness, but also in the part electricity plays in their growth, nutrition and
reproduction. Time was when the scientific world largely theorized on the physical basis of
life. We went a step further when we found that chemical actions accompanied and influenced
all vital phenomena. Mr. Baines takes us further still when he explains that chemical
functions are controlled by the electromotive force generated within the organism itself.
Perhaps one day we shall go higher still (if we have not done so already) and find that all
physical, chemical and electrical phenomena in the organism are dominated by the spirit
within, which is the ultimate basis of life and its various activities. The author’s main
contention is that man, like plants, is a self-contained electric machine, that the structure of
the body is primarily electrical and that electro-motive force precedes all chemical changes
in the body. He brings evidence to show that muscular impulse is due to neuro-electrical
and not to chemical disturbances, and that the nature of nerve impulse is also neuro¬
electrical. Whether vital resistance is synonymous with electrical resistance in the blood
and tissues, and how far we are justified in interpreting all life’s functions in electrical
terms, the future will decide. Meanwhile both Mr. Baines and Dr. A. W. Robertson set
out to prove that chemical degenerative changes are marked by electrical diffusion, and that
disease occurs when there is a loss of electrical resistance. A rise of temperature has much
the same effect upon enzymes as it has upon the velocity of nerve impulse, so that we may
well believe that enzymic and metabolic action instead of being wholly chemical may in
some measure be electrical. Besides raising the question of interpreting vital phenomena
in electrical values, the authors open up a wide field in indicating new lines of medical
research. The study of biochemistry and chemical pathology suggests that disease may be
due to some disturbance in the manufacture and elaboration of chemical elements such as
catalysts, enzymes, vitamines, &c. The study of electro-physiology and electro-pathology
may divert our research from bacterial and chemical factors to the generation and
>24
diffusion of electromotive force in the body system, and thus compel us to modify
or revolutionize our ideas concerning the aetiology, the diagnosis and treatment of
disease.
Lyon’s Medical Jurisprudence for India, with Illustrative Cases. By L. A. Waddell,
C.B., C.I.E., LL.D., M.B., F.L.S. Sixth edition. With 69 illustrations ; pp. xiii -f
783. Price 28s. net. Calcutta and Simla: Thacker, Spink and Co., 1918.
This book has been revised, and several of the chapters rewritten. Dr. Waddell follows
the arrangement usual in most text-books on forensic medicine. In his early chapters he
deals with medical relations with law courts, and he covers fully the special difficulties in
detecting crime peculiar to India. Methods of identification of both the living and the dead
are then considered, and in the succeeding chapters various forms of death from violence are
examined. Numerous illustrative cases call attention to the differences in medico-legal
methods in India and this country. In the chapter on rape, there is an interesting
diagram of the Trichomonas vaginalis drawn from life by Professor A'. Powell. This shows
that the figures of the organism which appear in the standard text-books are seriously
inaccurate in important respects. The second part of the book is devoted to toxicology, and
contains accounts of many Indian poisons which are unfamiliar in this country. Numerous
clearly drawn illustrations are included in the book.
Proth^se et Chirurqie Cranio-Maxillo-Faciale. Par J. Lebedinsky et M. Virenque.
Preface de Dr. H. Delageniere. With 421 illustrations ; pp. xvi + 398. Price 27 fr.
Paris : J. B. Baillkre et fils, 1918.
MM. Lebedinsky and Virenque, dentist and surgeon respectively, record their experiences
of eighteen months’ work and over 700 cases in the centre of surgery and prosthetics of the
fourth region. Perhaps the most interesting part of the work is that describing the technique
and results of osteo-periosteal grafts taken from the inner surface of the tibia and used in
cranioplasty, grafting of the mandible, and restoration of facial contour. From a short
preface we learn that the process is due to H. Delageniere, chief surgeon of the second
surgical section of the fourth region. An autograft must be used, and immobilization and
intimate contact between the graft and the receiving bone are essential since the available
evidence seems to show that part at least of the success of the operation is due to bone-
forming elements growing into the graft from the adjacent bone. Of fifteen cases of man¬
dibular grafting, nine resulted in complete cure, two showed slight mobility between the
fragments, one was unimproved—the patient being refractory, four were of too recent date
to report on. In cranioplasty and facial restoration the results have been uniformly good.
In cranioplasty the slight curve which the suggested graft takes as it is peeled off the tibia
becomes a useful factor in avoiding compression. A large part of the work is devoted to
injuries of the jaws requiring collaboration of dentist and surgeon. The dentist’s r61e con¬
sists chiefly in devising apparatus for the reduction of deformity and the maintenance of
immobility. Though there is nothing new in the various apparatus employed, nothing that
is useful has been omitted. Exception may perhaps be taken to the form of splint fixation,
figured on p. 158, in which a screw passes between two teeth—it appears unclean and painful.
The authors recommend early fixation of fractured jaws by means of an “ appareil de con¬
tention,” claiming that thereby disinfection is favoured and diffusion of infection prevented.
Many who have seen cases of early fixation at a later period will be inclined to argue that a
splinted jaw demands greater attention to the minutiee of cleanliness than an unsplinted
jaw. The fact, however, that MM. Lebedinsky and Virenque are able to report good results
from its use shows that, in careful hands, the patient may be given the undoubted advantages
of early fixation. The authors aim always at securing a soundly-healed jaw, holding that
no apparatus can compensate for the disability consequent on failure of bony union. Immo¬
bility of the jaw has been found in 96 per cent, of the cases to be amenable to bloodless
treatment by stretching, being most often of myopathic origin ; cases needing operation
might have been lessened by early treatment. Restoration of facial contour, especially of
25
the nasal part, is the subject of many interesting pages, and the authors record their obser¬
vations of practically every injury that occurs as a result of craniofacial wounds—traumatic
aneurysm, injury of cranial nerves, secondary haemorrhage, &c. Ever}' class of case is
illustrated from life, and the numerous photographs and X-ray pictures explain the text
most admirably. Throughout, the importance of early disinfection is insisted on, and one
cannot help feeling, after reading the book, that a sound application* of surgery is of more
importance, even in treating mandibular injuries, than skill in mechanics. The authors
show how much may be done to remedy facial deformity by skill and patience, but, to judge
by their records, do not seem to have had the handling of the severest cases in which large
parts of bone and soft parts have been torn away.
The Soldiers’ Heart and the Effort Syndrome. By Thomas Lewis, M.D., F.R.C.P.,
F.R.S., D.Sc. Pp. xi -f 144. Price 7s. 6d. net. London : Shaw and Sons, 1918.
Disorders of the cardiovascular system found in patients discharged from the Army for
“ disordered action of the heart ” (D.A.H.) and for “ valvular disease of the heart ” (V.D.H.)
form the main subject of this book. As at least one such patient has been kept in the Army
for every man discharged, no less than 70,000 soldiers have been classed under these headings
since the beginning of the war. These purely army terms are chiefly made up of disorders
and not diseases. The majority of cases consist of patients who have no structural heart
disease, but form, under the heading of “ effort syndrome,” which constitutes a complex of
symptoms and signs, a group showing exaggerated reactions of the body to exercise. The
term is used by Dr. Thomas Lewis to gather together certain usual symptoms and signs,
“ independently of the manner in which these are brought about or the disease from which
the patient actually suffers." Under “ effort syndrome ” are included breathlessness, palpita¬
tion, prtecordial pain, giddiness or faintness, fatigue and exhaustion, headache, sweating,
and other peripheral phenomena, together with increased heart-rate and rise of blood-pressure
on slight exertion. The author aims at helping the medical officers of recruiting, dis¬
charging, and pensioning boards, and others in charge of patients. Two appendices deal
with medical reports on discharged soldiers and with routine examination of the heart in
recruits, &c.
The Unsound Mind and the Law : A Presentation of Forensic Psychiatry. By
George W. Jacoby, M.D. Pp. xiv 4- 424. Price $3. New York and London :
Funk and Wagnalls Co., 1918.
The writer states he has written this work because he considers it the duty of every
neurologist and psychiatrist to contribute his share to the practical extermination of the extra¬
ordinary conceptions of mental disorder that conflict so sharply with our present-day
knowledge, and not infrequently place insuperable obstacles in the way of correct juristic
estimation of medico-legal problems affecting the insane. As an introduction, he shows
how antiquated the law is in dealing with Jhe questions of mental responsibility, and points
out the necessity for some training of the legal mind in this respect, without which justice
cannot be adequately meted out. An historical retrospect on the conceptions of mpntal
disease is given, and in modern times he thinks we can have no better pattern of the
medico-legal psychiatric practice than that furnished by the civil and criminal statutes of
Germany. Chapters follow on the notion of mental disorder, psychopathic disposition,
exogenous causes of mental disease, and the responsibility of those mentally afflicted.
Many pages are devoted to the examination of the insane, and are followed by a description
of the psychoses and neuro-psychoses with their differential diagnosis and forensic aspects.
The third part of the book deals with hypnosis in its'medical and legal aspects and the
anomalies of sexual sense. In conclusion, some practical examples are given of cases
where responsibility was in question, and written reports on their mentality are presented
in some detail. The author throughout is an advocate of psycho-physical parallelism,
and the value of the book would have been much greater had the writer’s conception of
26
mental disease been more modern. It seems important to draw attention particularly to
two statements made which are much at variance with present-day knowledge. “The
expression 1 mental disease ’ is misleading, inasmuch as it conveys the impression of
a disease of the mind as opposed to a,disease of the body. Mental disease is bodily disease,
and differs from other forms of such affliction merely by reason of the fact that it has its
seat in the brain.” And also that: “psychology is but part of the physiology of the
central ne/vous system.”
IproceeMnae of the 1?opal Society of flDebtcine.
SUPPLEMENT
(Vol. XII, No. 6, April-May, 1919).
NOTES ON BOOKS.
[The purpose of these “ Notes " is neither to praise nor to blame , but merely to draw
attention to some of the new books and new editions which have been added to the
Society's Library*— Ed.]
Tumours: their Nature and Causation. By W. D’Este Emery, M.D., B.Sc.Lond.
Pp. xx -f 146. Price 5s. net. London : H. K. Lewis and Co., Ltd., 1918.
•
The theory is advanced that cancers and tumours are of parasitic origin, the parasite
being of so small a size as to defeat our present means of observation. This ultra-microscopic
microbe lives inside the cell or its nucleus and produces a toxin which induces cell-division.
According to this theory, the microbe probably exists in a state of symbiosis with a tissue
cell and these together form the equivalent of a new individual which behaves as a parasite.
Reasons are offered in support of these postulates, and the natural history of neoplasms is
reconsidered in the light of the author’s theory. It is suggested that there is much in the
histology and conduct of neoplasms in favour of the theory and that experimental work
supports it. Qn the other hand difficulties which arise in connexion with transplantation,
the specificity of neoplasms, age-incidence and the production of immunity are all capable of
satisfactory explanation.
Hypnotic Suggestion and Psycho-therapeutics. By A. Betts Taplin, L.R.C.t. and
L.M.Edin. Pp. 168. Price 10s. 6d. net. Liverpool : Littlebury Bros., 1918.
A short summary of the subject, covering problems of (1) conservation, dissociation,
automatism, and emotional energy ; (2) therapeutics ;—re-education and persuasion, waking
suggestion, psycho-analysis, and hypnotic suggestion. The remaining third of the book is
devoted to the application of the author s teaching to conditions such as neurasthenia,
psychasthenia, dipsomania, neuritis, chorea, Meifldre’s disease, asthma, skin disease, and
moral insanity. Obviously, in a small work of 168 pp. the treatment of these topics is
concise, but as the work is intended primarily for medical men, the author has assumed
some knowledge of the subject on the part of the reader. His practical hints on methods,
culled as they are from an evidently wide experience, are of much value. The book is written
with conviction, and with a first-hand knowledge of the subject; the author wastes no time on
speculative matters, and his teaching will be appreciated both by students and practitioners.
One only wishes that Dr. Betts Taplin had given himself more scope, especially in his
account of the principles upon which medical psychology is based.
A— 12
28
Intravenous Injection in Wound Shock. Being the Oliver-Sharpey Lectures delivered
before the Royal College of Physicians of London in May, 1918, by W. M. Bayliss,
M.A., D.Sc., F.R.S. Pp. xi -f 172. Price 9s. net. London : Longmans, Green and
Co., 1918.
This is an amplification of the lectures published in May, 1918, and embodies the
conclusions of the “Special Committee for the Investigation of Surgical Shock and Allied
Conditions” appointed by the Medical Research Committee and presided over by the author.
The term “ wound shock,” suggested by Cowell in 1917, does not include the mental
disturbances sometimes known as “shell shock,” and its most obvious signs are a low
blood-pressure and the consequences of deficient blood-supply to the vital organs, and
especially the nervous centres, that result therefrom. The primary cause of wound shock is
unknown, and the author shows that the hypotheses that it is due to acapnia, exhaustion
of the adrenals or of the nerve centres, inefficient cardiac contraction, or vasomotor paralysis
are untenable. The question of acidosis is considered at length and the conclusion is
reached that the acidosis sometimes present in wound shock is innocuous in itself and may
even be beneficial in increasing the supply of oxygen by greater pulmonary ventilation.
The state brought about by haemorrhage alone is in practice very difficult to distinguish from
secondary wound shock, and the view that has most evidence in its favour at present is that
in both states there is a loss of blood from currency, or “ exaemia ” in Cannon’s phraseology.
One of the most serious causes of wound shock is the absorption from injured tissues,
especially muscles, of toxic products whfch, like histamine, dilate the capillaries and by thus
causing stasis withdraw the blood from circulation. The means of treatment are led up
to throughout and thoroughly discussed ; isotonic and hypertonic salt transfusions effect
transient improvement only, as the fluid escapes from the vessels in about half an hour, and
the use of vaso-constrictor drugs is deprecated. Transfusion of blood or injection of preserved
red blood corpuscles is the logical course, and in cases with haemorrhage it would naturally
be first employed, but the intravenous injection of a 6 per cent, solution of gum arabic in
0*9 saline solution does nearly or quite as well and has advantages in the greater ease with
which it can be obtained, and in other ways, such as absence of tests to avoid hemolysis
and agglutination of the red cells. A pint should be given at once and repeated if and when
necessary.
Papers on Psycho-analysis. By Ernest Jones, M.D., M.R.C.P.Lond. Revised and
enlarged edition. Pp. x -f- 715. Price 25s. net. London : Bailliere, Tindall and
Cox, 1918.
As the title implies the book is merely a compilation of papers on many of the topics
which oome within the scope of psycho-analysis; but the author gives his readers, step by
step, with almost as much system as a text-book, a clear account of the subject and the
light it throws upon the bases of human thought. The work is interesting and helpful,
not only to those who wish to., know what psycho-analysis is, but also to those already
engaged in psycho-analytic investigation. The psychological principles here discussed have
primarily a bearing upon the psychopathology and psychotherapy of functional nervous and
mental disorders ; but they are also of importance in every walk of life and will in future
have special significance in the education of the young. The work deals with such a wide
range of subjects and is everywhere so full of information that an abstract, if this were
possible, could only give erroneous impressions. The book itself must be read from cover
to cover. . #
The Adventure of Life. By Robert W. Mackenna, M.A., M.D. Pp. xiii -f- 306.
Price 6s. net. London: John Murray, 1919.
Addressed to the intellectual public, the author makes a strong appeal, mainly from the
biological standpoint, for the abandoning of the purely materialistic theory of life. The idea
of the immanence of God in nature and in human life is not inconsistent, he maintains,
with the workings of the great natural forces. “ Is it an impious assumption,” he asks.
“ to imagine that when we come to consider life we shall find that the Creator is true to His
29
own methods and uses a form of energy which we may call the life-force or life-wave to
quicken protoplasm to activity? ” The author holds that problems of life, dark and obscure
though many of them may be, are not incapable of solution, and encourages us to believe that
the clue to life’s mysteries has its origin in Law, while it ends in Providence. Written, as
this book was, in a little bell-tent within sight of a tortured city in Northern France, the
author derives consolation from the golden figure of the Madonna and Child towering over
the inhabitants from a lofty pinnacle of the church, which stands as “ a perpetual witness to
remind us that, though man may make a mess of his life and by the misuse of his talents
and opportunities bring suffering and evil upon the earth, over all and above all there still
reigns triumphant—God.”
Meat Inspection Problems ; with Special Reference to the Developments of
Recent Years. By William J. Howarth, M.D., D.P.H. Pp. viii + 143.
Price 6s. net. London : Bailli&re, Tindall and Cox, 1918.
The last four chapters of this book formed the Milroy Lectures in 1917. Chapter I gives
a brief account of the development of meat inspection in England. Chapter II deals with
general administrative problems as they concern the inspection of flesh meat. The inequality
of meat inspection in different parts of the country is emphasized, while the facilities which
exist for adequate inspection are considered. A good deal of attention is paid to the subject
of the marking of meat after inspection. The author considers that under existing conditions
a universal system of compulsory meat marking is impracticable, but he advocates such a
system on an adoptive basis under Government control. The continental system of a three
standard basis of meat inspection is only very sketchily dealt with. Chapter III deals with
the tuberculosis problem $>s affecting cattle. Extended consideration is given to the subjeot
of the paths of infection in cattle, and this is the'more valuable because of the detailed
description given, in Appendix I, of the lymphatic system. The Recommendations of the
Royal Commission receive careful consideration. Chapter IV deals in considerable detail
with the tuberculosis problem as affecting pigs. Chapter V is concerned with imported meat
and is largely occupied with a description of the pathological conditions which may be met
with in imported carcases and other parts of meat. The foreign meat regulations are briefly
described, and a short account is given of the regulation of cold stores. Chapter V concludes
with a number of definite recommendations which the author considers necessary in order
to put meat inspection on a more satisfactory basis.. The appendices include one upon the
inspection and manner of packing of imported offal and boneless meat and one upon
the sale of sterilized unsound meat.
The Intensive Treatment of Syphilis and Locomotor Ataxia by Aachen Methods
(with Notes on Salvarsan). By Reginald Hayes, M.R.C.S. Third edition. Pp.
vii -f 92. Price 4s. 6d. net. London : Bailli&re, Tindall and Cox, 1919.
The author has doubtlessly written this book with the object of bringing before the
present-day syphilologist what may be achieved, especially in nervous syphilis, by mercurial
inunctions, properly performed. Aachen was the German Mecca for sufferers from syphilis,
and owed its popularity not only to the efficient way in which inunctions were carried out,
but also to the fact that the combined treatment with sulphur was practised there. Now that
the rationale of the action of sulphur is understood, and excellent compounds of this drug
have been manufactured in England, the author shows that sufferers can now obtain as
efficient treatment in this country as by going abroad for it. Inunctions are not boomed
to the exclusion of arseno-benzene, but given a place where they are more suitable.
Handbook of Physiology. By W. D. Halliburton, M.D., LL.D., F.R.C.P., F.R.S.
Fourteenth edition (being the twenty-seventh edition of “ Kirke’s Physiology ”). With
numerous illustrations ; pp. xx -f 986. Price 16s. net. London : John Murray, 1919.
The present edition of this well-known text-book has followed so closely upon the previous
one that only minor alterations in the text have been necessary. An appendix on war diet
is of present-day interest, but, as the author says, all will hope that it will not be a
permanent feature of the book.
30
The Science and Art of Deep Breathing as a Prophylactic and Therapeutic Agent
In Consumption. By Shozaburo Otabe, M.B.Tokio, M.D.B&le. Pp. viii + 114.
Price 5s. Det. London: John Bale, Sons and Danielsson, Ltd., 1919.
The science and art of deep breathing is here recommended as a prophylactic and a thera¬
peutic agent in consumption. For many years past in this country the practice of deep
breathing has been recommended by certain physicians for this special object as well as in
its more general applications, and in Japan Professors Kitasato and Futaki have earnestly
recommended this most useful method. The author begins by stating the motive which
induced him to study and apply this method first to himself and then to a more extended
circle with beneficial results. He then deals with the methods which he advocates, and the
salutary effects of deep breathing on the whole body, the mind, and in the prevention of
consumption. Dr. Otabe has also found the method of service in the treatment of con¬
sumption, and compares it with the effects of graduated labour on the whole body, which
connotes gradual exercise of the lungs. “ Therefore, if we would take care of the physical
condition of the patient and the state of his disease, we should recommend deep breathing to
him with the same discretion and under similar rules as we recommend graduated labour.**
One chapter is devoted to experiments in deep breathing on animals, shoeing the pro¬
phylactic effects on consumption. These investigations carried out on marmots, infected
with tubercle bacilli through the blood and lymph, are held by the author to show that the
daily application of deep breathing to some extent prevented development of the tuberculous
process in the lungs, but one cannot say that the results are convincing. The book repre¬
sents an interesting attempt to direct more widespread attention to a method of prevention
and treatment which is ofttimes overlooked in the search for more dramatic if less certain
methods. ^ *
The Edinburgh School of Surgery before Lister. By Alexander Miles, Surgeon
to th9 Royal Infirmary, Edinburgh. With 8 plates : pp. viii -f 220. Price 5s. net.
London: A. and C*. Black, Ltd., 1918.
The various phases in the development of the pre-Listerian school of surgery in Edinburgh
are set forth in this little book in twelve chapters. The history of the barber-surgeons marks
the first phase in the genesis of the surgical school, whilst the early anatomical school, with
James Borthwick at its head, may be regarded as the next stage. The Faculty of Medicine in
the University was not founded, however, until 1726. The old Royal Infirmary was opened in
1741, but it was not until the second half of the eighteenth century that a definite school of
surgery arose in Edinburgh,* with Benjamin Bell as its “ Father.** In 1777 a Professorship
of Surgery was established within the University, and Alexander Monro, the second, was its
first holder. The College of Surgeons instituted a separate Lectureship in Surgery in 1804,
with John Thomson as the first professor. It was not until 1831, however, that the Crown
established a separate Chair of Systematic Surgery, on the recommendation of the Town
Council, with John William Turner as its first incumbent. The Chair of Clinical Surgery
had been erected in the previous year by King George III, and James Russell was the first
holder. Three years later the Chair of Military Surgery was also founded by Royal
patronage, with John Thomson as the first professor. The importance of the Extra-mural
Sohool as a factor in medical education is insisted upon, for from its ranks the professoriate
has been largely recruited. Such names as Robert Liston, John Lizars, William Fergusson,
Richard J. Mackenzie, and James Syme, suffice to show the brilliance of the Extra-mural
School in the fifty years preceding the Listerian epoch. The period of Liston and Syme
mark the zenith of the fame of the pre-Listerian era of the Edinburgh Surgical School. The
performance pf the first major operation under ether anaesthesia in England by Liston at
University College Hospital in 1846 is described, as well as the first amputation at the hip-
joint performed in Scotland by Syme in 1823. An account of Syme’s operation for axillary
aneurysm in 1869, is detailed on p. 198, and for the first time brings us into touch with
“ Mr. Lister,” who assisted. As an historical monograph, enriched by many photographs,
this book will be prized by students of medical history.
proceedings of tbe T?o^aI Society of flDebtctne,
SUPPLEMENT
(Vol. XII, No. 8, July, 1919).
NOTES ON BOOKS.
[The purpose of these 11 Notes 99 is not so much to praise or % to blame as to draw attention
to and describe some of the new books and new editions which have been added to the
Society's Library .— Ed.]
Gilbertus Anglicus : Medicine of the Thirteenth Century. By Henry E. Hander-
son, A.M., M.D. With a biography of the Author. Pp. 77. Published post¬
humously for private distribution by the Cleveland Medical Library Association,
Cleveland, Ohio, 1918.
This epitome of the Compendium Medicinse of Gilbertus Anglicus is published post¬
humously by a Committee of the Cleveland Medical Library Association of Cleveland, Ohio.
Dr. Samuel W. Kelley and Dr. Clyde L. Cummer, the editors, have done their work well and
modestly. They have prefixed a portrait and a short biography of Dr. Handerson, and have
then printed the essay without further comment. The facts about Gilbert’s life are few, and
it is difficult to determine the exact date at which he lived. Dr. J. F. Payne gives 1170-
1230; Mr. C. L. Kingsford places him twenty-five to thirty years later; and Dr. Freind later
still. Dr. Handerson, after a careful examination of all the facts, states that he was prob¬
ably bom about 1180; published the Compendium or Laurea Medicinse, as it is sometimes
called, in 1240, and died in 1250. He lived at any rate before the period when medicine and
surgery were as sharply separated as they afterwards became, for the work contains chapters
on surgery, though it is chiefly devoted to medicine. Dr. Handerson indeed goes so far as to
say that the chapters on surgery “ present a more scientific and complete view of surgical art,
as then known, than any contemporaneous writings of the Christian West, outside of Italy.”
The Compendium, as its name implies, is 44 a book of general and special diseases, selected
and extracted from the writings of all authors, and the practice of the professors.” This
is Gilbert’s own description of his book, and in another place he says: At It is our habit
to select the best sayings of the best authorities, and, where any doubt exists, to insert the
different opinions, so that each reader may choose for himself what he prefers to maintain.”
The book, therefore, like that of Bernard Gordon, is essentially a text-book, but Gilbert docs
not hesitate to state his own views on various questions, and, like all good teachers, he taught
dogmatically. There are a few misprints, none serious, but there is no index, and this the
editors should have supplied.
Organic to Human : Psychological and Sociological. By Henry Maudsley, M.D.
pp. viii *f 386. Price 12s. net. London : Macmillan and Co., Ltd., 1916.
The author attempts to trace development from organic existence to human life, and
holds the balance between various schools of thought, the spiritual and the material. He
deals with life and its crystallization into mere existence or mental expansion, from the
aspects of psychology and sociology ,and when human life as such is reached, it is considered
ju—21
32
psychologically and socially. As we pass towards the concluding chapters one seems to hear
the words of the preacher, “ All is vanity and vexation of spirit” ; “Mind is an organized
federation of many nervous plexuses or so-called complexes ” ; “ The largest part of mind is
usually quiescent in its habitual functioning, and a large part of its mentality always un¬
developed.” Mind, we are told, does not itself perform; the concrete person, not the
abstract metaphysical freewill in the particular self, is concerned with every conscious
thought and act. Mind being fundamentally life in mind, necessarily suffers with its
sufferings. If it is true that there is nothing good or bad, but thinking makes it so, it is
more deeply true that there is no thinking, good or bad, but the body makes it so. Sex and
its activities are considered in their relation to consciousness and continuity in life. This
onlooker upon the passing show of life seeks to see whither man’s activities trend. He
interrogates science—i.e., the teaching of observed phenomena and deductions therefrom.
Heredity, man-made schemes for melioristic advance ; Religion, with its clamant call to
prayer; Social Democracy, the aims of which, it is pointed out, are too often predatory
rather than moral—all pass under a searching review, weighed in the balance, and found
wanting. Yet the seer contends no one can doubt that betterment—physically, mentally,
and morally—is slowly being evolved through the welter of the ages which, so immense to a
generation, is a grain of sand in eternity. Education offers, it is hoped, a means for
advancement, but to what? Is each generation to gain, and then must come the end?
Free will cannot act without memory, and the exercise of memory needs that we take
account of the necessary physical antecedents of the ego, and of memory itself. Meta¬
physics must* without the aid of biology, prove a blind leader of sightless humanity, but
there are paths along which, if we admit their existence, biology leaves metaphysics un¬
guided and alone. The discarnate ethereal spirit, the yearning faith in God, and a super-
sensual communion in a life after death, remain problems unsolved save by him who admits
that what his finite mind cannot grasp, his trained finger may not probe.
A Text-book of Midwifery for Students and Practitioners. By R. W. Johnstone,
M.A., M.D., F.R.C.S., M.R.C.P.E. Second edition. With 264 illustrations. Pp. xxvi
-f- 495. Price 12s. 6d. net. London : A. and C. Black, Ltd., 1918.
This second edition follows the lines of the first edition, published in 1913. It gives in
482 pages all the midwifery that a student needs, and is a .welcome change from the
numerous large and expensive text-books that have been published in recent years both here
and in America. It contains the Edinburgh teaching in a concise and clear form and, in
places, saves space by being dogmatic. Tables and classifications are given that should be
of considerable use to a student preparing for examination. This edition has been thoroughly
revised in spite of the difficulties occasioned by the absence of the author on service, and
new articles on the use of scopolamine-morphine and of pituitary extract in labour have been
added. The articles on the development of the ovum and placenta, and on the physiology
of pregnancy, are unusually full for a book of this size.
Malaria and its Treatment, in the Line and at the Base. By Captain A. Cecil
Alport, R.A.M.C.(T,), M.B., Ch.B.Edin. With 8 coloured plates and 30 other
illustrations; pp. xii -j- 279. Price 21s. net. London: John Bale, Sons and
Danielsson, Ltd., 1919.
The author describes his experience in the treatment of several thousands of cases of
malaria in Macedonia. The outstanding feature of the work is the writer’s contention,
based on the results of personal observation, that larger doses of quinine than those usually
given are necessary for the successful treatment of this disease. Several chapters are
devoted to the treatment of severe types of the malady, such as cerebral malaria, bilious
remittent fever, &c., and in these cases intravenous and intramuscular injections of quinine
are strongly recommended in order to make an immediate attack on the parasites in the
blood. Records of the treatment and progress in a large number of cases are given to illus¬
trate the efficacy of the methods used. The technique for intravenous injection is described
33
in detail. In the treatment of chronic malaria, the author considers that inadequate doses
of quinine are frequently employed; and he recommends, generally speaking, 30 gr. per
diem for a period of several months. For malarial anaemia, he finds arsenic by the mouth
the most useful remedy, intravenous injections of galyl being of service only in special cases.
The value of lumbar puncture for the differential diagnosis of cerebral malaria from menin¬
gitis due to various causes is pointed out. The different views regarding the obscure aetiology
of blackwater fever are briefly discussed. The author is of opinion that it is due to negleoted
malaria, with cold and fatigue as predisposing causes of an attack, and he emphatically
advocates the administration of quinine as the correct line of treatment. A careful distinc¬
tion is drawn between blackwater fever and malarial haemoglobinuria (“ redwater fever ”),
on the one hand, and quinine hsemoglobinuria on the other. In the latter condition quinine
is of course withheld. A short description of the morphology and life-cycle of the malaria
parasite, of the natural history of mosquitoes, and of prophylactic sanitary measures in
malarial countries, are included in the volume.
The Twin Ideals; an Educated Commonwealth. By Sir James W. Barbett, K.B.E.,
C.B., C.M.G., M.D., M.S., F.R.C.S.Eng., Temporary Lieutenant-Colonel R.A.M.C.
In two volumes, with maps and diagrams. Pp. xxxii -f 512 and xx -f 504. Price 25s.
net. London : H. K. Lewis and Co., Ltd., 1918.
The author has published these volumes of essays, because of the interest his son, to
whose memory they are dedicated, took in the problems discussed. Captain K. J. Barrett
was killed in France on April 16,1917. The essays comprise a remarkable variety of subjects.
To enumerate the titles of all of them within the space at our command would be impossible.
Many are devoted to university questions ; others to education, medicine, venereal disease,
town-planning and playgrounds, rural life, travel and immigration, music, electoral reform,
Imperial and Australian politics. The cosmopolitanism of the author’s views, widely mani¬
fested, has been gained by travelling in countries for his personal information, and obviously
by extensive reading. His chief outlet for publication was the Melbourne Argus , but some of
the essays have appeared, as contributions, in the London daily newspapers. Candidly,
these volumes provide interesting instruction ; the views expressed are fresh and stimulating,
the style is vigorous and easy, and the remarkable fact remains that an ophthalmic surgeon
was able to find the time, amid his professional duties, to make himself an authority upon
so many diverse subjects.
Th® Australian Army Medical Corps in Egypt: an Illustrated and detailed
Account op the Early Organization and Work of the Australian Medical
Units in Egypt in 1914-1915. By Sir James W. Barrett, K.B.E., C.M.G., M.D.,
M.S., F.R.C.S.Eng., Temporary Lieutenant-Colonel, R.A.M.C., and Lieutenant P.
E. Deane, A.A.M.C. With 37 Plates. Pp. xiv -f- 259. Price 12s. 6d. net.
London:- H. K. Lewis and Co., Ltd., 1918.
A record mainly based upon the authors* experience in connexion with No. 1 Australian
General Hospital in Egypt. This hospital was the first effort of the Australian Government
to organize a medical service at Alexandria. Provision was made for 520 beds in the Heliopolis
Palace Hotel, and then began a stupendous work, which oulminated in the bed accom¬
modation being extended to 10,500 cases. The organization was barely in hand before the
arrival of the wounded from Gallipoli. The book must be read in order to obtain some idea
of the difficulties which were encountered, and how they were successfully overcome. The
narrative is one of a great achievement, of much self-sacrifice, of skilful organization,
creditable to all concerned in the enterprise. The book contains the reproduction of
numerous photographs, illustrative of scenes of the work. The value of the assistance of
the British and Australian Red Cross is ungrudgingly acknowledged. In looking back upon
their experience the authors attribute most of their initial difficulties to a policy of unpre-
paredness. The organization of the hospitals, they hold, should have been under revision,
in peace time. “ Our policy for the future,” they say, li must be one of scientific organization
and calculated preparation in every department.”
/
34
Crime and Criminals: being the Jurisprudence of Crime, Medical, Biological, and
Psychological. By Charles Mercier, M.D., F.R.C.P., F.R.C.S. With an Intro¬
duction by Sir Bryan Donkin, M.A., M.D.Oxon., F.R.C.P. Pp. xvii -f 291- Price
10s. 6d. net. London : University of London Press, JLtd., 1918.
A book for which the author has received the Swiney Award from the Royal Society of
Arts and the Royal College of Physicians, on a second occasion, needs little commendation.
In this work, the author, in his usual forceful fashion has arraigned a mass of evidence to
prove that, from a medioo-jurist’s point of view, crime and criminals are the result of the
interaction of both internal, individual and external environmental factors; opportunity and
circumstances are fundamental but these constitute but a portion of the factors at work.
The book is divided into nine chapters, entitled: The Factors of Crime, the Psychology of
Crime, the Nature of Crime, Kinds of Crime, Private Crimes, Family and Racial Crimes,
Criminals, Kinds of Criminals, and Prevention, Detection and Punishment of Crime. The
experience of Dr. Mercier makes him regard the reform of Society as a problem more
complicated than one of Laws, Housing and Politics. His views will greatly interest those
engaged in psychological and sociological problems.
What is Psycho-analysis? By Isador H. Coriat, M.D. Pp. 124. Price 3s. 6d. net.
London : Kegan Paul, Trench, Triibner and Co., Ltd., 1919.
This is admittedly a popular exposition of psycho-analysis. The print is large and the
pages are small, so that the whole might quite easily have been produced in fifty ordinary
pages. It is written in the form of questions and answers, the questions having been put or
suggested to the author by people in various walks of life, to whom a knowledge of psycho¬
analytic principles might be useful. The book contains too much information for a pro¬
spective patient and too little for a prospective psycho-analyst; yet it touches upon nearly
all the most important features and applications of psycho-analysis. We have noted a few
errors, but they are unimportant having regard to the class of reader for which the book is
intended. Of late we have come across several descriptions of psycho-analysis in articles
and books by writers who obviously know nothing about the subject (they are invariably
adverse). To such authors we would recommend the perusal of Dr. Coriat’s little book. It
may not convince them of the truths of psycho-analysis, but it might convince them of
their own lack of knowledge. Judging by the subject-matter of the book, the author appears
to be a Freudian, but his bibliography is catholic rather than select and does not supply any
clue as to the order in which the works it mentions should be studied by the beginner.
Anatomy, Descriptive and Applied. By Henry Gray, F.R.S., F.R.C.S. Twentieth
edition, edited by Robert Howden, M.A., D.Sc., M.B., C.M. Notes on Applied
Anatomy revised by A. J. Jex-Blake, M.A., M.D.Oxon., F.R.G.P.Lond., and
W. Fedde Fedden, M.B., M.S.Lond., F.R.C.S. With 1,168 illustrations of which
520 are coloured; pp. xvi+1824. Price £1 17s. 6d. net. London : Longmans, Green
and Co., 1918.
The continued issue of new editions of Gray’s Anatomy since 1858, has probably estab¬
lished a record in the history of English medical text-books. From the first it commended
itself to the student, and the services of five successive editors, including the author, having
been required to keep it up to date. Professor Howden, the present editor, in this, the
twentieth edition, has added a new feature by contributing a short biography of the famous
author, with a portrait. Henry Gray died at the premature age of 34, from confluent small¬
pox, and thus at this early age a life of great promise was suddenly cut off. During his
short life he gained many honours ; when only 25 he was elected a Fellow of the Royal
Society. This short biography, full as it is of interesting details of the author’s pre¬
eminence, should be continued as a permanent addition to his work, as further editions are
called for. The present issue includes about sixty new illustrations drawn by Mr. Sydney
A. Sewell. The Basle terminology is used throughout the text.
35
Manual op Bacteriology. By Robert Muir, M.A., M.D., Sc.D., F.R.S., and James
Ritchie, M.A., M.D., F.R.C.P.Ed. Seventh edition. With 200 illustrations in the
text and 6 coloured plates; pp. xxiv -f 753. Price 16s. net. London: Henry Frowde,
Hodder and Stoughton, 1919.
To the seventh edition of this well-known text-book only nine pages have been added, but
by the judicious use of $mall type for matter of less importance, a large amount of new
information has been incorporated. The first part of the book dealing with laboratory
methods has been brought up to date by the addition of descriptions of new media such as
Gordon’s trypagar for the meningococcus, Bordet’s medium for the whooping-cough bacillus,
the author’s method of sterilizing blood serum media, &c.; whilst new stains for the
spirochsete, &c., are also given. The section on antiseptics contains a concise description of
the recent work of Lorrain Smith, Dakin, Daufresne, Browning and others. In the chapters
devoted to the various bacteria much new matter has been added. We note, in the case of
the pneumococcus, fresh paragraphs on the work of the Rockefeller Institute on anti-serum
treatment and the classification of the organism by means of anti-sera; and in the same
chapter similar details'of Gordon’s work on the meningococcus. The account of the coli-
typhoid group also includes much of the recent work done during the war on the paratyphoid,
and dysentery bacilli, the agglutination tests and differentiation of strains, the use of anti-sera,
the question of mutation and other new problems. The chapter dealing with the anaerobic
bacteria has been largely re-written, and at the same time enlarged, so that it now contains
a comprehensive review of this important group. Naturally the largest portion is devotdd to
the Bacillus tetanus , but a number of the less common anaerobic bacteria are also described
in some detail. It is to be hoped that bacteriologists will soon arrive at a unanimous
decision as to the names of some of these less common anaerobes. At present the variations
in nomenclature in different text-books is somewhat confusing. Paragraphs on infective
jaundice and rat-bite fever have been added to the account of the spirochaetes and an
additional appendix inserted on trench fever. Fresh information, together with new illustra¬
tions, has also been incorporated with the appendix on amoebic dysentery.
Rack Regeneration. By E. J. Smith, Member of National Birth Rate Commission.
With 85 plates; pp. xii -f 223. Price 7s. 6d. net. London: P. S. King and Son,
Ltd., 1918.
The author is the Chairman of the Health Committee of the Bradford Corporation; he
has also written another book on maternity and child welfare. The declining birth-rate is
discussed in one chapter, and the author’s experience on the National Birth Rate Commission
lends weight to the opinions expressed in the chapter. The subject of housing is handled in
two chapters, and Mr. Smith explains the effects of bad housing on race regeneration.
Other subjects discussed are those of Racial Poison, Endowment of Motherhood, Clean Milk
Supply, the National Balance Sheet. The Bradford Scheme pf Maternity and Child Welfare
is given in full and should be perused by those not familiar with it. There are numerous
photographic reproductions.
Lice and their Menace to Man. By Lieutenant Ll. Lloyd, R.A.M,C.(T.). With a
Chapter on Trench Fever by Major W. Byam, R.A.M.C. With 13 illustrations;
pp. xiii + 136. Price 7s. 6d. net. London : Henry Frowde, Hodder and Stoughton,
1919.
An opportune book, intended for the general reader rather than for a specialist, on a
subject that has become of first-class importance during the last four years. The structure,
the life history, and habits of the body louse, with its mode of dissemination, are given at
length. Several methods of disinfestation are discussed. An important chapter is that
containing the results of experiments on the migration of the body louse in fevers. In the
chapter on Relapsing Fever references are made to the condition of the second Roumanian
army in 1917, and the havoc wrought by lice in the Wittenberg Camp and in Serbia is
mentioned in the chapter on Typhus. A chapter on Trench Fever by Major Byam, R.A.M.C.,
is added.
36
The Anatomy op the Peripheral Nerves. By A. Melville Paterson, M.D., F.R.C.S.,
Lieutenant-Colonel R.A.M.C. With 64 illustrations; pp. xi + 165. Price 12s. Gd.
net. London : Henry Frowde, Hodder and Stoughton, 1919.
The author’s object is to provide a brief account of the peripheral nerves for the use of
students and surgeons, and particularly for those engaged in military orthopaedic work.
It gives a concise description of the peripheral nervous system, including its morphology and
development, together with topographical and surgical anatomy. It is interesting to notice
that the author casts doubts upon the older doctrine of nerve-regeneration, according to
which new fibres were supposed to be derived by outgrowth from the axis-cylinders of the
central cut end. Colonel Paterson emphasizes the fact that new nerve-fibres can be demon¬
strated in the distal, as well as in the proximal, portion of a divided nerve. For these and
other reasons, he ranges himself with the more modern school, according to which the new
axis-cylinders are secreted by the neurilemma cells. The book is fully illustrated.
Introduction a l’6tude de la MfcDECiNE. Par G. H. Roger, Professor a la Faculte de
M^decine de Paris. Sixth edition. Pp. xvi + 795. Price 13fr. 13. Paris : Masson
et Cie, 1918.
The author, an experienced physician, teacher and author, has collected the important
facts of science bearing on clinical medicine. After an introduction and preliminary notes,
physics are dealt with ; mechanics, heat, light, sound and electricity. Biology is divided
into animal and vegetable parasites and bacteria. Next, main principles of medicine describing
the etiology and general pathology of infections are followed by nervous phenomena and
nutrition, including auto-intoxication. Embryology is dealt with under the heading of
pathology of the foetus and heredity; here are mentioned experiments dealing with mechanical,
physical and chemical agents, acting on eggs to produce monsters. The more essential facts
of clinical medicine are discussed under the headings of inflammation, septicaemia and
pyaemia, tumours, atrophy and degeneration. Taking as the text, that no disease remains
local, or that every disease becomes diffused, functional combinations and morbid sympathies
are treated as is possible only by an exponent of the best period of French neurology. Evolu¬
tion of disease treats of onset, course and terminations. The outlines of clinical medicine deal
with examination of patients, new methods of diagnosis, with prognosis. The last chapter
is devoted to therapeutics. Each left hand page of the book has a heading to indicate the
subject dealt with in the chapter, the heading of the right hand pages show the subject-
matter in the separate pages ; this method of heading gives little trouble to the printer and
materially aids study and reference. The work cannot fail to interest teachers of medicine,
and of all sciences associated with medioine ; especially those who desire to place themselves
and their pupils in a position to appreciate the best of continental science and medicine.
•
Military Medical Manuals. General Editors: Sir Alfred Keogh, G.C.B., M.D.,
F.R.C.P., and Lieutenant-General T. H. J. C. Goodwin, C.B., C.M.G., D.S.O.
Mental Disorders of War. By Jean Lepine. Edited, with a Preface, by Charles
A. Mercier, F.R.C.S., M.D., F.R.C.P. Pp. xxviii + 215. Price 7s. 6d. net.
London : University of London Press, Ltd.; Paris : Masson etrCie, 1919.
Dr. Lepine’s book is based upon his experience during three years of warfare and with
nearly six thousand cases. He has, he states, seen in them symptoms already described and
mental types not varying from those met with in ordinary times “ but their origin and
development are frequently different from those of peace time.” In the first place he deals
with acute mental disorders—confusional conditions, states of depression, neurasthenia,
shell shock, mania, &c. Much stress is laid on the toxic effects of alcohol. It is looked
upon as the sole and primary cause in at Beast a third of the cases he has seen : and,
“ taking into account those in whom it is only of slight importance, it would appear that
half, sometimes close on two-thirds, of our patients have been influenced by alcohol.”
Much space is given to the consideration of shell shock. Reference is made to those cases of
shock which so closely resemble general paralysis of the insane that differential diagnosis
37
(( may be impossible, temporarily at least,’' and in which examination of the cerebro-spina)
fluid, with its lymphocytosis and slight albuminosis, increases the uncertainty. In regard
to prognosis in shell shock he affirms that it should be extremely guarded and even pessimistic
as regards duration, but relatively favourable as to eventual complete recovery. Chronic
mental disorders, such as mental debility, chronic confusion, general paralysis of the insane,
are discussed. The circumstances of war have had a very distinct accelerative effect in the
last-named disease: and the author thinks that this justifies a liberal conception of what
is due to general paralytics and their families in all that concerns invaliding and pensions.
Special cases are referred to—traumatic cerebral lesions, epilepsy, hysteria, psych asthenia.
“ There does not seem to be any doubt that the war has produced an increase of epilepsy ” :
but it is more especially the number of fits rather than the number of cases. The fits, too,
are of a more severe type. In the second part the author deals with the practical application
of expert knowledge to the questions which arise from mental disorder. Simulation has-
been uncommon. “ Those who will insist in seeing a malingerer in every mental case would
be making a very silly blunder.” A description of some of the crimes committed is given
and the duty of the psychiatric expert in respect to these is outlined. The desiderata in
regard to hospital accommodation, personnel, and general treatment are described: also such
matters as length of leave, discharges from the service, pensions and gratuities. In con¬
clusion, Dr. Lupine states that the total amount of mental disorder has been by no means,
disproportionate to the strain and the stress to which the men have been subjected.
“ Neither in the hell at Verdun nor elsewhere have there been any mental epidemics, either
through fear or through horror.”
*
Animal Parasites and Human Disease. By Asa C. Chandler, M.S., Ph.D., Instructor
in Zoology, Oregon Agricultural College. With numerous illustrations ; pp. xiii -f 570*
Price 21s. net. New York: John Wiley and Sons, Inc.; London: Chapman and
Hall, Ltd., 1918.
This volume is compiled particularly for the benefit of those who, while not specialists in
parasitology, are yet practically interested in the subject of the prevention of human
diseases due to animal parasites. Scientific terms are avoided as far as possible, and it
is written in such a style that it can be easily read and understood by public health
and immigration service officers, teachers of hygiene and domestic science, students,
farmers, &c. It is divided into three parts, dealing respectively with Protozoa, “ Worms,”
and Arthropods. In the first of these, the parasites of syphilis, malaria, sleeping sickness,
dysentery, &c., are described, and the symptoms and treatment of each of these diseases are
briefly considered. Of the worms, the flukes, tapeworms, and hookworms, receive the most
attention; the manner of infection with, and the preventive measures against these
organisms, being adequately dealt with. In the last part the author gives a compre¬
hensive account of insects, in their dual role of pests and carriers of disease. The habits
and relationship to disease of mites, ticks, bugs, lice, fleas, mosquitoes, Ac., are explained,
and the most up-to-date methods for destroying their breeding places, and measures for
individual prophylaxis are pointed out. The local treatment of the various insect bites,
and the,general treatment of the infective diseases to which they may give rise, are also
described. A noticeable feature of the work is the omission of controversial problems, the
inclusion of which would only serve to confuse the practical reader.
Thyroid and Thymus. By Andre Crotti, M.D., F.A.C.S., LL.D. With 96 illustrations
and 33 plates in colours ; pp. xix -f- 567. Price $10.00. Philadelphia and New
York : Lea and Febiger, 1918.
The anatomy, histology and embryology of the thyroid and thymus glands are described
and figured by the author who was formerly a pupil of Professor Stilling, of Lausanne, and
Professor Kocher, of Berne : a synoptic table of tumours of branchial origin has algo been
drawn up. A distinction must be made between the functions of the thyroid and para¬
thyroid glands, though Gley considers their functions are inter-related, as removal of the
thyroid causes myxcedema and removal of the parathyroids tetany. In thyroidectomy the
38
onset of myxcedema may be prevented if one-eigbth of he gland be left. Not even one
parathyroid should ever be removed or its blood-supply interfered with. Tetany should be
treated by the administration of parathyroid and of calcium lactate. Iodine, arsenic, phos¬
phorus, and certain lipoids appear to be the most important chemicals in the thyroid
secretion. Experimental thyroidectomy is followed by hypertrophy of the pars intermedia
of the pituitary; the same condition is found in myxoedema. 1 The hypertrophied tissue
shows vesicles containing colloid like that of the thyroid but without iodine content,
and pituitary extract is of no value in treating myxoedema. A new parasite, discovered
by Chagas, of Brazil, which is transmitted by the bite of an insect, often causes severe
thyroiditis which may be followed by goitre; it is thus probable that other forms of
goitre are caused by a yet unidentified parasite. Embryology plays an important part
in the pathology of the tumours of the thyroid; they are classified partly according to
the embryological, and partly according to the clinical, aspect. Goitres becoming
malignant arise from simple goitre in 90 per cent, of the cases, and the change to the
malignant condition often takes place in women about the time of the menopause: early
operation is essential. The close association between endemic goitre, cretinism, myxoBdema
and cachexia strumipriva is pointed out, and the history of successive discoveries related,
commencing with Sir William Gull’s paper published in 1874.* The connexion between
endemic goitre and water-supply has been known for centuries: the river Struma, in the
Balkans, was so called from the occurrence of goitre among those dwelling along its banks.
The onset of goitre after drinking the water has no connexion with the geological formation
of the district, nor with any inorganic salts contained in the water; it is due to an infective
material, so far unidentified, which has contaminated the water. One curious instance of
this kind of infection is recorded in the case of those members of the crew of a ship com-
. manded by Captain Cook who became affected with goitre after drinking water derived from
an iceberg. McCarrison has recorded several instances of water-borne infection. If one
cannot leave the neighbourhood thus infected, boiling the water is the best prophylactic.
The medical treatment of goitre consists in the external application or internal administra¬
tion of iodine. X-rays have no effect on simple goitre. Operative treatment must be
undertaken if medical measures fail. Graves’s disease is fully discussed ; the causation of
the ocular symptoms, of the tremors and muscular weakness of the nervous and emotional
symptoms and of the alimentary disturbances is explained. Glycosuria is common and
diabetes occurs in about 8 per cent, of the cases. The aetiology of Graves’s disease is still a
matter of speculation but there is reason to think that some of the cases are primarily of
nervous origin. There is no specific medical treatment of exophthalmic goitre; the
administration of thyroid extract only makes the patient worse. Operation, undertaken to
relieve the pressure of an enlarged thyroid, was found to relieve the other symptoms as well;
this led to its general adoption. About 20 per cent, of the cases die when treated medically ;
the mortality after operation skilfully done may be nil as in the author’s last series of 137
cases. Dr. Grotti prefers general to local anaesthesia when operating. A subcutaneous
injection of 1 gr. of pantopon and gr. of scopolamine are given before operation. A
light ether anaesthesia is generally induced as well. In cases of shock after operation blood
transfusion is carried out by the author’s indirect method. Resection of the front part of
both thyroid lobes and of the isthmus is the operation of choice. The X-ray treatment of
Graves’s disease is not recommended. Lastly, the diseases of the thymus gland are discussed.
Excision of the thyroid causes hypertrophy of the thymus and vice versfc. The thymus is
enlarged in about 80 per cent, of cases of Graves’s disease. In one case of Graves’s disease
in which operation on the thyroid had failed, subsequent excision of the thymus cured the
patient. The author’s results have shown further improvement since he has combined
removal of part of the thymus with a thyroid operation.
1 See F. W. Mott, F.R.S. “ Changes in the Central Nervous System in Hypothyroidism.’'
Proceedings , 1917, x (Sect. Path.), p. 61.
* Trans . Clin. Soc. Land ,, 1874, vii, p. 180.
proceedings of tbe Ro^al Society of flDedtctne,
SUPPLEMENT
(Yol. XII, No. 9, August, 1919).
NOTES ON BOOKS.
[The purpose of these “ Notes ” is not so much to praise or to blame as to draw attention
to and describe some of the new books and new editions which have been added to the
Society's Library .— Ed.]
Surgical Aspects op Typhoid and Paratyphoid Fevers. FouDded on the Hunterian
Lecture for 1917. Amplified and Revised, by A. E. Webb-Johnson, D.S.O., M.B.,
Ch.B.Vict., F.R.C.S.Eng., Temporary Colonel, A.M.S. With plates and other illus¬
trations ; pp. 190. Price 10s. 6d. net. London: Henry Frowde, Hodder and
Stoughton, 1919.
The opening chapter is devoted to a brief survey of the history of the surgical complications
of typhoid, illustrated with portraits of men, from Willis to W. W. Keen, who have con¬
spicuously contributed to our knowledge of them. This is followed by a general survey of
the field containing a tabulated list of the frequency of tbe chief complications in inoculated
and uninoculated subjects. The remainder of the book deals in successive chapters with the
complications of the various systems—e.g., alimentary tract, spleen, joints, <fec., in greater
detail. The final chapter is devoted to the “ carrier ” problem in which the r61e of the spleen
is especially emphasized.
Equilibrium and Vertigo. By Isaac H. Jones, M.A., M.D., Major, M.R.C., United
States Army. With an Analysis of Pathologic Cases by Lewis Fisher, M.D.
With 130 illustrations; pp. xv + 444. Price 21s. net. Philadelphia and London:
J. B. Lippincott Qo., 1918.
The writer insists on the importance of the study of disturbances of equilibrium to the
physician, the ophthalmologist and the neurologist, though primarily to'the otologist.
He demonstrates the value of the “labyrinth” tests (as practised by the otologist) in the
diagnosis of diseases of the nervous system, by means of a large number of actual cases in
which the tests were carried out on a plan which combines completeness with comparative
simplicity. A special chapter is devoted to the consideration of the ear in relation to
aviation, showing how the rotation tests quickly separate the obviously fit from the unfit
without resorting to the caloric test which is reserved for the doubtful cases. The author
claims for the vestibular tests considerable value in the diagnosis of syphilis in the early, the
active and tbe latent stages, as also in the decision as to the efficiency of treatment. As an
indication of the value to the neurologist, “ fourteen points” are set out indicating a central
nervous lesion, and four a peripheral one. These are well illustrated in some of the actual
AU—43
40
cages. The reader of these will agree in the main that “ no operation upon the brain should
be undertaken without giving the patient the benefit of an ear examination** (p. 61).
This applies most particularly to cases of suspected cerebellar and cerebello-pontile angle
lesions. Tbe positions of the head for bringing the various canals into vertical and
horizontal planes as required are illustrated with unusual clearness. The tests which depend
upon the induction of nystagmus, vertigo and past-pointing are set forth in great detail both
as regards the methods of carrying them out and the inferences to be drawn from the results.
Much of the difficulty connected with them is removed by the insistence on the acceptation
of past-pointing as a manifestation of the vertigo. Great care is taken to make it clear when
the slow vestibular drag is referred to and when the quick cerebral twitch, but, even with all
this, confusion is apt to arise in the mind of the reader unless he exercises considerable
concentration and alertness. Thus on p. 152 the statement that “ the eyes are always drawn
in the direction of the endolymph movement ” does not refer to what is usually accepted aa
the direction of the nystagmus but to the slow component, as indicated in parenthesis-
on p. 149 by the words “ we will discuss only the vestibular or slow component.** Nystagmus-
and after-nystagmus induced by rotation have also to be carefully distinguished (p. 150).
With such precautions the reader should be able to acquire a clear idea of the theory ae well
as the practice of vestibular testing. Every means of illustration is employed, including
stereoscopic photographs of the anatomical structures, cinematographic films of the
manipulations required, charts for the registration of the results of tests, and blank diagrams
in which to indicate the locality and size of any supposed lesion. This is probably the very
latest statement on the subject and if it may be suggested that it might have been uttered in
a shorter and more condensed form, we can only say that whoever reads it for the first time
will derive much benefit from the repetition, recapitulation, elaboration and summarizing.
The reader who goes through the book for the second time will be able to do the abbreviating
and condensing for himself.
Dispensaries : Their Management and Development. A Book for Administrators,
Public Health Workers, and all interested in better Medical Service for the People.
By Michael M. Davis, junr., Ph.D., and Andrew R. Warner, M.D. Pp. ix -f 438.
Price 92.25. New York : The Macmillan Go., 1918.
The authors trace the developments of dispensaries from the first one established in the*
buildings of the Royal College of Physicians, London, after the Great Fire in 1666 to their
present scope in the United States. In the book will be found details of the construction of
dispensaries, their management, tbe type of patients who should attend, and the organization-
of these clinics, medical and administrative. There are copies of a series of elaborate records
and statistics, and “follow-up” systems are explained, in view of the setting up of the
Ministry of Health in this country, and the recent utterances of medical politicians, it is a
book that can be read with profit and interest; though the systems detailed in the book are
not in favour with the bulk of medical opinion in this country.
Diseases of the Skin. By James H. Sequeira, M.D.Lond., F.R.C.P.Lond., F.R.C.S.Eng.
Third edition. With 52 plates in colour and 257 text-figures ; pp. xiv + 644. Price
36s. net. London : J. and A. Churchill, 1919.
The publication of the third edition of any leading medical text-book is calculated to raise
its value both in the estimation of the author and the profession. This has certainly bee
done in the new issue of Dr. Sequeira’s “Diseases of the Skin,” first published in 1911.
The volume appears in its original form, but, by re-arrangement and the use of fresh types,
has not been increased in size. Numerous sections have been re-written and by a genera
revision the whole work has been brought up to date. The additional coloured plates include
dermatitis herpetiformis, eczematoid ringworm of the extremities, necrotic tuberculides, and
trench-foot, besides a number of new text-figures in black-and-white. Chapter XI contains
sixty-two pages on syphilis, with a concise description of modern treatment, and is numerously
illustrated with coloured plates and text-figures. Brief descriptions are also added of
41
myringoxnyoosis, trench-foot, and the cutaneous lesions caused by high explosives (a list
of which is included with notes), gas dermatitis and gangrene. The appendices contain
practical information on the important subject of treatment which will prove of much value
to the practitioner and student, and the index is complete and well typed. We congratulate
the author upon the continued success of his work.
A List op somb op the Old Masters op Medicine and Surgery, together with
Books on the History op Medicine and on Medical Biography, in the
possession of Lewis Stephen Pilcher. With Biographical and Bibliographical
Notes, and Reproductions of some Title Pages and Captions. Pp. vii + 201.
Brooklyn, New York: (privately printed), 1918.
Of this interesting and attractively produced volume 250 copies are issued, the one
presented to this Society being number two. This catalogue raisonn£ is divided into two
parts, namely (a) special lists, such as incunabula, of which there are fourteen, Mundinus
and the Pre-Vesalian anatomists, Ambrose Par4, William Harvey and Sir Thomas Browne;
and (6) general lists, namely, bibliographical, biographical, historical, anatomical, surgical
and medical. Among the works catalogued under the heading of “ The Medical Life ” is a
•copy of the proceedings and addresses at the reception and banquet in honour of this veteran
bibliophil on the completion of his services of fifty years as a Doctor of Medicine, on
May 16, 1916, and among the well-chosen modern works there are Conan Doyle's 14 Round
the Red Lamp”; and Osier’s “ ^Equanimitas ”; and Stephen Paget’s “Gonfessio Medici.”
The author’s book-plate, like the other illustrations, has been well executed, and the volume
•contains much information in the condensed notes.
The Medical and Surgical Aspects of Aviation. By H. Graeme Anderson, M.B.,
Ch.B., F.R.C.S., Surgeon-Lieutenant R.N. With Chapters on “Applied Physiology of
Aviation,” by Martin Flack, M.A., M.B., Lieutenant-Colonel R.A.F., and “The
Aero-Neuroses of War Pilots,” by Oliver H. Gotch, M.B., Ch.B., M.R.C.P.Lond.,
Surgeon-Lieutenant R.N., and an Introduction by the Right Hon. the Lord Weir of
Eastwood, P.C. With 27 plates and 20 text illustrations; pp. xvi -f 255. Price
12s. 6d. London : Henry Frowde, Hodder and Stoughton, 1919.
The science of aviation has already been productive of many books but this is the first
one we have met with which deals fully with its medioal and surgical aspects. The author
is able to write from his personal experience in dealing with flying men, and be has as
collaborators Lieutenant-Colonel Martin Flack, who writes on the applied physiology of
aviation, and of Surgeon-Lieutenant Oliver H. Gotch, who writes on the aero-neurosis of war
pilots. After an historical introduction, the author proceeds to deal with the medical selection
of candidates, and the standards and tests which have been gradually evolved by the
authorities of the Royal Air Force. The previous health and habits and occupation are
carefully inquired into, and various tests, physiological and psychical, are employed. The
psychology of flying is dealt with in an interesting chapter. This subject is considered first,
when the pupil is undergoing his dual-control training, secondly during his first few solo
flights, and thirdly, when he is a qualified aviator engaged in war flying or instructing.
The ideal flying temperament, as it has been called, is not easily determined by any form of
examination before actual flying experience. In his own practice the author laid down the
rule that “as soon as a pupil showed loss of confidence in flying and exhibited any of
the signs or symptoms of aero-neurosis he must be discharged from the air station as unfit
for further flying.” We are convinced that the experience of medical boards and hospitals
would strongly support this decision. The purely surgical section of the book opens with a
series of photographs showing the results of aeroplane accidents, which are of surpassing
interest. The chief caus& of accidents and the methods to be adopted for preventing them
are discussed. The surgery of aviation as contrasted with that in civil life differs in this,
that in that of aviation, one is called on mostly to deal with the results of high velocity
accidents associated with falls at varying angles and from varying heights.
42
Infection and Resistance; an Exposition of the Biological.Phenomena underlying
the Occurrence of Infection and the Recovery of the Animal Body from
Infectious Disease. By Hans Zinsser, M.D. With a Chapter on “ Colloids and
Colloidal Reactions,” by Professor Stewart W. Young. Second edition, revised.
Pp. xiii -f 585. Price 54.25. New York : The Macmillan Co., 1918.
The second edition of this book contains an account of new work to the extent of some
forty pages of text. Whilst making numerous alterations on important subjects such as.
Abderhalden's serum reaction on which opinion has changed very considerably, the^author
has endeavoured to retain his original aim of presenting to the reader the “ fundamental
principles underlying the biology of infectious diseases ” rather than compiling a practical
clinical laboratory handbook. The chapters on anaphylaxis have been largely re-written in
order to include new work. Unfortunately it is almost impossible to keep text-books up to
date on this subject, and although the index contains over four pages of references it is still
not quite complete. Nevertheless this section of the work is a comprehensive survey on a
subject to which American authors have paid great attention during the last few years.
In dealing with the vexed question of the part played by complement in immune processes
the author gives full information as to recent theories. The chapter on immunization in
man has also been much enlarged. It now contains a section on poliomyelitis, which includes
an account of the recent researches of Flexner and Noguchi, and an extensive section on
syphilis. The latter deals at considerable length with the various difficult problems of
antibody reaction in man and in animals, and includes a resume of the author's work on the
subject. The lack of cellular reaction in syphilis, or, as Zinsser expresses it, the “ tissue
indifference,” receives special consideration. The chapter on serum enzymes has been
revised. The author now believes that Abderhalden’s reaction is entirely “ a non-specific
enzyme activity of normal serum."
Psycho-analysis and its Place in Life. By M. K. Bradby. Pp. xi -f 266. Price
8s. 6d. net. London: Henry Frowde, Hodder and Stoughton, 1919..
This is a clear and concise account of psycho-analysis, written for 44 the ordinary educated
man or woman who has begun to study psycho-analysis and is puzzled,” but it is quite as
well suited to those who have never studied the subject at all. The chapters are arranged in
six groups : (1) The unconscious mind, (2) some psycho-analytic theories, (8) dreams, (4) uncon¬
scious primitive traits in present-day thought, (5) place of psycho-analysis in life, and (6)
light on biography from psycho-analysis. The author does not lay sufficient stress on the
importance of infantile experience for the subsequent psychology of unconscious thought, and
therein falls short of a complete acceptance of Freud's doctrines. On the other hand, she
sees quite clearly the weakness of Jung's hypotheses. The result is that her analysis of
dreams and personalities does not penetrate deeply enough from either point of view. It
is in the very nature of true psycho-analysis that it arouses opposition and resentment
in everybody who is not prepared to face its unpleasant home truths, but we doubt whether
anybody will object to psycho-analysis as expounded in “ Psycho-analysis and its Place
in Life.” For this reason it may be strongly recommended to those who know nothing
about the subject. '
War Neubose8 and Shell Shock. By Fredk. W. Mott, M.D., LL.D., F.R.S., F.R.C.P.,
Brevet Lieutenant-Colonel, R.A.M.C.(T.). With Preface by the Right Hon.
Christopher Addison, M.P. With 3 coloured plates and 93 other illustrations;
pp. xx -f 848. Price 16s. net. London : Henry Frowde, Hodder and Stoughton,
1919.
This work comprises much that has been published before in the author s “ Lettsomian
Lectures ” and other communications, but it also contains th£ product of liter years*
observation at the Maudsley Hospital. It is not to be wondered at that riper experience
has led Sir Frederick Mott to recognize that the psychogenic factor is the predominant
causal agent in the production of the war psychoneuroses, and that the cases of shell shock
43
due to any pathological changes in the central nervous system were relatively infrequent.
His opening pages deal with the effect of shock upon the neuron and the causation of instan-
taneous death from high explosive action, with a discussion on the signs and symptoms of
commotional shock with its consecutive phenomena. Various possible emotional and
abnormal mental states that may follow shock are dealt with, such as different forms of
mental confusion, amnesias and speech defects, illustrative cases being quoted. It is shown
how important is a neuropathic tendency for the development of these war neuroses, and the
sufferers’ dreams in their various relations are mentioned. The author credits MacCurdy ^ith
the term “ conversion hysteria,” whereas it was coined by Freud long ago. Nearly a hundred
pages are then devoted to the hysterical signs and symptoms mainly met with, the differential
diagnosis of functional from organic disease, with a short summary of neurasthenic states.
Notwithstanding the title of the book a few pages are devoted to the psychoses, among which
“ psychasthenia ” is for some reason included. In such a space only a few bald statements
can palpably be made concerning them. An error here must be noted (p. 200)—viz., that 20
per cent, of the mental cases admitted to “D” Block, Netley, were sent on to neurological
hospitals. During the years 1917 and 1918 only just over 2 per cent, were so transferred.
Malingering and the relation of alcohol to the war neuroses are briefly spoken of, while the
concluding part of the book is devoted to carbon monoxide poisoning and the treatment
of the various neurotic states. A bibliography and an appendix on the examination
of nervous Service patients are added. The Right Hon. C. Addison, M.P., introduces
the wdrk in a short preface. The inclusion of 93 illustrations and some coloured plates
enhances its value.
The Newer Knowledge op Nutrition : The Use op Food for the Preservation op
Vitality and Health. By E. V. McCollum, School of Hygiene and Public
Health, Johns Hopkins University. With illustrations ; pp. ix + 199. Price #1.50.
"New York: The Macmillan Co., 1919.
The contention of the writer of this book is “ that the biological method for the analysis
of single foodstuffs and mixtures of foodstuffs has made it evident that the former practice of
regarding protein, energy aod digestibility as the criterion of the value of a food mixture,
must be replaced by a new method based upon a biological classification of the foodstuffs,
the latter having its foundation in the function of the substance employed in the diet.” The
book is devoted to maintaining this thesis, and describes the results of feeding animals on
different mixtures of foodstuffs and their effects on health and vitality. Considerable
attention is also given to the “ deficiency ” diseases, and the proposition is advanced that there
are only two unidentified dietary essentials—fat-soluble (a) and water-soluble (5). The former
prevents the development of a pathological condition of the eyes (xerophthalmia), the latter of
beri-beri. Many of the diseases believed to be due to “ vitamine ” starvation—e.g., scurvy—
are probably to be attributed to other causes. The “ unidentified essentials ” are abundantly
present in milk and green vegetables, which may be spoken bf as “ protective foods.”
Practical considerations which should guide us in the planning of the diet in view of
biological results are considered in the final chapter. A full bibliography and a short index
are appended.
Cerebrospinal Fever : The Etiology, Symptomatology, Diagnosis and Treatment of
Epidemic Cerebro-spinal Meningitis. By C. Worster-Drought, B.A., M.B.,
Captain (Temp.), R.A.M.C.,and Alex. Mills Kennedy, M.D., Captain, late R.A.M.C.
With 8 full-page plates and 56 other illustrations; pp. 528. Price 80s. net.
London : A. and C. Black, 1919.
This work embodies the experience gained at the Herbert Military Hospital, Woolwioh*
during three years by a neurologist and a bacteriologist, and also contains a review of
current work with a full bibliography. There are twenty chapters which cover the wholb
subject. After some general observations on the geographical distribution, seasonal prevalence,
age and sex incidence* a chapter is devoted to the bacteriology dealing with the meningo¬
coccus and allied organisms. Full recognition is given to the publications of the Medical
44
Research Committee, and especially to Gordon’s work; out of 183 strains of meningococci
tested by his agglutinating serums 50 belonged to type I, 97 to type II, 22 to type III, and 11
to type IV. The dissemination of the disease and the part played by “ carriers ** is fully
considered, and many statistics brought forward. As regards the disposing causes the
author’s observations are to the effect that there is not any obvious relation between low
atmospheric temperatures and the incidence of the disease, but that there appears to be some
connexion between a diminished rainfall and an increased case incidence. A short incuba¬
tion period iB regarded as probable, and the view is taken that the meningococous first enters
the blood stream and is usually thus carried to the meninges within a few hours without
causing a real septicaemia. The full account of the symptoms is illustrated by figures, par¬
ticularly of facial herpes, and numerous temperature charts. From their experience it
appears that there is some degree of limitation in flexion of the head before Kemig's sign is
at all definite, and that the knee- and ankle-jerks are not of any diagnostic value, being of
academic interest only. The influence of a rash on prognosis is shown by a mortality of 44
per cent, among those with a petechial eruption as compared with 18 pdr cent, in cages
without a rash. In the systematic account of the complications evidence is brought forward
to show that nephritis, which has hitherto received little attention in this connexion, may
occur. The important subject of treatment is discussed in practical detail; if a case is seen
in the pre-meningitic stage and the cerebro-spinal fluid is clear, serum should be given
intravenously or intramuscularly. The minimum period for the administration of serum
intrathecally, no matter how great the improvement in the patient’s condition may be, and
this is often striking on the second or third day, is four days, and on no account should
the injections be omitted while the cerebro-spinal fluid contains meningococci. An interesting
account is given of the manifestations of serum disease, and the concluding chapter on
sequelae shows that contrary to popular supposition serious after-results have become
considerably less frequent than in the past.
Precis de Radiodiagnostic Technique et Clinique. Par le Dr. Jaugeas. Preface de M.
le Dr. Beclere. Second edition. With 63 plates and 220 other illustrations; pp.
xxviii + 563. Price 22fr. net. Paris : Masson et Cie, 1919.
The title of this work very well describes it : it deals with the whole subject of radio¬
diagnosis. There is an introduction of considerable length by Dr. B£cl£re, in which he insists
that, in order to be an efficient X-ray diagnostician, a man must possess a clinical know¬
ledge as well as a high degree of technical skill. A feature of the book is that normal
skiagrams of all parts of the body are shown. Illustrations are liberally dispersed throughout
the book, and are in the form of reproductions of prints, not of negatives. Radiodiagnosis
of the chest and abdomen are very fully dealt with, about 130 out of a total of 544 pages
being devoted to this section. The description of apparatus and of the organs of the
body occupies about the same space: the instruments dealt with are almost all of French
manufacture.
The Early Diagnosis op Tubercle. By Clive Riviere, M.D., F.R.C.P. Second edition.
With 35 illustrations ; pp. xiv -f 314. Price 10s. 6d. net. London : Henry Frowde,
Hodder and Stoughton, 1919.
In this second edition, which has been called for after an interval of five years, whole
sections, especially those devoted to physical signs, have been practically re-written, others
have been much augmented, and the account, based on personal experiences, of hilus tuber¬
culosis in the adult is expanded from two to twenty pages. This term is applied to disease
starting in the deep part of the lung around its roots ; it tends to spread outwards along the
bronchi and vessels in a fan-shaped manner and bilaterally. In contrast to the apical
crepitations of ordinary pulmonary tuberculosis, the earliest signs may appear at almost any
point in the chest, often at the base behind, or the middle of the upper lobe in front, or in
the axilla. Its bilateral character is generally shown in two ways, equality of movement on
the two sides, and double apical contraction, as shown by measurements of Kronig's areas,
“ the sign-manual of hilus tuberculosis,” for without evidence derived from this source it is
45
often impossible to detect the lesion in any but its latest stage. Kronig’s areas of apical
resonance, which the author has been accustomed for years to mark out as a routine practice
in all cases of pulmonary disease, are illustrated by four diagrams. The work is divided into
two parts, dealing with tuberculosis of the lungs in adults and in children respectively. “ The
reflex bands of dullness, the author’s sign in pulmonary tuberculosis,” are illustrated and
explained; gentle percussion of the back of a patient with pulmonary tuberculosis at
whatever stage, reveals bands of slight impairment at the apices and across the lower
scapular regions on both sides, though better marked on the diseased side. These bands of
impairment, though normally absent in a healthy chest, can be produced by the methods that
bring out Albert Abrams’ “lung reflex of contraction.” In the section on examination for
tubercle bacilli the author insists that it is disastrous to wait for the presence of tubercle
bacilli in the sputum before making the diagnosis, and that before the sputum can with
certainty be said to be free from tubercle bacilli Much’s granules must be looked for. Dia¬
gnosis by means of tuberculin tests is- described in fuller detail, and clear indications of the
value and limitation of the tests are given.
A Vision op the Possible: What the R.A.M.C. might become. An Account of some of
the Medical Work in Egypt; together with a Constructive Criticism of the R.A.M.C.
By James W. Barrett, K.B.E., C.B., C.M.G., M.D., M.8., F.R.C.S.Eng., Temporary
Lieutenant-Colonel, R.A.M.C. Pp. xx + 182. Price 9s. net. London: H. K. Lewis
and Co., Ltd., 1919.
This book will be read with interest, if not with grim satisfaction, by every medical officer
who has served with the R.A.M.C. Its mere publication indicates that the authorities are
alive to the criticisms which it contains, offered in no destructive spirit, but with the earnest
desire to see the Royal Army Medical Corps elevated to the status of a corps d'6lite. It is not
a little significant that its appearance coincides with the appointment, by the War Office, of
directors, assistant directors, and deputy directors of hygiene and pathology. With these
as a nucleus it should not be difficult to group around them men of high professional
attainments, selected from the vast number of medical men who are by now conversant with
Army requirements, and thus organize a headquarters staff in medical science of the utmost
efficiency. The author hints at the sterilizing influence of administrative work upon medical
officers, who find that the only road to promotion runs through an office and not through
the clinical wards and laboratory. He suggests that the field of specialism is too often
controlled by officers in the higher ranks of the R.A.M.C. who are wholly out of touch with
“ the drift of modern thought.” Most medical men who held temporary commissions in
the R.A.M.C. will confirm the author’s statements from their own experience, and it is &
hopeful sign that “ the powers that be ” did not censor a book which deals largely with their
own shortcomings. Apart from questions affecting the organization of the corps, there is a
section in which the treatment of diseases of the ear, nose and throat is discussed, and
the author shows how simple precautions in chronic otorrhoea can prevent a great deal of
man-wastage. The work of medical boards is analysed, and there is an important chapter
on the management of venereal disease, and the prophylactic measures adopted at Port
Said. Sir James Barrett in the past has shown his keen interest in matters of education
and reform, and this, his most recent work, deserves serious study by all who are concerned
with the welfare of the R.A.M.C.
Recherches becentbs sub les Ictebes—les Retentions biliaires—par Insdffisance
hEpatique. Par M. Brule, Chef de Laboratoire & la Faculty de Medecine de Paris.
Pp. ix + 182. Price 4 fr. 95. Paris : Masson et Cie, 1919.
In this review of the recent work done by the author and his colleagues the predominating
idea is that in the large group of cases of jaundice occurring in connexion with infective
and toxic conditions there is not any obstruction in the small intrahepatio bile canaliculi,
but that the jaundice is due to disordered function of the hepatic cells which show definite
histological changes. In support of this contention appeal is mainly made to the phenomena
of dissociated jaundice, which is described in full detail and with many examples. In cases
46
of gross obstruction of the large bile ducts there is 44 complete ” jaundice, both- the bilirubin
and the bile salts entering the circulation and passing into the urine; in infective and
toxic jaundice, on the other hand, the bile pigments alone may enter the blood and
appear in the urine, while the bile salts still pass into the intestine and so do not appear
in the urine; in some cases without jaundice, for example in cirrhosis, bile salts alone
are present in the urine ; this is dissociated jaundice and has been produced by the
injection of hepatic cytolytic serum. The important deduction is drawn that', as the
selective secretion into the circulation, instead of into the bile canaliculi, of bilirubin
or of bile salts can be performed by the hepatic cells only, the detection of dissociated
jaundice in any given case, is incompatible with the view that the jaundice is due to
obstruction. An interesting comparison is drawn between hepatic and renal pathology as
regards lesions of the excretory ducts on the one hand and of the secretory cells on the
other hand; gross mechanical jaundice, such as that caused by cancer of the head of the
pancreas, corresponds to obstructive anuria Such as results froln compression of the ureters
by malignant disease of the uterus, whereas dissociated jaundice due to lesions of the hepatic
cells is comparable to the retention of urea or chlorides in parenchymatous nephritis. From
numerous investigations which show the frequency of dissociated jaundice, the obstructive
origin of jaundice is minimized and the part played by functional disorder of the hepatic
cells emphasized ; thus what is commonly called catarrhal jaundice due to obstruction of the
lower end of the common bile duct is claimed as the result of changes in the hepatic cells.
Jaundice may be caused by three processes—namely, gross obstruction of the ducts, functional
disorder of the liver cells, and independently of the liver by the transformation of free
haemoglobin into bilirubin. The last form, haemolytic jaundice, is described in a separate
chapter.
Military Medical Manuals. General Editors: Sir Alfred Keogh, G.C.B., M.D., F.R.C.P.,
and Lieutenant-General T. H. Goodwin, C.B., C.M.G., D.S.O. Electro-Diagnosis
in War: Clinical, Medical Board Technique and Interpretation. By A.
Zimmern and Pierre Perol. Edited with a Preface, by E. P. Cumberbatch, M.A.,
M.R.C.P., B.M.Oxon. With 44 illustrations; pp. xxiv + 212. Price 7s. 6d. net.
London: University of London Press, Ltd., 1918.
Chapter I begins with a rtsunu* of various forms of apparatus and their use, and then
gives an Account of the normal reactions of nerves and muscles to electrical stimulation and
the technique employed to elicit them. The latter part of the chapter is a condensed
description, with diagrams, of the more important nerve distribution and motor points.
Care is taken to avoid any overcrowding of detail, and it is pointed out that the various
motor points are somewhat inconstant and vary with the individual. Chapter II describes
the various abnormal reactions and conditions in which they occur. Attention is drawn to
the special pitfalls in the examination and the liability of misinterpreting the meaning or
cause of a particular reaction. The reaction of degeneration in its various stages is fully
described, its theory and clinical significance. One section of the chapter emphasizes the
need for adopting a uniform technique in electro-diagnosis. There is a brief description of
the technique and advantages of electro-diagnosis obtained with condensers of variable
capacity and variable charges. The chapter concludes with a section on chronaxy. It is
insisted upon that the condition of nerves and muscles cannot be properly gauged without
consideration of the time factor in addition to the intensity of the current. Means of time
measurement are described and discussed together with the significance of the results obtained.
Chapter III deals with motor paralyses, their occurrence, differential diagnosis, and course.
Attention is drawn to apparent discrepancies which may occur, and to some special peculi¬
arities of certain nerves. The second half discusses lesions of the cord, combined functional
and organic disorders and the reflex paralyses and contractures. Chapter IV gives a short
account of sensory disturbances, and methods of distinguishing between organic and
functional disorders of sensation. It is shown that sensory changes may be of great
assistance in localizing lesions in the brain and cord. Chapter V describes the relation
of voltaic vertigo to various head injuries, the different phenomena encountered and their
47
significance. Chapter VI points out the value of a careful and complete electro-diagnosis
and the need for so examining patients before judgment is passed by a medical board.
The whole volume is, as Sir Alfred Keogh says of the Series, “ marked not only by a wealth
of detail but by clearness of view and logical sequence of thought.’*
Psychological Principles. By James Ward, Sc. 1).Cantab., Hon. LL.D.Ed., Hon.
D.Sc.Lond. Pp. xvi -f- 478. Price 21s. net. Cambridge: Cambridge University
Press, 1918.
This book is an expansion of the article on the same subject contributed by the author to
the tenth edition of the 44 Encyclopedia Britannica.” The first chapter deals with the
definition of psychology, consideration being given to the views of Aristotle, Descartes, Kant
and others. Subsequent chapters deal with the theory of attention, the theory of pre¬
sentations, perception, imagination or ideation, feeling, intellection and conduct. It will be
seen from this list of the contents that the author approaches psychology on the classic lines,
and his book will not appeal strongly to medical men as such. Professor Ward’s attitude to
recent medical work in this sphere is indicated by the following extract from his preface:
44 But there is a psychology which arrogates to itself the title of * new.’ New it undoubtedly
is, and there are signs that in its present form it will not long survive. In any case it is not
psychology — save in so far as it occasionally furnished the psychologist with material of some
value. As a method in the hands of psychologists it has done some good: as a pretended
science in the hands of tyros whose psychological training has not even begun, it has done
infinite harm.”
Sir William Turner, K.C.B., F.R.S., Professor of Anatomy and Principal and Vice-
Chancellor of the University of Edinburgh : A Chapter in Medical History.
By A. Logan Turner, M.D. With 7 portraits ; pp. xviii + 514. Price 18s. net.
Edinburgh and London : William Blackwood and Sons, 1919.
One of the truly great biographies of the year, this book sketches the main incidents in
the life of one of the great heads of the profession, whose sixty-two years of devoted service
have left an indelible impression for good upon all who came within the sphere of his
influence. From the earliest days of his apprenticeship to Christopher Johnson, junr., his
scientific bent was recognized and fostered in the chemical classes he attended in the
Mechanics* Institute in Lancaster. At the age of 1C Turner was made a Freeman of the
City, and when his term of apprenticeship was up he entered the medical school of St.
Bartholomew’s, where he came under the influence and teaching of Paget. He qualified as
M.R.C.S.Eng. iu 1853. The following year he accepted the appointment, which had been
offered to him by Professor John Goodsir, of Demonstrator of Anatomy in the University of
Edinburgh. His acquaintance, which afterwards ripened into a friendship, with Lister
began in 1855, and his relationship with his contemporaries was of the happiest. Turner’s
success as a teacher was assured from the first, and in 1857 he published his atlas and hand¬
book on “ Human Anatomy and Physiology,” which was later translated into Arabic. In
the same year he took the M.B.Lond. His marriage with Agnes Logan took place in 1863,
and upon the death of Goodsir four years later he was elected Professor of Anatomy at the
age of 35. He looked upon the pursuit of anatomical knowledge by the medical student
as of prime importance, because by the study of this science 44 the habit of observation is
cultivated in order to see truly and completely the objects to be examined.” He regarded
preparation for examinations as a most important mental discipline, and he believed that
44 sluggish contentment is the enemy of all progress in individuals, institutions, and com¬
munities.” Possessed of a wonderful memory, he would speak of his pupils as his 44 family,”
and upon more than one occasion he would recognize an old member of his class years after¬
wards, recalling his name from the tone of his voice. During his tenure of office from 1867
to 1903, no less than 10,500 names were entered upon the roll of attendance at his anatomical
lectures, whilst no fewer than twenty-three Chairs, including the succession to his own, came
to be occupied by men who had received their anatomical training at his hands. This record
AU— 43a
48
must indeed be unique. After forty-nine years of teaching and lecturing he succeeded Sir
William Muir as Principal of the University of Edinburgh. As the representative of the
Universities of Aberdeen and Edinburgh Turner entered the General Medical Council in 1873,
but after ten years of service he resigned in favour of a representative from Aberdeen Uni¬
versity. He was returned three years later, however, to the reconstituted Council as the
representative of Edinburgh University, succeeding Sir Richard Quain as President in 1898,
but he retired from this office in 1904 in favour of Sir Donald MacAlister. Turner’s rule was
characterized by “ a forward policy, in regard both to education and discipline, and his action
usually carried the Council onward in the direction which events showed was the right one.’*
A similar policy was pursued by him in relation to educational progress, university finance
and extension, for as he said : “ In education there is no finality. We cannot stand still in
such matters.” From his knighthood in 1886, he was the recipient of many honours,
including the Presidency of the British Association, but none gave him more satisfaction
than his admission in 1909 to the Freedom of the City of Edinburgh. At the age of 84 he
died, as he had lived, in harness. Turner’s wide outlook on life, the charm of his personality,
his fearless leadership, and his devotion to duty at all times and in all places, rendered him
a conspicuous light throughout his active life.
INDEX
Proceedings of the Royal Society of Medicine, Vol. XII, 1919
INDEX
(Prepared by Mr. A. L. Clarke, Assistant Editor)
Note .—The different parts of the Society’s Proceedings are indicated by (i) M.B.L. [Marcus
Beck Laboratory Reports], (ii) R.S.M. Disc. (Infl.) [Discussion on Influenza],
(iii) R.S.M. Disc. (Shock) [Discussion on Shock] . They are placed first in the bound
volumes under the heading 41 General Reports.” They are followed by the Pro¬
ceedings of the Sections, which are arranged alphabetically, each Section being
separately paged. The Proceedings of the Sub-section of Proctology are included in
the Section of Surgery and indicated by the abbreviation “Proct.” preceding the
numerals. The references indicated by the Roman numerals under the headings
“Med., Path, and Epid.” refer to the combined discussion held by the Sections
of Medicine, Pathology and Epidemiology, the report of which appears in the bound
volumes immediately after the reports eithor of the Section of Medicine, the Section
of Pathology or the Section of Epidemiology. The reference indicated by the Roman
numerals under the heading “ Ophth. and Laryng.’* refers to the joint discussion
held by the Sections of Ophthalmology and Laryngology, the report of which appears
in the bound volumes immediately after the reports either of the Section of Ophthal¬
mology or the Section of Laryngology. N.B.—The Section of History is printed as
a separate Supplement, with a separate index, and is only supplied to those who
make application for it at the beginning of the Session.
Abdomen, unusual tumour of, case (J.-E. Adams), Child. 75
Abdominal disorders, treatment by diathermy (C. E. Iredell), Electr. 34
-neoplasm, pregnancy considered as, Obst. 87
-operations, acute, spinal anaesthesia in, Anaesth. 12, 13
-at Samaritan Free Hospital conducted upon Lister’s methods, Obst. 2
-, mortality from, 1884 and 1916 compared, Obst. 7
-, nursing of cases after, Obst. 1
-conducted without use of antiseptics, mode of death following, Obst. 5
---, question of giving or withholding opium after (1884), Obst. 3, 4
-section in man with thoracic aneurysm, under oil-ether anaesthesia (F. E. Shipway),
Anaesth. 22
-surgery administration of stovaine in, Anaesth. 10
-, developments in, since 1S84 (Presidential Address) (John D. Malcolm), Obst. 1
-, general, relation of gynaecological surgery to, Obst. 7
Abdomino perineal excision for carcinoma recti followed three years after by recurrence in
posterior vaginal wall, case (W. S. Handley), Surg. 46
Abductor paralysis following gunshot wounds of neck, Laryng. 181
Abercrombie, R. G.—Discussion on influenza, R.S.M. Disc. (Infl.) 91
Aberdeen, measles in (1856-85), deaths from, periodicity, Epid. 107, 108
Ablution tent, measures adopted against venereal diseases in, at Port Said, R.S.M. Lect. 9
Abortion, criminal, medical responsibility in, teaching of, Obst. 55
Abrahams, A.—Discussion on influenza, R.S.M. Disc. (Infl.) 97
IV
Index
Abreaction, emotional, restoration of in case of war neurosis with amnesia, Psych. 58
-, theory of, Psych. 57
Abscess cavities, inflation of, Path. 55
---, specimen from case of, Path. 56 *
-, extradural, complicating chronic middle-ear suppuration, Otol. 51
-, temporo-sphenoidal, complicating chronic middle-ear suppuration, Otol. 51
Abscesses, peribronchial, complicating influenza, R.S.M. Disc. (Infl.) 48
Accessory sinuses, nasal, and nose, gunshot wounds of, epidiascopic demonstration of methods
of treatment of (G. Seccombe Hett), Laryng. 135
-and orbit, inflammatory diseases of, Ophth. and Laryng. xxvi, liii
-, injuries and inflammatory diseases affecting, discussion on, Ophth. and
Laryng. i-lxvii (L. V. Cargill, ii; E. D. D. Davis, xxxviii; H. Leighton Davies, xlvi ;
James Donelan, lxii ; H. D. Gillies, xliv; G. Seccombe Hett, xi; W. M. Mollison, lii ;
J. F. O’Malley, liii; A. W. Ormond, xxviii; G. H. Pooley, lv ; W. T. Holmes Spicer,
i; E. H. E. Stack, lvii; W. Stuart-Low, lviii; H. Tilley, lx ; H. Lawson Whale, lxi)
-and orbit, war injuries of, Ophth. and Laryng. v, vi
-, bullet wounds of, through and through, Ophth. and Laryng. lii
-, loss of smell and parosmia following, Ophth. and
Laryng. lii
-, close connexion of orbit with, Ophth. and Laryng. ii
-, complications in chronic suppurative otitis media, Otol. 31, 32
-, disease of, and retrobulbar neuritis, Ophth. and Laryng. lxv
-, causing orbital cellulitis, Ophth. and Laryng. xxvii, lxiii, lxvi
-, gunshot injuries of, treatment, operative, Ophth. and Laryng. xxxix
-wounds of (J. F. O’Malley), Laryng. 241
-, cause of suppuration after operation, Ophth. and Laryng. lxii
-, control of haemorrhage in, Laryng. 242
-, early suture, Ophth. and Laryng. xliv, xlv, lxiv, lxv
-:-involving two or more, injuries to eye in, Ophth. xxx, xxxi
-, irrigation'of antra contra-indicated, Laryng. 243
-, inflammatory diseases of, ocular symptoms produced by, Ophth. and Laryng.
xlvi, xlVii
-, inflammation of, complicated by retrobulbar neuritis, Ophth. and Laryng.
xxvii, lxiii
-, complicating influenza, R.S.M. Disc. (Infl.), 54
-, infected, micro-organisms found in cultures from, Laryng. 223, 225, 227
-, injury and inflammation of, cases resulting from wounds, Ophth. and
Laryng. Ii
-, resulting from wounds, drainage of sinuses into nose before repair
of socket or lobe, Ophth. and Laryng. Ii
-, lesions of, rare in cases of unilateral retrobulbar neuritis, Ophth. and
Laryng. lx
-, pus not present in, in cases of retrobulbar neuritis, Ophth. and Laryng. liii
-, question of infection in atrophic rhinitis, with ozaena, Laryng. 232
-, suppuration in, always co-existent with orbital cellulitis, "Ophth. and
Laryng. lxi
- f causing orbital cellulitis, Ophth. and Laryng. liii
-, eye lesions in children possibly due to, Ophth. and Laryng. lxi
-symptoms rarely mentioned by patients with, Ophth. and Laryng. lx
-, in young children, effects on orbit, Ophth. and LaryDg. xxxvii
-or disease of, causing retrobulbar neuritis, with loss of vision, Ophth.
and Laryng. xlii
-, suppurative lesions and pneumonia, relation between, R.8.M. Disc. (Infl.) 67
-, wounds of, cases, casts, &c., illustrating methods of repair of (G. Seccombe
Hett), Laryng. 115
Index
v
Accessory sinuses, nasal wourfds, methods of repair (G. Seccombe Het ), Laryng. 117, 136
-with fracture of orbital wall, Ophth. and Laryng. lii
- : -, see also Orbit and accessory sinuses
Accidents, industrial, causation and prevention of (H. M. Vernon), Epid. 47
-, frequency in men and women at different factories compared. Electr. 51, 52
-, personal factor in, Epid. 52
-, prevention of, methods, Epid. 51
-, reduction at Port Sunlight, Epid. 51
Accommodation, disturbances of, due to inflammatory affections of nasal accessory sinuses,
Ophth. and Laryng. xlvii
Acetabulum, fixation of femur to by means of bone-spike in case of morbus coxae, Surg.
30, 31
Achalasia of cardia, compensated, represented by muscular hypertrophy of oesophagus
without dilatation, Laryng. 100
-, origin of, Laryng. 99
-, synonym for cardiospasm, Laryng. 35
-, reflex, of oesophagus due to irritation of gastric ulcer, skiagram (S. G. Shattock),
Laryng. 94
Achondroplasia with hydrocephalus, case (H. C. Cameron), Child. 9
Acidosis, complicating influenza, K.S.M. Disc. (Infl.) 69
-in shock explained, R.S.M. Disc. (Shock) 13
-, result of low blood pressure, R.S.M. Disc. (Shock), 2, 3
Acne complicated by intestinal stasis, general improvement effected by dia^iermy (H. \V.
Barber), Electr. 37
-indurata, pus infection in, Derm. 16
-urticata, alternative diagnosis of case diagnosed as dermatitis herpetiformis, Derm. 73
Actinomycosis (?), tumour of right submaxillary region and of floor of mouth (W. H. Jewell),
Laryng. 215
-, case (E. G. Graham Little), Derm. 12
-pulmonary, treatment, Clin. 1, 3
-, thoracic, case (V. Z. Cope), Clin. 1
Action, problems of, not solved by mechanistic psychology, Psych. 4
Adams, Joseph E.—Carcinoma of the appendix, Surg. 37
_. f case of shortening of the limbs on one side of the body, ? osteogenesis imperfecta
unilateralis, Child. 5.
-of unusual tumour of the abdomen, Child. 76
Adams, John. —Treatment of ante-ratal and post-natal syphilis, Obst. 9
Adamson, H. G.—Case for diagnosis, Derm. 33
-, discussion on alopecia of scalp and eyebrows associated with Graves disease, Derm. 41
-on ca^e of epithelioma of face, Derm. 2
-of “ multiple benign, tumour-like new growths,” Derm. 22
-multiple idiopathic haemorrhagic sarcoma of Kaposi (miscalled), Derm. 51
-on guttate morphoea, Derm. 4
-on white-spot disease (morphoea guttata), Derm. 26
Addison, Mrs. K.—Case of trichorrhexis nodosa (with report by Dr. Mary Schofield),
Derm. 59
Addison’s disease, pigmentation in malaria resembling, Med. 38
-not due to, Derm. 28
Adenitis complicating influenza, Med. 68, 69
-, onset of, Child. 34
Adenocarcinoma of breast with giant-celled sarcomatous stroma, Path. 8-13
-, microscopic examination, Path. 9-13
-of prostate with metaplasia in squamous-celled carcinoma, associated with sarcomatous
stroma, Path. 18-23
-, operation material, microscopic appearances,
Path. 20, 21, 22
VI
Index
Adenocarcinoma of the thyroid gland disseminating as a polymorphic-celled sarcoma, Path. 4,8
- of uterus: polyp showing areas of squamous-celled carcinoma associated with
sarcomatous stroma, Path. 13-17
Adenocarcinomata, polymorphism in, Path. 2
Adenoid facies, main features of, Child. 32
-- tissue, masses of around Luschka's gland, Child. 34
-around orifices of Eustachian tubes, Child. 34
-in fossre of Rosenmiiller, Child. 34
-of nasopharynx, hyperplasia of, inherited tendency to, Child 38.
Adenoids, aetiology, factors in, Child. 20, 27, 30, 45, 54
-and enlarged tonsils, removal, in preventive treatment of acute otitis media, Otol. 55
-and gastro-intestinal toxaemia, relation between, Child. 56
-and nasal catarrh, association, Child. 31
-, antiquity of, Child. 47
--, association with enlarged tonsils, Child. 33
-, catarrh accompanying, treatment, Child. 49
-causing interference with nasal and oral respiration, Child. 33
--, classification of cases of, Child. 51
-—, climatic distribution, Child. 30
-factors in causation of, Child. 47
-complicating chronic suppurative otitis media, Otol. 32
--, deafness associated with, Child. 34
-definition of, Child. 20, 47
-, development of, coincident with introduction of bottle feeding, Child. 31. 45, 48
-with spread of rickets, Child. 31
-, diminution of, by change in dietetic customs, Child. 30
-, discussion on, Child. 20-58 (J. H. Badcock, 40 ; H. C. Cameron, 45, 52 ; Harry Campbell*
26, 50 : Edmund Caul lev, 30, 57 ; A. R. Colyer, 54 ; William Hill, 50 ; W. H. Kelson,
51 ; C. P. Lapage, 44 ; W. Stuart-Low, 37 ; Irwin Moore, 47 : J. Porter Parkinson,
40,42; Eric Pritchard, 41, 53: J. Sim Wallace, 35; H. L. Whale, 49; W. Camac
Wilkinson, 39)
-due to dietetic errors, Child. 20, 45
-to nasopharyngitis, Child. 30
-, ear affections associated with, Child. 34, 48
-, effects on children, Child. 32
--, enlargement of Luschka’s tonsil in, Child. 48, 50, 51
-, examination for, when unnecessary, Child 31
-, fibrosis of. Child. 48
-, geographical distribution, Child. 28, 30
-, hereditary tendency to, Child. 38, 40, 45, 47
-, in adults, Child. 40, 43
--in young children, treatment hv alkaline detergent lotions, Larvng. 219, 220
-by breathing exercises, Laryng. 217, 219
--by snuffing, condemned, Laryng. 217, 219, 220
---- by thyroid extract, Laryng. 217, 219
--- by vaccines, Larvng. 217
-, operative, Laryng. 218, 219
--, indications for, Laryng. 218, 219, 220
-, suggested alternatives to (J. Donelau), Laryng. 21G
-, when contra-indicated, Laryng. 219
-, infective origin, Child. 44
-, inspection by post-nasal mirror, Child. 50, 52
-, nasal obstruction and, Child. 32
-, not merely a local disease, Child. 53, 56
-, over-crowding and ill-ventilation in relation to, Child. 45
Index
vii
Adenoids, pathogenesis of, Laryng. 217
-, prevalence among children sleeping in cold and damp atmosphere, Child. 37
-in Australia, Child. 39, 57
-in British dependencies, Child. 28, 56
-in England, Child. 28
-, shape of pad in, Child. 50
-, shrinkage of, Child. 49
-, small, treatment by medical measures recommended, Child. 52
-, treatment by application of paint, Child. 43
-by respiratory exercises, Child. 43, 49, 53
-contra-indicated, Child. 35, 49, 58
-by sneezing exercises, Child. 35, 39
-, climatic, Child. 51
-, from dental standpoint, Child. 54
-, non-operative, Child. 37, 49
-, operative, advocated, Child. 38, 51
-, contra-indications for, Child. 31, 44
-, delay of, ill-results following, Child. 39
-, dependent on degree of hyperplasia present, Child. 57
-, good results following, Child. 39
-, indications for, Child. 34, 45, 50
-, risks of, Child. 43
-, unnecessarily performed, Child. 43
-, preventive, Child. 35, 45, 54, 55
-, by exposure to fresh air, Child. 55
-, by removal of sources of infection, Child. 55
-, individual, Child. 55
- 1 national. Child. 55, 56
Adenoma of ventricular band of larynx, Laryng. 201
-(right), case of, Laryng. 149
-of vocal cord, cases recorded in literature, Laryng. 200
-, microscopic specimens and report on sections, Laryng. 148, 149
-, removed by thyro-fissuro, case (A. L. Macleod), Laryng. 148
-, sections showing, Laryng. 202, 203
-of wall of ventricle of larynx, Laryng. 201
Adenomata, development of, normal histology of vocal cord and ventricle of larynx considered
in connexion with, epidiascopic demonstration (Irwin Moore), Laryng. 199
-, multiple, complete resection of large bowel for, case (J. P. Lockhart-Mummerv),
Proct. 43
Adiposis dolorosa, see Deratin's disease
Aditus, findings in, at radical mastoid operations, Otol. 36
Adler, recognition of principles of self-assertion and self-abasement or submission by,
Psych. 6
Adrenal growth (sarcomatous) with secondary metastasis in skull (E. Cautley), Child. 90
---, blood count in, Child. 90
Adults, adenoids in, Child. 40, 43
-, unfit, rearing of, as result of supervision of pregnant women, Obst. 53, 56, 60, 72
Aerated water, appearance of gas bubbles on foreign body immersed in, explanation, Path. 69
Aerophagy, Path. 55
-in horse, Path. 55
Aeroplane crashes, test for eflect of, Epid. 41
^Etiology, modern conception of, Psych. 70
Affect, conception of, Psych. 6
Affective therapeutics, Psych. 33, 34, 35
Africa, South, influenza epidemic in (1918), R.S.M. Disc. (Iufl.) 29
Age in relation to length of normal oesophagus, Laryng. 49
Index
viii
Ahusquy, waters of, drinking of, effect on leucocyte reaction, Bain. 4
Air core transformer, use in diathermy, Electr. 19
-, compressed, driving into mouth or anus, danger of, Path. 55
-driven from right heart through lungs, into left, experimentally post mortem, in cat
Path. 64
-embolism, Path. 63
-, fatal case occurring during urethroscopy, Path. 63, 64
-entering joint, Path. 55
- entrance into serous cavities, connective tissue, or alimentary or genito urinary tracts,
pneumatoses due to, Path. 50
-, entry of, emphysema of connective-tissue from, Path. 56
-, fresh, exposure to, in prevention of adenoids, Child. 55
-, introduction, experimentally, into circulation, through vein, without fatal result, in
dog, Path. 64
-into lumen of intestine, effect on gases, Path. 70
-passages, upper, acute inflammation in fatal cases of influenza, R.S.M. Disc. (luff.) 55
-pilots, breath-holding test for, Epid. 37, 38
-s candidates for, physical efficiency tests for, results, Epid. 40
-rejected, by physical efficiency tests, Epid. 41
-, grading as extra fit for duty, Epid. 42
-, indication of power to fly, Epid. 38
-, vital capacity of, Epid. 38 '
-, presence of, in genito urinary and alimentary tract, Path. 52
- sac, abdominal, rapid over-distension causing sudden death in Chilian sea-eaglo,
Path. 63
-sacs of birds, Path. 61
-, source of air in, Path. 61
-, question of assistance to birds during singing, Path. 63
-, trilobed upper limit at root of neck in nestling tit, Path. 61, 62
-in pigeon, Path. 61
-wave, momentary changes of unit-pressure, multiplication in liquid of cochlea, Otol. 84
Ala, restoration of, Laryng. 117
Alae, tip of nose and columnella, loss of, Indian mutilation type, operation for, Laryng. 120
-, restoration of, Laryng. 120
Albee’s operation for transplantation of bone from tibia to fix spinous processes of diseased
vertebrae, Surg. 23
-for low dorsal caries, fate of bone-graft, Surg. 31
Albuminuria complicating influenza, R.S.M. Disc. (Infl.) 69
-in pulmonary type of influenza, Med. 55
Alcohol, consumption of, as factor in production of industrial accidents, Epid. 49, 50
Alcoholic psychoses, toxic, in warfare, Psych. 4$
Alcoholism as factor in production of mental disease in war, Psych. 39, 40
-, history of, in paranoid states, Psych. 46
-, important predisposing cause of war psychoses, Psych. 39
Aldershot, influenza epidemics at, June, 1918; September, 1918, R.S.M. Disc. (Infl.) 41
Alexander’s operation, ventrifixation substituted for, Obst. 220
Algesia following indirect concussion from high explosives, Neur. 48
Alienists, knowledge of psychology indispensable to, Psych. 65
-, natural science only training of, Psych. 63, 64
Alimentary tract, entrance of air into, pneumatoses due to. Path. 50
-, presence of air in, Path. 52
Alopecia areata following partial thyroidectomy, Derm. 42
-of scalp and eyebrows associated with Graves’ disease (H. W. Barber), Derm. 41
Altitudes, capabilty for holding breath at, best test for, Epid. 37
Alveolar union, incomplete fractures of mandible with, bone-grafting in, Surg. 17, 21
Index
IX
Alveolus, nose and larynx, extensive lupus of (E. D. D. Davis), Laryng. 212
-, palate and premaxilla, total loss of, Odont. 90
Amatol, detonation of, effects on men, experimentally tested, Neur. 45
Amaurosis, amelioration of, in disseminated sclerosis, how explained, Neur. 22
Ambrine, application after radical mastoid operation, Otol. 39
American monkeys, variation in position of teeth of (J. F. Colyer), Odont. 39
-troops aboard a transport, outbreak of respiratory disease among, R.S.M. Disc. (Infl.) 71
Ammonal, detonation of, effects on men, experimentally tested, Neur. 45
Ammonium, benzoate of, see Urotropin , benzoate of ammonium and salicylate of sodium.
Amnesia, as war neurosis, Psych. 55
-, deafness and mutism in walking case of war neurosis, Psych. 54
-following direct concussion from high explosives, Neur. 47
-indirect concussion from high explosives, IJeur. 48
-in war neurological cases, Psych. 56
-, treatment, Psych. 56, 60
-of, in France and England, results compared, Psych. 57
-with deaf-mutism, in war neurological case, treatment by hypnotism, result, Psych. 58
Amplitudes corresponding to period of 100 weeks and 20 rows, Epid. 116
-, method of determining, Epid. 114
-, range of, due to a period, Epid. 115
Amyotonia congenita of Oppenheim, see Dystrophy , primary atrophic muscular
Anaemia and pallor, difference between, Med. 34
-, aplastic, case; blood-count in, Child. 2
-ending fatally, blood-count, Child. 73
-, necropsy, Child. 73
-(previously shown), (J. Porter Parkinson), Child. 2
-shown after recovery from (J. Porter Parkinson), Child. 72
-, specimens from (J. Porter Parkinson), Child. 110
-, main cause of, Med. 10
-, transfusion of blood in, Med. 12
-, untoward symptoms following, Med. 8
-, cerebral, in shock, R.S.M. Disc. (Shock) 20
-in post-operative shock, R.S.M. Disc. (Shock) 33
-, pernicious, blood-picture of, distinguishing feature in, Med. 10
-, case of, transfusion of blood in, Med. 5
-, accident following, Med. 6
-, transfusion of blood in, results, Med. 10, 11, 12
-, plastic, prognosis in, Child. 3, 4
Anaesthesia general and local, combination of, Anaesth. 14
-, intra-alveolar in dental operations, Odont. 3, 5
-local, in dental operations (F. N. Doubleday), Odont. 1
-, cases illustrating, Odont. 4, 5
-, methods of induction, Odont, 2, 3
-, removal of pharyngeal diverticulum under (W. H. Kelson), Laryng. 248-250
-, regional, in mandible, methods, Odont. 3
-, in maxilla, method, Odont. 3
-, spinal, Caesarean section under, case (Llewelyn Powell), Anaesth. 21
-, care of patient before, Anaesth. 12
-, contra-indications for, Anaesth. 9
-, dangerous for patients suffering from shock, Aneesth. 9
-, fall of blood-pressure associated with, Anaesth. 9, 10
-, in operations associated with shock, Anaesth. 8, 9
-, indications and contra-indications for use in heart disease, Ansesth. 10
-for, Ansesth. 8
-, induction with general anaesthetics, Anaesth. 3, 4
X
Index
Anaesthesia, spinal, operations for which employed, Anaesth. 9
-for which suitable, Amesth. 12, 13
-posture in, Anaesth. 3, 12, 14
-, preliminary administration of scopolamine-morphine administration before,
Amesth. 12
-, present position of, discussion on, Amesth. 1-14 (J. Blomfield, 14 * Percival P.
Cole, 12; J. P. Lockhart-Mummery, 11; Felix Rood, 1; F. E. Shipway, 13)
-, vomiting rare after, Anaesth. 13
Anaesthetic, choice of factors to be considered in giving an, Anaesth. 11
-necessary under diathermy in treatment of inoperable cancer of cervix uteri, Electr. 18
Anaesthetics, administration, protection of patients against fear before, Anaesth. 11
-, vomiting under, Anaesth. 11
-during operations on subjects of traumatic shock, R.S.M. Disc. (Shock), 32
-in cases of shock, R.S.M. Disc. (Shock), 23
Anaesthetist, presence at labour a necessity, Obst. 90
Anal region excised eighteen months ago, chronic X-ray dermatitis of, case (J. P. Lockhart-
Mummery), Proct. 45
Analysis and anamnesis, Neur. 16
-and psycho-analysis not identical, Psych. 2G
-as therapeutic measure, upon what based, Psych. 26
-, distinction from suggestion and persuasion, Psych. 27
-, suggestion and persuasion, relation between as therapeutic methods, Psych. 27
-therapeutic indications for use of suggestion and persuasion, apart from, Psych. 31
-superiority over suggestion and persuasion indicated, Psych. 28, 29, 30
Anamnesis and analysis, Neur. 16
-, value of, in treatment of neuroses, Neur. 16, 17
Anaphylaxis and thermal cure, Bain. 8
Andrews, H. Russell.— Cases of extra-uterine pregnancy, Obst. 173
-, discussion on high maternal mortality of child-bearing, Obst. 103
-on teaching of obstetrics and gynaecology, Obst. 72
-, severe retroperitoneal bleeding after dilatation of the cervix, Obst. 199
Aneurysm, aortic, causing obstruction of oesophagus, with dilatation above, Laryng. 100
-, thoracic, abdominal seetiou in case of, method of anaesthesia employed, Amesth. 22
--, in man with (F. E. Shipway), Amesth. 22
Angoioid streaks in retina (E. \V. Brewerton), Ophtli. 33
Angiofibroma, nasopharyngeal, case (G. W. Dawson), Laryng. 174
-, method of removal, Laryng. 175
Angioma of left arytamoid (G. \V. Dawson), Laryng. 150
-of retina (II. Goldsmith), Ophth. 3
-, case of (E. \V. Brewerton), Ophth. 20
- -, cases reported, Ophth. 21
-serpiginosum, case of (A. M. H. Gray), Derm. GO
-, vascular lesions of, Derm. 61
Angiomata, cavernous, congenital, Ophth. 21
Aniline group of antiseptics in sterility of birth area, Obst. 89, 94
Animals without diastasic ferment in saliva, Child. 27
Ankylosis, bilateral, of vocal cords ; case for diagnosis (Andrew Wylie), Laryng. 160
-, extra-articular, prevention in imunited fractures of mandible, Surg. 12
Anosmia following injury to upper part of anterior ethmoid, Ophth. and Laryng. xxxiii
Anoxaemia, heliotrope cyanosis of influenza same as that of, R.S.M. Disc. (Infl.) 99
Ante-natal clinics, importance of, Obst. 54
-, laboratory research work in, Obst. 55
-. subjects to be taught in, Obst. 55
Antibodies formed against malarial parasites, Med. 40 .
-, productiou of, after injection of new antituberculous medicament, Therap. 4
Index
xi
Antigen from single strain of parasites (Plasmodium vivax ), use in preliminary experiments
carried out in known cases of benign tertian malaria with Plasmodium vivax present
in blood, Med. 43
-, malarial, composed of ten cultures of benign tertian malaria (Plasmodium vivax), series
of cases with use of, Med. 45
-, dilution, Med. 42
-, testing of, method described, Med. 41
--, number of tubes required, Med. 41
-prepared from spleen of malignant tertian case and antigen prepared from cultures of
Plasmodium vivax , experiments made by using, Med. 45
Antigens, malarial, anti-complementary, Med. 41, 42
-, malarial, preparation of, method described, Med. 40, 41
-preparod from cultures of malarial parasites (Plasmodium falciparum and Plasmodium
vivax), experiments on complement-fixation in malaria with (J. Gordon Thomson),
Med. 39
-, specific, possibility of preparation for benign and malignant tertian malaria, experiments
to determine, Med. 44
-, various experiments carried out to determine if separate strains of parasites react
differently to, Med. 44
Antimony in treatment of Delhi boil, Derm. 72
Antiseptic mouth-washes, Odont. 30, 31
-surgery, main principle of, Obst. 81
-system, Lister’s definition of, Obst. 3
Antiseptics and toothbrush, use of, in mouth, Odont. 29
-, discoverer of, Obst. 99
Antituberculous medicament, new, contents of, Therap. 3
--, injection by intratracheal route in pulmonary tuberculosis, results in patients,
Therap. 5
-—, subcutaueous, general and local reactions produced by, Therap. 4
--, production of antibodies after, Therap. 4
-, site of, in pulmonary tuberculosis, Therap. 3
---specific (E. A. Bossan and A. Balvay), Therap. 1
Antityphoid inoculation among Belgian civilian population by Friends’ Ambulance Unit,
statistics, Epid. 30
--made compulsory, Epid. 30
-, British Army alone adequately protected by, in Flanders, Epid. 17
-not protective against paratyphoid infection. Epid. 33
Antra (maxillary), irrigation of, contra-indicated in guushot wounds, Laryng. 243
Antro-choanal polypus, see Polypus, antro-choanal
Antrum, mastoid, conditions under which affected, Otol. 52
-, findings in, at radical mastoid operations. Otol. 3G
-, implication in chronic middle-ear suppuration, how indicated, Otol. 52, GO
-, rupture of roof in case of fracture of the base of skull (J. S. Fraser), Otol. 110
-, maxillary, and orbit, gunshot wounds involving, case histories and treatment, Ophth.
and Laryng. xiv, xv, xviii, xix
-, injury to, Ophth. and Laryng. ix, x
-, thrust wound of, Ophth. arid Laryng. vi
-, carcinoma of, recurrence after lateral rhinotomy (Irwin Moore), Laryng. 24
-, disease of, series of cases with some points of interest (W. S. Syme). Laryng. 255
-, distension causing pressure on optic nerve and blindness, Ophth. and Laryng.
lvi
-, epithelioma of, glaucoma associated with, Ophth. and Laryng. xxxvi
-, ethmoid and orbit, injury to, Ophth. and Laryng. viii, ix
-, extensive injury, method of drainage, Ophth. and Laryng. xl
-*-, foreign bodies in, removal, Ophth. and Laryng. xxxix, lxv
Xll
Index
Antrum, maxillary, gunshot injuries of, treatment, operative, Ophth. and Laryng. xxxix.
-wounds involving, treatment, Ophth. and Laryng. xii
-, healing of, Ophth. and Laryng. lxvi
-, injuries to eye following, Ophth. and Laryng. xxxiv
-, operation for removal of foreign bodies, Ophth. and Laryng. liv
---, treatment, operative, Ophth. and Laryng. xxvi
-, with injury to eye, Ophth. and Laryng. liv
-, inflammation, acute or sub-acute, Ophth. and Laryng. lix
-, method of opening in case of localized growths, Laryng. 23, 24
-, perforating wounds of, treatment by intra-nasal drainage, Ophth. and Laryng. xi
-, right, perithelioma of, radium treatment (J. Gay French), Laryng. 114
-, and orbit, carcinoma of, treated by excision, radium and X-rays (Norman
Patterson), Laryng. 194
-, sarcoma of, lateral rhinotomy, recurrence in glands, radium treatment (Irwin
Moore), Laryng. 21
--, shrapnel embedded in, Ophth. and Laryng. lix
-, sphenoid and orbit, injury to, with foreign body retained in sphenoid region,
Ophth. and Laryng. x
-, upper jaw and ethmoid, unilateral perithelioma of, removed at one operation,
after ligature of external carotid (H. Lawson Whale), Laryng. 179
Anuria, puerperal, post-mortem findings in cases of, Obst. 29, 31
-, two cases, renal capsule incised and portions of kidney substance removed for
.examination (Clifford White), Obst. 27
-, sections from kidneys in, compared with section from normal kidney,
Obst. 29
Anus as centre of infection in childbirth, Obst. 88
-, driving of compressed air into, danger of, Path. 55
-, elimination from birth area, Obst. 89
-, musical, Path. 54
-, references to, Path. 54
-, proximity of birth area to, danger denied, Obst. 102
Anxiety, depressive, as war psychosis, Psych. 43
-, traced to ungratified sexual desire, Psych. 43
-, neuroses always preceded by, Neur. 14
-, underlying, in neuroses, treatment necessary, Neur. 14
Aphasia, emotional utterances in, explanation, Neur. 7
-following direct concussion from high explosives, Neur. 47
-, varieties, how interpreted, Psych. 3, 4
Aphonia, functional, cases of early pulmonary tuberculosis mistaken for and treated as,
Laryng. 31
-, of ten months* duration, with laryngitis, case (J. Dundas Grant), Laryng. 30
-, of three months* duration, case (J. Dundas Grant), Laryng. 29
-, treatment, Laryng. 30, 31, 32
-by suggestion, Laryng. 31
Apophysitis of os calcis (Paul B. Roth), Child. 99
Appendicitis, acute, operations for, spinal anaesthesia indicated in, Anaesth. 8
-, chronic, X-ray examination in, Electr. 11
Appendix vermiformis, carcinoma of (J. E. Adams), Surg. 37
-, age-incidence, Surg. 38
-, cases recorded, Surg. 89, 40
-, cured case of, Surg. 39
-, forms of, Surg. 41
- f malignancy of, Surg. 88
-, other forms of malignant growth resembling, Surg. 41, 42
- 1 prognosis after operation, Surg. 41
Index
xm
Appendix vermiformis, carcinoma, type of cell in, Surg. 38
-, treatment by appendicectomy, results, Surg. 40, 41
-, endothelioma of, case, Surg. 39
-, examination of by X-rays (E. T. Spriggs), Electr. 9
-, malignant disease of, primary, Surg. 41
-, microscopical detection, Surg. 4*2
-, perforation, pneumoperitoneum from gas formation following, Path. 50|
Appbrly, R. E.—Notes of a case of heart failure following change of position, Ansesth. 17
Apyrexial symptoms in malaria (Gordon Ward), Med. 15
Archibald, R. G., Major, D.S.O., and Christopherson, J. B.—Case of primary nocardiasis
of the lachrymal gland caused by a species of Nocardia hitherto undescribed, Ophth. 4
Argyll-Robertson pupil, sign conclusive of structural changes in central nervous system,
Neur. 25
Arm, paralysis of, functional, destruction of conviction of, by suggestion, Psych. 22
-, development, Psych. 20
-, hysterical, in soldier, therapeutic superiority of analysis over suggestion and
persuasion in dealing with, indicated, Psych. 29, 30
Armies, fatality of measles among, R.8.M. Disc. (Infl.) 15
Armour, Donald, C.M.G.—Discussion on case of tumour of roof of orbit, Ophth. 20
-and Lang, William.— Ivory exostosis growing from the roof of the frontal sinus into
the orbital and cranial cavities, removed through an osteoplastic opening in the
cranium by Mr. Donald Armour, Ophth. 16
Army, American, in France, influenza epidemic in (1918), R.S.M. Disc. (Infl.) 28
-, meningitis in, R.S.M. Disc. (Infl.) 29
--, influenza epidemic in (1918), R.S.M. Disc. (Infl.) 61-67
-, Belgian, enteric fever in (1914-1915), Epid. 22
-, British, alone adequately protected by antityphoid inoculation in Flanders (1914),
Epid. 17
--, excess of paratyphoid over typhoid cases in, Epid. 33
-, in France, influenza epidemic in (1918), R.S.M. Disc. (Infl.) 27
-, effect on troops, R.S.M. Disc. (Infl.) 28
-, spread by re-distribution of troops, R.S.M. Disc. (IniL) 28
-in United Kingdom, incidence of cerebro-spinal fever and pneumonia in, compared,
1915-1918, R.S.M. Disc. (Infl.) 6, 7
-, proportion of paratyphoid fever A and B among, Epid. 26
-of typhoid and paratyphoid fevers occurring among, Epid. 26
-, French, not adequately protected by antityphoid inoculation in Flanders (1914),
Epid. 17
-, proportion of paratyphoid fever A and B among, Epid. 26
-of typhoid and paratyphoid fever among, Epid. 26
-, German, in Flanders, enteric fever in (1914-1915), Epid. 21, 22
-, not adequately protected by antityphoid inoculation in Flanders (1914), Epid. 17
-, Italian, proportion of typhoid and paratyphoid fevers among, Epid. 26
Arsenic colloids in Choussy-Perrifcre waters, Bain. 3
-, leuconychia striata following administration of, Derm. 29.
-, occurrence of pneumonia in those taking, Clin. 18
Arsenical pigmentation and hyperkeratosis occurring in course of dermatitis herpetiformis,
Derm. 31
-in case of lymphadenoma (Miss E. O’Flynn), Clin. 17
-poisoning among beer drinkers, associated with herpes zoster, Clin. 18
Arteries, carotid, compression with Crile’s clamps in removal of nasopharyngeal angeio-
fibroma, Laryng. 175, 176
-, constriction, in clinical shock, R.S.M. Disc. (Shock) 6, 9
Artery, brachial, severance of, two cases illustrating effect of (A. Rocyn Jones), Neur. 33
XIV
Index
Artery, carotid, external, ligature of, followed by operation for unilateral perithelioma of
maxillary antrum, upper jaw and ethmoid (H. Lawson Whale), Laryng. 179
-, femoral, superficial, anterior division, forehead flap containing, Laryng. 142, 143
-, retinal, central, with patent branches, obstruction of, following electric flash (P. A.
Juler), Ophth. 58
-, case of, history, Ophth. 58, 59
-, condition of eyes, Ophth. 59
Arthritis, acute suppurative, of right knee, mobilization treatment in (J. Everidge), Clin. 16
-, rheumatoid, acute, treatment by diathermy, Electr. 35, 36
-, association with orbital cellulitis, Laryng. 225
---, due to latent sinusitis with appendicitis, Laryng. 222
-, with chronic catarrhal deafness, Laryng. 220, 221
-, septic, of knee, due to shell-wound, results of treatment, Clin. 15
Aryteenoid, left, angeioma of (G. W. Dawson), Laryng. 150
Asylums, badly administered and crowded, worst cases of katatonia and dementia'a product
of, Psych. 66
-, pleasant surroundings in, good effect on insane patients, Psych. 67
Aspergillus fumigatus , from nasal sinuses, specimens of (Douglas Harmer and T. Jockos),
Laryng. 187
-, experimental injection of rabbit with, Laryng. 187
Associationism and sensationism, combination of, Psych. 2
-, definition of, Psych. 2
Asthenia, general, in encephalitis lethargica, Med., Path, and Epid. xv., xix
Asthma, treatment by diathermy, Electr. 36
Astringents, application to enlarged or diseased tonsils, Laryng. 244
Ataxy, hysterical, Friedreich’s, ataxic paraplegia associated with, case, Neur. 23
Ateles (Spider monkeys), variations in positions of teeth in, Odont. 46
- melanochir , rare condition of irregularity of teeth in, Odont. 46
- vellerosus , irregularity of maxillary premolars in, Odont. 46, 47
Atropine in treatment of cardiospasm, Laryng. 51
-test in diagnosis of typhoid fever in inoculated soldiers, Epid. 3, 5
Attic, findings in, at radical mastoid operations, Otol. 37
-, implication, in chronic middle-ear suppuration, how indicated, Otol. 52, 60
-, perforations found at radical mastoid operation, Otol. 44
Aura, epileptic, migraine spectrum compared with, Ophth. 50
Aural shield, use of after radical mastoid operation, Otol. 56
Auricle, cardiac, and ventricle, contraction of, sequence in, Electr. 66
-, contractions of, delay between, Electr. 66 ; see also Heart-block
-, right, intra-cardiac blood-pressure in, influence of bodily position on, R.S.M. Disc.
(Shock.) 25
Auricle, fibroma of, at entrance of meatus (W. Stuart-Low), Otol. 79
-, lupus erythematosus of, extensive symmetrical (W. Stuart-Low), Otol. 5
-, malformations, Otol. 25
-, whole, mal-development of, embryological tissue concerned in, Otol. 22
Auricles, abnormal, proportion in otosclerosis and nerve-deafness, Otol. 27
-, defective, association with degeneration deafness, Otol. 19
-, case illustrating, Otol. 19, 20
-—, proportion among the deaf, Otol. 19
-, well-formed and defective, respective proportions in individuals with sound and defective
hearing, Otol. 19
-, well-formed, association with good hearing, Otol. 18, 19
Auscultation, detection of heart sounds by, Electr. 68
Australia, campaign against venereal diseases in, R.S.M. Lect. 1, 2
-, human acute infective polio-encephalo-myelitis, occurring in, conveyance of virus to
monkeys, sheep, calf and foal (J. B. Cleland), Path. 33
Index
xv
Australia,Jiuman acute infective polio-encephato-myelitis in, seasonal and geographical dis¬
tribution, Path. 33
-, prevalence of adenoids in, Child. 39, 57
-, rickets unknown in, Child. 39, 57
Australian troops at Port Said, prophylactic measures against venereal diseases among*
R.S.M. Lect. 8, 9
-in Egypt, percentage suffering from venereal diseases, R.S.M. Lect. 6
- f venereal diseases among, educational propaganda against spread among,
R.S.M. Lect. 6, 7
-, warning to, respecting venereal diseases, R.S.M. Lect. 5, G
Auto-erotic association, war psychoses connected with, Psych. 43
Autognosis, in treatment of late cases of war neurosis, Psych. 60, G1
Auto-intoxication, acute, symptoms of shock identical with those of, R.S.M. Disc. (Shock) ‘27
-, intestinal, as cause of shock, R.S.M. Disc. (Shock) ‘2G
Auto-suggestion in hysterical tabes dorsalis, Neur. 2‘2
-, need for definition and limitation of term, Psych. 20
Axilla, radiation of, in advanced breast cancer, Electr. 48, 50
Axillce, injection of saline solution into, to obviate shock following operation for acute
intestinal obstruction, R.S.M. Disc. (Shock) 27
Axons of nerve end-cells of dental pulp, Odont. 12
Babington, B. G., first demonstration of laryngeal mirror by, Laryng. 2
Babinski’s theory of suggestion, in war neuroses, Psych. 55
Bacillus aerogenes , cause of gas production in vaginal w r all in vaginitis emphysematosa,
Path. 49
- coli infection of urine in extra-uterine pregnancy, Obst. 184
-, tolerance for injected culture of, proved experimentally after injection of mineral
waters, Bain. 7, 8
- influenza cultivation difficult, R.S.M. Disc. (Infi.) 95
- typhosuSj strains isolated from cases of typhoid in inoculated soldiers, Epid. 13
Back, Ivor. —Discussion on complete resection of large bowel for multiple adenomata,
Proct. 44
Backman, Captain, U.S.A. —Discussion on radiography of gall-stones, Electr. 85
Bacteria, gas-forming, closed tympanitic abscess due to, Path. 49
Bacterial infections, cause of circulatory depression in, R.S.M. Disc. (Shock) 6
Bacteriologists and epidemiologists, differing views of problem of disease taken by, Epid. 75
Badcock, J. H.—Discussion on adenoids, Child. 40
Baker, P. M.—Discussion on the electrocardiograph, Electr. 70
Balfour, Andrew, C.M.G.—Discussion on apyrexial symptoms in malaria, Med. 37
Ball, W. Girling.— Discussion on treatment of ante-natal and post natal syphilis, Obst. 14
Ballance, Sir Charles, K.C.M.G., C.B., M.V.O.—Discussion on mastoid operations, Otol. 58
Balvay, A., and Bossan, E. A.—New specific antituberculous medicament, Therap. 1
Bandages, use of, to avoid soiling clothes, in prophylaxis against venereal diseases, R.S.M.
Lect. 9
Banks-Davis, H. J.—Discussion on angeioma of left arytamoid, Laryng. 150
-, discussion on bilateral ankylosis of vocal cords, Laryng. 162
-on case of acute mastoiditis followed by thrombosis of internal jugular vein,
recovery, Otol. 10
-of chronic adhesive otitis, Otol. 96
--unilateral laryngitis, Laryng. 165
---on choanal polypi in two children, Laryng. 154
-on extensive symmetrical lupus erythematosus, Otol. 6
-on deafness associated with stigmata of degeneration, Otol. 26
-on foreign body removed from nose, Laryng. 160
-on sarcoma (?) of left tonsil, Laryng. 27
-on septic infection of lateral sinus injured during mastoidectomy, Otol. 74
XVI
Index
Barber, H. W. —Alopecia of the scalp and eyebrows associated with Graves’ disease,
Derm. 41
-, case for diagnosis, Derm. 37
-of acne complicated by intestinal stasis in which a general improvement was
effected by diathermy, Electr. 37
-, discussion on case of multiple idiopathic haemorrhagic sarcoma of Kaposi (miscalled),
Derm. 51
-, two cases of granulosis rubra nasi in boys, Derm. 40
Barium sulphate and buttermilk meal in X-ray examination of appendix, Electr. 9
Barker, A. E., records of spinal anaesthesia, quoted, Anaesth. 7
Barkla, C. G., secondary radiation, quoted, Electr. 13
Barlow, Sir Thomas, Bt., resemblance of infantile paralysis in early stages to influenza, quoted,
Med., Path, and Epid. xii.
Barrett, Sir James W., K.B.E., C.B.—The management of venereal diseases in Egypt
during the war, R.S.M., Lect. 1
Barrett, Lady, C.B.E.—Discussion on teaching of obstetrics and gynaecology, Obst. 65
Basilar membrane, Otol. 82, 85
-connexion of Corti arches with, Otol. 85
-zones of, Otol. 84
-union, incomplete fractures of mandible with, technique employed, Surg. 17, 21
Batten, Rayner D.—Symmetrical disease of macula (with drawing of left eye), Ophth. 35
Battle, W., case of carcinoma of appendix, quoted, Surg. 39
Baudouin, Marcel, curious example of rectal pneumatosis, quoted, Path. 54
Baylis8, W. M., F.R.S.—Discussion on shock, R.S.M. Disc. (Shock), 1, 33
Bazett, H. C., M.C., Captain R.A.F.—Discussion on shock, R.S.M. Disc. (Shock), 31
-, indication of power of pilot to fly, quoted, Epid. 38
Beer-drinkers, arsenical poisoning among, associated with herpes zoster, Clin. 18
Belgian refugees in England, cases of enteric fever among, 1914, Epid. 16 .
Belgium, enteric fever among inhabitants of area occupied by Allies, Epid. 22
Belief, element of, in treatment of neuroses, Neur. 13, 14
Beliefs, emotional basis for, Psych. 17
Bbnians, T. H. C.—Discussion on four cases of atrophic rhinitis with ozgena undergoing
treatment by glycophylic methods, Laryng. 186
-, a method of treating atrophic rhinitis based on an alteration in composition and
reaction of the substrate on which the bacterial ferments are acting ; Part 1, Bacterio¬
logical, Laryng. 227
Beri beri, aetiology of, Odont. 23
Bevan’s operation for undescended testicle, Child. 63
Bhat, K. S.—New counting chamber for cells, <fcc., in fluids, Child. 4
Bibliographies and references :—
Antituberculous treatment, new (E. A. Bossan and A. Balvay), Therap. 7
Aspergillus fumigatus in nasal sinuses (W. Douglas Harmer and T. Jockes), Laryng. 187
Buccal and sucking pads (Wyatt Wingrave), Laryng. 256
Complement fixation in malaria with antigens prepared from cultures of malarial
parasites (J. G. Thomson), Med. 48
Enteric fever in Flanders (E. W. Goodall), Epid. 34
Immunity and mineral water treatment (Paul Ferreyrolles), Bain. 12
Lipoma of broad ligament (C. Lockyer), Obst. 199
Mandibular bone-grafts (C. W. Waldron and E. F. Risdon), Surg. 19
Oesophagus, dilatation of, pathology (Irwin Moore), Laryng. 68-77
Otosclerosis associated with fragilitas ossium (J. G. Fraser), Otol. 131
Peace and war neuroses, inter-relation between (T. A. Ross), Neur. 20
Periodicities of epidemics of measles (J. Brownlee), Epid. 117
Polymorphism of the malignant epithelial cell (E. H. Kettle), Path. 32
Pregnancy, extra-uterine, full term (with abstracts of cases) (Gordon Ley), Obst. 157-170
Index • xvii
Bibliographies aud references : —
Psychotherapy, methods of (Bernard Hart), Psych. 34
Pyorrhoea, bacteriology of (J. G. Turner and A. H. Drew), Odont. 118
Bile-duct, common, and gall-bladder, situate in different planes, Electr. 78
Bile-ducts and gall-bladder, relations to surrounding structures, radiograms showing,
Electr. 78
-, gall-stones in, correct diagnosis important, Electr. 76
Billington, William, Pabbott, Abthub H., and Round, Habold.— Bone-grafting in
gunshot fractures of the jaw, Odont. 55
Biphasic reaction in central nervous system, Neur. 11
Bird, cochlea in, construction of, supporting Wrightson’s theory of hearing, Otol. 89
Birds, air sacs of, Path. 61
-, question of assistance during singing, Path. 63.
-, subcutaneous emphysema of neck in, Path. 60
Birdwood, General W. R., C.B., letter respecting behaviour of Australian troops in Egypt f
R.S.M. Lect. 4
Bibkett, H. S., C. B., Brigadier-General C.A.M.C.—Discussion on gunshot wounds of nasal
accessory sinuses, Laryng. 242
Birmingham, encephalitis lethargica epidemic at, Med., Path, and Epid. xiv
-, measles, epidemics in, amplitudes, Epid. 90, 91, 95
--— in, deaths from, average weekly prevalence for forty years, Epid. 98
Birnbaum, exhaustion psychoses, quoted. Psych. 38
Birth area, accesibility, Obst. 90
---, elimination of anus from, Obst. 89
-, proximity to anus, danger of, denied, Obst. 102
-, sterilization of, Obst. 88
-, antiseptics suitable for, Obst. 89
Birth phantasy in relation to suicide, Psych. 50
-rate, decline of, Obst. 53
-, low, causation of, teaching of, Obst. 55
-, of England and Wales, exceeded by civilian death-rate (1918), Obst. 53
Biskra, prevalence of oriental sore at, Derm. 34
Bismuth iodoform paste, application to cavity after removal of suppurating dermoid cyst,
Laryng. 193, 194
Black bread, main article of diet among poorer classes in Germany, Child. 41
Blackeb, G. F.—Discussion on teaching of obstetrics and gynaecology, Obst. 56
Bladder, urinary, calculus in, radiogram showing, Electr. 79
-, female, Kelly’s speculum for, modus operand i, upon what dependent, Path. 53
-, entrance of air into, Path. 54
Blastomatoid conditions, separation of true neoplasms from, Path. 1
Bleeding, irregular, in extra-uterine pregnancy, one hundred cases, Obst. 153
-, see also Hcemorrhage.
Blindness, accompanying malignant disease of pituitary body, Ophth. 45, 46
-associated with sphenoidal sinus suppuration, Ophth. and Laryng. xxxv, xxxvi
-- common in subjects of wounds of frontal sinus and ethmoid, Ophth. and Laryng. lii
——, complete, following pressure on optic nerve, due to distension of maxillary antrum,
Ophth. and Laryng. lvi
-due to inflammatory affections of nasal accessory sinuses, Ophth. and Laryng. xlvi, xlvii
-following intra-vagina! haemorrhage of optic nerve, how prevented, Ophth. and Laryng. lxiii
-, partial hysterical, following organic blindness caused by wound in occipital region and
associated with hysterical deafness, psychotherapy curing case, Neur. 29
Blind spot, enlargement of, in inflammatory diseases of nasal accessory sinuses, Ophth. and
Laryng. xlviii
Blomfield, J.—Discussion on present position of spinal anaesthesia, Anaesth. 14
Blood changes in influenza, Med. 67
2
XV111
Index
Blood, circulating, experimental introduction of air into, through vein, without fatal result,
in dog, Path. 64
_ f flooding with toxic products, R.S.M. Disc. (Shock) 27
-circulation, defective, in relation to shock, R.S.M. Disc. (Shock) 24
- f depression in bacterial infections, R.S.M. Disc. (Shock) 6
-, re-establishment after bone-grafting, Surg. 22
_ f clotting of, prevention by use of sodium chloride solution in transfusion, Med. 7, 8
-concentration in septic cases of post-operative shock, R.S.M. Disc. (Shock) 32
-corpuscles, pigmented, value in diagnosis of malaria, Med. 31
_ f red, agglutination and destruction during blood-transfusion, avoidauce, R.S.M.
Disc. (Shock) 24
- 1 diminution in manufacture of, in aplastic anaemia, Med. 10
_, number in capillary and venous blood in shock, R.S.M. Disc. (Shock) 14, 15
_, rapid manufacture and destruction in pernicious anaemia, Med. 10
-, transitional, explanation of, Med. 31
- count in case of adrenal growth (sarcomatous) with secondary metastasis in skull.
Child. 90
-of aplastic anaemia, Child. 2, 3
-ending fatally, Child. 73
-in recovery. Child. 72
-of erythrodermia with lymphatic leukaemia, Derm. 54, 55
_of lymphadenoma with arsenical pigmentation, Clin. 18
-of multiple glanduiar swellings, Child. 91
-of myelogenous leukaemia, Derm. 56
-cultures from cases of typhoid fever among inoculated soldiers, Epid. 9
-in cases of obscure fever in tropics, Med. 40
-, deficiency in circulation in shock, R.S.M. Disc. (Shock) 2
-, dilution, during operations on head, in subjects of traumatic shock, R.S.M. Disc.
(Shock) 32
_ t diminution in blood-vessels in shock, R.S.M. Disc. (Shock) 12
-disappearance from heart and great vessels in surgical shock, R.S.M. Disc. (Shock) 8
-, diseases of, transfusion in (0. Leyton), Med. 5
_film, examination for parasites before treatment in cases of obscure fever in Tropics,
Med. 39, 40
_, negative, value in diagnosis of malaria, Med. 31
-, gases liberated in in caisson disease, origin, Path. 68
-out of circulation in shock, R.S.M. Disc. (Shock) 18
-picture in malaria, Med. 31
-, portal, in small intestine, toxicity of, R.S.M. Disc. (Shock) 26
__pressure, arterial, fall of, with vaso-dilatation under action of histamine, R.S.M. Disc.
(Shock) 7
_, arterial, lowering of, in shock, R.S.M. Disc. (Shock) 5
-, fall of, in shock, R.S.M. Disc. (Shock) 21
-, spinal anaesthesia associated with, Aneesth. 9, 10
---, under stovaine anesthesia, Anaesth. 5, 6
-in cases of war neurosis in the field, Psych. 58
--, intracardiac, in right auricle, influence of bodily position on, R.S.M. Disc.
(Shock) 25
-, low upright posture during, causing fatal collapse, R.S.M. Disc. (Shock) 30
- f testing of, during attacks of migraine, Ophth. 53
-supply to limb, precautions against interference with in filling of bone-cavities, Surg. 5
-, transfused, donors of, selection, Med. 8
- f recipients of, rigors and pyrexia in, Med. 10
-transfusion followed by injection of saline in shock, results, R.S.M. Disc. (Shock), 21,
22, 33
Index
xix
Blood transfusion, hypodermic injection of morphine and hyoscine into recipients before
Med. 10
-in diseases of blood (O. Leyton), Med. 5
-, preparation of patients for, Med. 9
-in pernicious anaemia, results, Med. 10, 11, 12
---, accident following, Med. 6
-in plastic anaemia, untoward symptoms following, Med. 8
-in shock, B.S.M. Disc. (Shock) 3, 4, 18, 24
-, f needles fitted with cannulae used in, Med. 6, 7
-, use of sodium chloride in, Med. 7
-, syringes used in, Med. 7
-transport, carbon-dioxide of, combination with haemoglobin, Path. 70
-vessels, cerebral, changes in, in shock, R.S.M. Disc. (Shock) 20
-—, effect of encephalitis lethargica upon, Neur. 63
-> contraction throughout body produced by stimulation of sensory nerves, R.S.M.
Disc. (Shock) 10, 33
-, with unimpaired heart’s action in shock, R.S.M. Disc. (Shock), 11, 12
-* dilatation, with fall of arterial pressure under action of histamine, R.S.M. Disc.
(Shock) 7
-in cornea, arborescent form, Ophth. 1
-, brush or besom form, Ophth. 1
- f terminal loop form, Ophth. 1
-, large, application of diathermy with caution in neighbourhood of, Electr. 27
---, peripheral, stasis, in subjects of traumatic shock, R.S.M. Disc. (Shock), 32
-supplying placenta and foetal sac, preliminary ligature in treatment of intra-uterine
pregnancy, Obst. 185
Bodily pressure, influence on capacity of heart to fill with blood during diastole, R.S.M. Disc.
(Shock) 25
-influence on position of heart in chest, R.S.M. Disc. (Shock) 25
Body-cavities, temperature of, thermometer for testing, Electr. 55, 56
-temperature, determination in thermo-electric couples, Electr. 55
- 1 measurement by electrical methods (Robert S. Whipple), Electr. 54
-, recording apparatus for, Electr. 55
-of cattle, taken by resistance thermometer, Epid. 59
-of normal individual, effect of tuberculin on, Electr. 61, 62
quickly changing, use of thermo-couple thermometer in determining, Electr. 60
-, tuberculin test, experimental, in cow and calf, Electr. 57
-temperatures, measurement by electrical methods (R. S. Whipple), Electr. 54
-in preliminary stages of phthisis, study of, Electr. 55
Boiling water, liberation of steam from, following addition of fragments of earthenware, Path.69
Boise, E., state of heart in shock, quoted, R.S.M. Disc. (Shock) 11
Bolam, R. A.—Discussion on guttate morphoea, Derm. 4
Bombardments, demoralizing effects of, Neur. 46
Bombs, aerial, demoralizing effects of, Neur. 46
Bond, C. J., C.M.G.—Discussion on shock, R.S.M. Disc. (Shock) 24
Bone, acellular type of, factor in causation of chronic discharge following acute inflammation
of middle ear, Otol. 52
-cavities, closure of (Percy Sargent), Surg. 1
-» precautions againsf interference with blood supply to limb, Surg. 5
-, selection of cases for, Surg. 3
-, healing of, how prevented, Surg. 1
-, obliteration of, Broca’s method, Surg. 1
-, modification, Surg. 1, 2
-conduction, hearing by, effect of closure of fenestra ovalis on, Otol. 83
-disease in otosclerosis, Otol. 132, 133
XX
Index
Bone disease, syphilitic, diagnosed by presence of disseminated choroiditis, Child. 86
-, diagnosis, Child. 84, 85, 86
-graft, bed for, Surg. 25
-, close contact to host bone important, Surg. 32
-, effect of removal from tibia, Surg. 26
-, fracture of, Surg. 31, 32
---, fate and function of, Surg. 26, 30
_, implantation elsewhere in body of same patient, result, Surg. 22
_in gunshot fracture of mandible,, choice of, Odont. 61
-plates, boiled, Surg. 23
-, size of, Surg. 25
-, source of, Surg. 25
-, survival of, Surg. 28, 29
-, suture of, Surg. 25
_, unilateral fixation to host bone, Surg. 33
- f union at one end only, Surg. 33
_ f ununited at one end, effect of function without weight bearing, Surg. 33, 34
Bone-grafting, application in military surgery, Surg. 23
--, contra-indications for, Surg. 30
_ f discussion on, Surg. 23, 85 (Major Naughton Dunn, 23 ; W. E. Gallie, 2 ; Alwyn
Smith, 29)
-, drainage after, Surg. 25, 26
_, excision of scar-tissue of wounds before, advantages of, Surg. 25
_in cases of ununited fracture of humerus, Surg. 27
_in fractures of mandible, operation for, Surg. 14
____, ansesthetic used in, Surg. 14
_, preparation of operative field for, Surg. 15
_, results, Surg. 18
_, time of removal of splints after, Surg. 17
_:-when to be undertaken, Surg. 13
___with incomplete alveolar union, Surg. 17, 21
_incomplete basilar union, Surg. 17, 21
__ in gunshot fractures of jaw (W. Billington, A. H. Parrott and H. Round),
Odont. 55
__ dental technique before, Odont. 57
__ operation, Odont. 60-63
___, surgical technique, Odont. 59
__of mandible, results, Odont. 63 66
_, results, cases illustrating, Odont. 64-66
_, skiagrams illustrating, Odont. 66-72
_in septic cases, conditions under which permissible, Surg. 30
_in tuberculous disease of spine, Surg. 23
_in ununited fractures of bones of upper extremity, Surg. 24
_fracture of forearm, Surg. 27
_of long bones, value of, Surg. 23
_of mandible (P. Cole and C. H. Bubb), Odont. 13
_of radius, Surg. 27
_, necessity for, discussed, Surg. 23
_, operation of, Surg. 25, 34
_, statistics and results, Surg. 34
-, plates used for, Surg. 23
-, position of limb for, Surg. 25
_postponement till after wound healing, Surg. 30
-, principal aim in, Surg. 22, 23
_, re-establishment of circulation after, Surg. 22
Index
xxi
Bone-grafting seldom necessary in fractures of lower extremity, Surg. 23
-, selection of cases for, Surg. 2G
-, success in, factors on which dependent, Surg. 22, 25
-, use of motor driven circular saw in, Surg. 32, 34
-with slide inlays of bone, disadvantages, Surg. 34
Bone-grafts, autogenous, advantages over heterogenous, Surg. 31, 32
-, and boiled bone, result following insertion of, contrasted, Surg. 22
--, composition of, Surg. 25
-, fixation of, Surg. 25
-in fractures of mandible, method of insertion, Surg. 17
-mandibular (C. W. Waldron and E. F. Risdon), Surg. 11
-, sources of, Surg. 1(5
-, periosteal and endosteal surfaces to be included in, Surg. 13
-, selection of, Surg. 23
-, splitting of, reason for, Surg. 23
--, see also Transplant grafts
Bone, jagged piece of, impacted in oesophagus removal by indirect method (W. Jobson
Horne), Laryng. 171
-, loss of, in old injuries of maxilla*, prosthetic treatment. Odont. 77
-, micro-organisms in, demonstrated in sections from cases of pyorrhoea, Odont. 115
-, staining methods employed, for demonstration from cases of pyorrhoea, Odont. 105
-, obliteration of semi-circular canals and part of cochlea by, in labyrinthotomy for
vertigo (R. Lake), Otol. 77
- spike, fixation of femur to acetabulum by means of, in case of morbus coxae,
Surg. 30, 31
-, transplanted and bone-fragments, relative osteogenetic activity of, Surg. 13
-, cancellous, rate of replacement in, Surg. 13
-transplanted, compact, rate of replacement in, Surg. 13
-, osteogenetic properties of, Surg. 13
-w’ounds, healing of, sinuses developing after, Surg. 4
Bones, affection of, in rickets, Odont. 26
-, long, fracture, uuumted, bone-grafting in, value of, Surg. 23
Bonhoeffer, exhaustion psychoses, quoted, Psych. 38
Bonney, Victor.—T he continued high maternal mortality of child-bearing : the reason and
the remedy, Obst. 75
-, discussion on teaching of obstetrics and gynaecology, Obst. 04
Bony nasal growth (G. W. Dawson), Laryng. 213
Bossan, E. A., and Balvay, A.—New specific antituberculous medicament, Therap. 1
Botella, case of pin inhaled into lung, quoted, Laryng. 10, 17
Bottle feeding as factor in causation of adenoids, Child. 35, 45
-, introduction of, development of adenoids coincident with, Child. 31
Botulism, diagnosis of encephalitis lethargica from, Med. Path, and Epid. ii
Bougieing, in examination of oesophagus in cases of dysphagia, Laryng. 236, 237, 238
Bowel, great, and rectum, gunshot wounds of (Arthur Keith), Proot. 47
Bowers, removal of floor of bony meatus in radical mastoid operation, quoted Otol. 35
-, results of hearing after radical mastoid operation, quoted Otol. 42
Bowman, Sir William, zones of basilar membrane, quoted, Otol. 84
Boyle, H. E. G.—Case of laryngofissure with removal of intralaryngeal growth performe
under gas and oxygen, Ansesth. 20
Brachyteles (woolly spider monkeys), variations in position of teeth in, Odont. 46
Brachyurus (Oukari monkeys), arrangement of teeth in, Odont. 53
Bradford, Sir J. Rose, and Lawrence, T. W. P., post-mortem findings in cases of puerpera
anuria, Obst. 29, 31
Brain, abscess of, from injury to frontal sinus, recovery, Ophth. and Laryng. vii
-and mind, diseases of, identity from materialistic standpoint, Psych. 63
XXII
Index
Brain and spinal cord, injuries and diseases of, resulting in changes without loss of function
but with permanent presence of organic physical signs, Neur. 24
-, base of, removal of pistol bullet successfully from, case showing (Henry Head, F.R.S.),
Neur. 53
-, blood-vessels of, effect of encephalitis lethargica upon, Neur. 63
-, cortex, lesion of, effect on appreciation of special aspects of external stimulus, Neur. 8, 9
-, loss of control over optic thalamus, Neur. 7
-, lesion, affecting speech, how manifested, Neur. 9
-, hfemorrhages into substance of, in shell shock, R.S.M. Disc. (Shock), 20
-, lesions'of, in epidemic encephalitis lethargica, Med., Path, and Epid. i, ii
-, following experimental inoculation of virus of human acute infective polio-
encephalo-myelitis, Path. 41
-, multiple punctate haemorrhages in substance of, Neur. 36
-physiology, speculative, Psych. 3
-, sound analysis in, Otol. 93
-, vascular changes in, in various kinds of shock, R.S.M. Disc. (Shock), 19
Bread, over-consumption, factor in causation of adenoids, Child. 45
Breast, adenocarcinoma of, with giant-celled sarcomatous stroma, Path. 8, 13
-, cancer of, advanced, radiation of axilla in, Electr. 48, 50
-, beneficial effect of erysipelas on, Clin. 18
-, microscopic foci in supraclavicular or anterior mediastinal glands of same side,
Electr. 48
-, microscopic, growing edge, failure of operation to eliminate, Electr. 47
-, mode of dissemination, Electr. 41
-, site of application of X-rays to, Electr. 45
-, treatment by diathermy, Electr. 29
-by X-rays and radium compared, Electr. 50
-before operation, Electr. 50, 51
---, position of patient during, Electr. 46
-, prophylactic, Electr. 47
-, use of diaphragms in, Electr. 47
-by radiation without operation, Electr. 45
-feeding by syphilitic mothers unreliable, Obst. 10, 11
-in prevention of adenoids, Child. 35, 55, 57
-of infants universal in Sutherland, Odont. 28
-universal among German children, Child. 41
Breath, holding, extent of capability for, at ground level, a test of capability for, at altitudes,
Epid. 37
-holding test, minimum standard for admission to Royal Air Force, Epid. 38
-, without preliminary deep breaths, as test of physical efficiency, Epid. 37
Breathing exercises in treatment of adenoids in young children, Laryng. 217, 219
Breech presentations, demonstration of, to students, Obst. 37
Brewerton, Elmore W.—Angeioid streaks in the retina, Ophth. 33
-, case of angeioma of retina, Ophth. 20
Bristol, measles epidemics in, amplitudes, Epid. 90, 91, 95
-in, deaths from, average weekly prevalence for 40 years, Epid. 98
British, cereal foods of, wrong method of consumption, Child. 29
-dependencies, prevalence of adenoids in, Child. 28, 56
-Isles, largo towns of, measles epidemics in (1856-1917), Epid. 88-91
-(1870-1910), amplitudes in, periodograra analysis, Epid. 95
-, measles in, deaths from, average weekly prevalence in eight large towns for
40 years, Epid. 98
-races, jaws of, defective development, cause, Child. 29
-, vegetable food of, requires little mastication, Child. 29
Index xxiii
Broad ligament, lipoma of (Cuthbert Lockyer), Obst. 105
-, as distinguished from prevertebral lipoma, Obst. 198, 199
-, rarity, Obst. 188
-, r6sum6 of cases reported, Obst. 196
-, right, fibrolipoma weighing 13 lb. which invaded or originated in W. S. A
Griffith), Obst. 188
Broca’s method of obliteration of bone-cavities, Surg. 1
Bronchi, foreign bodies in, removal, by safe pattern of hooks, Laryng. 20
-—, forceps for, Laryng. 20
Bronchiole of posterior lobe of right lung, pin in, failure to remove by bronchoscope, coughed
up eighteen months later (Hunter Tod), Laryng. 10
Bronchiolitis found post mortem in influenza, Med. 61
Bronchitis following stovaine anaesthesia, Aneesth. 7
-, purulent, complicating influenza, R.S.M. Disc. (Infl.) 97
-, stench from body in, R.S.M. Disc. (Infl.) 100
Broncho-pneumonia, tuberculous, acute, following influenza, R.S.M. Disc. 68
Broncho-pneumonic consolidation in influenza, Med. 63-65, 66
Bronson, Miss E.—Case for diagnosis, ? xanthelasmoidea (urticaria pigmentosa), Child. 21
-, discussion on case of myoclonus multiplex, Child. 20
-, fragilitas ossium and its association with blue sclerotics and otosclerosis, quoted,
Otol. 126
-, hypertrichosis in a mentally defective child, Child. 22
-, multiple neurofibromatosis (von Recklinghausen’s disease), Child. 21
-, osteogenesis imperfecta, Child. 15
Brorstrom, influenzal nature of poliomyelitis, quoted, Med., Path, and Epid. vi
Brouardel, emphysema of wall of stomach occurring about site of simple ulcer, quoted, Path. 75
Brown, William—W ar neurosis : a comparison of early cases seen in the field with those
seen at the base, Psych. 52
Brownlee, John.—P eriodicities of epidemics of measles in the large towns of Great Britain
and Ireland, Epid. 77-120
Bruce, Sir David, K.C.B.—Discussion on spirochaetosis icterohsemorrhagica. Med. 4
Bruns, Paul, case of adenoma of vocal cord, quoted, Laryng. 200
Bubb, Charles H., and Cole, Percival.—B one-grafting in ununited fractures of the
mandible with special reference to tho pedicle graft, Odont. 13
Buckmaster, G. A., combination of transport CO* of blood with haemoglobin, quoted, Path. 70
Bull-dogs fed on unsuitable diet attacked with fatal marasmus, Odont. 37
Builet-wound, deep, across perimeum, explosive effect, Proct. 48
-wounds, through-and-through, of accessory sinuses, Ophth. and LaryDg. lii
Bunch, J. L.—Case of urticaria pigmentosa. Child. 1, Derm. 1
-, discussion on case of lichen obtusus corneus, Derm. 17
-on guttate morphoea, Derm. 4
-, epithelioma of face, Derm. 2
-, keratosis follicularis (Darier’s disease), Derm. 67
-, white-spot disease (morphcea guttata), Derm. 24
Burger, nerve deafness associated with fragility of bones and blue sclerotics, quoted, Otol. 130
Burgess, W. M.—Discussion on hypertrichosis in mentally defective child, Child. 23
Buru-shock, changes in brain in, R.S.M. Disc. (Shock), 20
Burnford, Julius.—F urther notes on the epidemic (influenza) with special reference to
pneumonia, in Macedonia, Med. 49
Burning due to secondary radiation, personal experience (J. Metcalfe), Electr. 13
- y treatment, Electr. 15
Burns more frequent in women at shell factory than at fuse factory, Epid. 52
-, shock following, similarity to surgical shock, R.S.M. Disc. (Shock) 29
Butter-milk and barium sulphate meal in X-ray examination of appendix, Electr. 9
Buttock, gunshot wounds of, through-and-through, Proct. 48
Buzzard, E. Farquhar.—D iscussion on epidemic encephalitis, Med. xv
-, encephalitis lethargica, Neur. 56
XXIV
Index
Cachexia, malarial, explained, Med. 34
-, factors necessary to complete picture of, Med. 34
Ciecum, peritoneum investing, rupture of, in cases of extreme intestinal distension, Path. 75
-- f in reduction of ileo-ca??al intussusceptions, Path. 75
-, walls of, sub-mucous emphysema, case of, clinical history and details of operation,
Path. 79
-, submucous emphysema, case of, description of specimen, Path. 79-82
Caesarean section in case of obstructed labour duo to venirifixation, Obst. 217
-under spinal anaesthesia, case (Llewellyn Powell), Anresth. 21
Caiger, F. Foord. —Discussion on outbreak of typhoid fever in inoculated soldiers, Epid. 11
Caisson disease, origin of gases liberated in blood in, Path. (38
Calcification, sclerodermia with, in mongols (F. S. Langmead), Child. 94
Calcium chloride, sterilization of Belgian water supplies by, Epid. 31
Calculi, renal, and gall-stones, X-ray diagnosis between, Electr. 81
Calculus after removal from bladder, exhibiting definite nucleus, radiogram showing,
Electr. 79
- in urinary bladder, radiogram showing, Electr. 79
-, salivary, radiogram showing, Electr. 79
Calf, human, acute infective polio-encephalo-myclitis in, manifestations, Path. 38
-, mode of transmission, Path. 38
Calves, tuberculinized, reproduction of condition in human subjects in pulmonary tuber¬
culosis, Electr. 59
Callithrix (Titi monkeys), variation in position of teeth in, Odont. 51
Calomel ointment, application as prophylactic against venereal diseases, R.S.M. Lect. 9
Cameron, H. C.—Case of achondroplasia with hydrocephalus, Child. 9
-of oxycephaly with symmetrical polvsyndactylia, Child. 8
-of primary atrophic muscular dystrophy (amyotonia congenita of Oppcnheim)
(previously shown), Child. 25
-, discussion on adenoids, Child. 45, 52
-on case of chronic priapism, Child. 11
-of lymphangioma of tongue, Child. 79
-of osteogenesis imperfecta, Child. 16
-on shortening of limbs on one side of body, Child. G
-on syphilitic bone disease, Child. 84
-on undescended and imperfectly descended testes, Child. 62
-, section from a case of tuborculous meningitis of the spinal cord simulating anterior
poliomyelitis, Child. 23
Campbell, Harry. —Beneficial effect of intercurrent influenza in case of malignant disease
of liver, quoted, Clin. 18
-, discussion on the aetiology, prevention, and non-operative treatment of adenoids,
Child. 26, 56
Camphor in treatment of influenza, R.S.M. Disc. (Infl.) 93
Cancor cells, degenerative or regressive changes in, Electr. 48, 19
-, effect of irradiation of fibrosing lymphatics on, Electr. 50
-in full vital activity, attack of, Electr. 49
-, permeation by, mode of extension, Electr. 44
-of lymphatic vessels, Electr. 42, 43
-, dissemination, summary of conclusions on, Electr. 43
-, microscopic growing edge of, Electr. 43, 44, 47, 48
-, most active portion of, when growing, Electr. 43, 46
-, natural cure of, Electr. 48
-of breast, dissemination, mode of, Electr. 41
-, treatment by diathermy, Electr. 29
-by radiation without operation, Electr. 45
-of uterus-cervix, inoporable, treatment by diathermy, Electr. 40
Index
XXV
Cancer of uterus-cervix, treatment by diathermy, Eleetr. 10
-, spread of, mode of, in relation to treatment, by radiation (W. Sampson Handley),
Eleetr. 41. See also Carcinoma
Canine, maxillary right, misplacement in Chrifsothrix sciureus , Odont. 51
Canines, maxillary, filling, under submucous infiltration amesthesia, Odont. 2
Cannon, Major, disappearance of blood from heart and great vessels under surgical shock,
R.S.M. Disc. (Shock), 8
Cannule, needles fitted with, use in transfusion of blood, Med. G, 7
Capillary tone, relaxation of, under histamine, R.S.M. Disc. (Shock), 8
Carbohydrate food, disabling effect on bactericidal function of lymphatic tissue, Child. 41
Carbolic, cauterization with, in treatment of Delhi boil, Derm. 72
Carbon dioxide and oxygen, direction of passage in cutaneous respiration contrasted, Path. 70
-, excretion from human skin in cutaneous respiration, Path. 68
--in treatment of grauulosis rubra nasi, Derm. 40
-of keratoma senile, Derm. G5
-of mevo-carcinoma. Derm. 42
-, oxygen and nitrogen, relative difTusibility through intestinal wall, Path. 70
-, transport, of blood, combination with hemoglobin, Path. 70
Carcinoma, inoperable, in women, early relief of, not taught to students, Obst. 38
-of epiglottis, squamous-celled, in combination with spindle-celled sarcoma, appearances
of the two growths contrasted, Path. 25, 26
-of rectum, abdomino-perinoal excision for, followed three years later by recurrence in
posterior vaginal wall (NV. S. Handley), Surg. 46
- of right antrum and orbit, treatment by excision, radium and X-rays (Norman Patterson),
Larvng. 194
-of vermiform appendix (J. E. Adams), Surg. 37
-, periphery of, development of sarcoma at, Path. 3
-, propagation of, development of sarcoma during, Path. 3
•-, resection of rectum for, case showing result of (Percival P. Cole), Proct. 45
-sarcomatodes, Path. 3
-, secondary, with megacolon, case (J. P. Lockhart Mummery), Proct. 44
-, squamous-celled, in case of adono-carcinoma of the uterus, associated with a sarco¬
matous stroma, Path. 13-17
-, metaplasia in, associated with sarcomatous stroma in adeno-carcinoma of prostate,
Path. 18-23
-of skin, associated with melanotic sarcoma, Path. 27-31
-, associated with melanotic sarcoma, microscopic appearance, Path. 28, 29, 30
Carcinomata, polymorphic growth in, Path. 2, 4
Carcinomatous melanotic growth (G. Pernet), Derm. 11
Carcino-sarcomata, majority incapable of analysis by histological methods alone, Path. 31
Cardia, displacement through opening between crura, Larvng. 92, 97
-, normal, showing crura of diaphragm, Laryng. 92, 97
-, stenosis of oesophagus at, Laryng. 34
-, see also Achalasia of cardia
Cardiac orifice and canal (normal), specimen (S. G. Shattock), Laryng. 78
Cardiospasm, appearances of hiatal oesophagus in, Laryng. 50, 51
-, case of (A. Brown Kelly), Epid. 56
-, demonstration, Laryng. 57
-, compensated, represented by muscular hypertrophy of oesophagus without dilatation,
Laryng. 100
-, death directly due to, Laryng. 56
-, feeding in, Laryng. 51, 52, 53
-, hyperesthesia in, Laryng. 50, 5
-, synonyms for, Laryng. 35
-, treatment, Laryng. 48
XXVI
Index
Cardiospasm, treatment by drugs, Laryng. 51
-, local, Laryng. 52-56
-, by bougies, Laryng. 52
-, by distensible bags, Laryng. 52, 53
-, results, Laryng. 55
- f by divulsors, Laryng. 54
-operative, Laryng. 56
-, types of oesophageal obstruction connoted by term, Laryng. 35
Cargill, L. V.—Discussion on injuries and inflammatory diseases affecting the orbit and
accessory sinuses, Ophth. and Laryng. Ixii
-, pituitary tumour (hypopituitarism), Ophth. 41
-and Lindsay, W. J.—Pigmented connective tissue immediately in front of and covering
optic disk, Ophth. 57
Caries, dental, early development connected with mouth-breathing, Child. 34
-, increase of, causes of, theories respecting, Odont. 27
—.-, not prevented by use of tooth-brush, Odont. 30
-, prevalence among Scottish lowlanders, Odont. 29
-, heredity in relation to, Odont. 27.
Carrel-Dakin method, application after radical mastoid operation, Otol. 39
Carruthers, J. F.—Case of intra-ocular growth, Ophth. 36
Cartilages, lateral, of nose, displacement of (Irwin Moore), Laryng. 108.
Carver, Alfred, and Dinsley, A.—Some biological effects due to high explosives, Neur. 36
Cass, Miss K.—Case of pseudohypertrophic muscular paralysis in a girl aged 10 years (shown
for Dr. F. J. Poynton), Child. 18
-, discussion on case of myoclonus multiplex, Child. 20
Cat, air driven experimentally, post-mortem, from right heart through lungs into left heart
in, Path. 64
-, female, bladder of, distension by introduction of cocaine, Laryng. 59
Catalepsy in encephalitis lethargica, Med., Path, and Epid. xix
Catarrh, nasal, accompanying adenoids, treatment, Child. 49
-, and adenoids, association, Child. 31
-, and post-nasal, transmitted to infants by kissing, Child. 39
-, treatment of, important, Child. 35
-, nasopharyngeal, prevalence in cold and damp climates, Child. 36
-, post-nasal, main cause of nasal obstruction, Child. 32, 38
Catarrhal diseases, chief, death-rates from, R.S.M. Disc. (Infl.) 3
-, epidemic, possibilities of control, R.S.M. Disc. (Infl.) 18
Cattle, temperature of, taken by resistance thermometer, Epid. 59
-, tuberculin test of temperature in, Electr. 57, 59
-, tympanites of rumen in, Path. 55
Caustics, application to enlarged or diseased tonsils, Laryng. 244
Cautley, Edmund.—C hloroma or adrenal growth with secondary metastasis in skull.
Child. 90
-, discussion on adenoids. Child. 30, 57
-, on case of myoclonus multiplex, Child. 19
-, multiple glandular swellings, Child. 91
Ccbida?, variations of position of teeth in, Odont. 39
Cebus (Sapajous or Capuchin monkeys), typical dental arch in, Odont. 39, 40
-, variation of position of teeth in, Odont. 39, 40
- apella , misplaced maxillary, left, first premolar in, Odont. 40, 41
- liypolcucus , irregularity of position of maxillary right, second and third molars, Odont. 42
-, of premolars in, Odont. 40, 41
-(unclassified), “ Echelon ” arrangement of right maxillary molars in, Odont. 42, 43
-, irregularity of molars in, Odont. 42
- xanthocephalus , mandibular third molars tilted and rotated inwards in, Odont. 43
Index
XXVll
Cell, rising-floor, to facilitate microscopy of cerebro-spinal fluids (F. Eve), Neur. 32
Cells in fluids, new counting chamber for (K. S. Bhat), Child. 4
Cellulitis, orbital, association with rheumatoid arthritis, Laryng. 225
-, cause of, Ophth and Laryng. liii .
-, drainage of orbit for, Ophth. and Laryng. xxxix
-, due to nasal disease, Ophth. and Laryng. xxvii, lxiii, lxvi
-, of ethmoidal origin in infant, Ophth! and Laryng. lxiv
-, sinus suppuration always co-existent with, Ophth. and Laryng. lxi
Cementum, micro-organisms in, demonstrated in sections from cases of pyorrhoea, Odont.
107,108
Cereal foods, wrong methods of consumption among British, Child. 29
Corebellum, abscess of, complicating chronic middle-ear suppuration, Otol. 51
Cerebro-spinal fluid, abnormal cells in, conclusive sign of structural change in central nervous
system, Neur. 25
-, examination in epidemic encephalitis lethargica, Med., Path, and Epid. iii, iv,
xxi, xxii
-, mobility of stovaine solutions in, Amvsth. 2, 3
-fluids, microscopy of, facilitated by rising-floor cell (F. Eve), Neur. 32
(’erumen, diminished secretion iu otosclerosis, Otol. 26
Cervical ribs with weakness and wasting in right hand, case of (Henry Head, F.R.S.),
Neur. 53
Champneys, Sir Francis, Bt.— Discussion on high maternal mortality of child-bearing,
Obst. 98
Chapple, Harold.—D iscussion on high maternal mortality of child-bearing, Obst. 104
Characters, acquired, inheritance of, future solution of, discussion as to, Psych. 11
Chastity, obstacles to early marriage a bar against, R.S.M. Lect. 11
-, problem of, discussed, R.S.M. Lect. 11
Ch&tel-Guyon, waters of, lesions following experimental injection, Bain. 10
Cheatle, Arthur.—D iscussion on mastoid operations, Otol. 51
Cheeks, painful inflation of, in players on wind instruments, Path. 59
Chemical poisoning, shock due to warfare injury a condition of, R.S.M. Disc. (Shock) 29
Cherry gum process, use of in treating sections from cases of pyorrhoea alveolaris, Odont. 105
Chest, deformity of, cause, partly due to impeded respiration, Child 33
-flap rhinoplasty in gunshot wound of face, Laryng. 142, 144,145
-, paracontesis of, local inflation of subcutaneous tissue around puncture in, Path. 60
Cheston, R. B., case of mature foetus contained in osseous cyst and remainin in abdomen
of mother fifty-two years, quoted and abstracted (H. Williamson), Obst. 171
Child, results of operation to, when living, in cases of extra-uterine pregnancy, Obst.
154, 155
Child-bearing, accidents and diseases of, other than sepsis, death-rates per 1,000 births in
United Kingdom, Obst. 78
-, death-rate, Obst. 119
-, in United States, no definite decrease, Obst. 78
-, how differing from other physiological processes, Obst. 85
-, maternal mortality, chief causes of death, Obst. 79
-, continued high, reason and remedy (Victor Bonney), Obst. 75
---, decline in, Obst. 98, 101
-, not diminished after introduction of Lister's methods, Obst. 80
Child-birth in houses of middle-class and poorer classes, unhygienic surroundings, Obst. 86
-, unclean surroundings of, Obst. 86, 103, 105
Childhood, early, orbital inflammation in, due to acute sinusitis, Ophth. and Laryng. iii, lxiv
Child welfare clinics and maternity ward, liaison officer between, Obst. 46, 47
—-, posts connected with, under Ministry of Health, Obst. 52
Children, choanal polypi in (D. Guthrie), Laryng. 153
-, chronic ear discharge in, Otol. 55
xxviii Index
Children, chronic ear discharge in, treatment, Otol 55
-, cortical mastoid operation indicated tor, Otol. 55
-, diseases of, department for, and department of obstetrics at St. Thomas's Hospital,
connection between, Obst. 46
-, epidemics, periodicity of, how accounted for, Epid. 96
-, effects of adenoids on, Child. 32
-, eye lesions in, possibly due to sinus suppuration, Ophth. and Laryng. lxi
-of syphilitic mothers remaining permanently free from syphilis after treatment, Obst,
14, 16
--, osteomyelitis of maxilla or frontal bone in, causing infection of orbital tissues, Ophth.
and Laryng. liii, lv
-, prevention of infectious colds in, Child. 35
-”, radical mastoid operation contra-indicated in, Otol. 55
-, rickety, small size of nasopharynx in, Child. 51
-, sinus suppuratiou in, effects on orbit, Ophth. and Laryng. xxxvii
-, sleeping in cokl and damp atmosphere, prevalence of adenoids among, Child. 37
-surviving extra-uterine pregnancy, future health of, Obst. 182
-, training in nasal respiration, Child. 50
-•, tuberculous mastoiditis in, due to infected milk, Otol. 7, 8.
-, Wassermann reaction in, positive becoming negative slower than in infants, Obst. 15
-well-nourished and ill-nourished, condition of Fever's patches seeu in, post-mortem.
Child. 52
-, large proportion of lymphoid tissue in, Child. 5*2
-, young, adenoids and enlarged tonsils in, suggested alternatives to operation for (J.
Donelan), Laryng. 216
-, development of ethmoidal and sphenoidal sinuses in, Ophth. and Laryng. lx
Chitral sore, synonym for oriental sore, Derm. 34
Chloroma or adrenal growth with secondary metastasis in skulls (E. Cautley), Child. 90
Chodak, Mrs.—Chorea, complicated by gangrene of the fingers, Child. 87
Choking when lying on back, case of, cause ascertained, Neur. 18
Cholera, treatment by continuous saline infusions, R.S.M. Disc. (Shock) 30
Cholesteatoma accompanying intracranial complications of chronic middle-ear suppuration,
Otol. 50
-, found at radical mastoid operation, Otol. 43, 44
-, radical mastoid operation for. with preservation of matrix, two cases (J. Duudas
Grant), Otol. 12
Cholesterin, gall-stones and liver tissue, relative deusitv, radiograms showing, Electr. 84
Chorea, complicated by gangrene of fingers (Mrs. Chodak), Child. 87
-, in pregnant women, demonstration to students, Obst. 38
Chorionic ferments preventing development of spirocha?tes in mother, Obst. 12, 13
Choroid, melanoma of (R. Foster Moore), Ophth, 60
Choroiditis, disseminated, presence of, only means of diaguosing syphilitic bone disease,
Child. 86
Choussy-Perriere Spring, gases of, Bain. 3
--, waters of, action on phenomena of anaphylaxis, Bain. 8
-, arsenic colloids in, Bain. 3
-, effect on leucocytosis reaction, Bain. 4
-, immunity to, how obtained experimentally, Bain. 5
-, intraperitoneal injection, experiraontally, followed by leucocytosis re¬
action, Bain. 4, 5
-, intravenous injection, experimentally, followed by leucocytosis reaction,
Bain. 5
-, radium emanation in, Bain. 3
Christopherson, J. B., and Archibald, R. G., Major, D.S.O.—Case of primary nocardiasis
of the lachrymal gland caused by a species of Xocardia hitherto undescribed, Ophth. 4
Index
xxix
Chrysothrix (Squirrel monkey), variation and position of teeth in, Odont. 50
- sciureus , misplacement of maxillary right canine in, Odont. 51
Ciliary muscle, pigmented cells of, in case of melanoma of choroid, Ophth. 61
Cinnamon, oil of, in treatment of influenza, R.S.M. Disc. (Infl.) 93
Civil life, mental disease in war cannot be compared with that in, Psych. 51
Claisse, effect of chloride of sodium bath on white cells, quoted, Bain. 4
Cleanliness, surgical, in cases of labour, application of principles, Obst. 44
Ci.eland, J. Burton.—T he conveyance of the virus of a human acute infective polio-
encepbalo-myeliti8 occurring in Australia to monkeys, sheep, a calf and a foal,
, Path. 33
Climate, in treatment of adenoids, Child. 51
-, predisposing cause of war psychoses, Psych. 39
Clinical methods, examination of candidates for Royal Air Force by, Epid. 44
Clutton, H. H., inflation of abscess cavities, quoted, Path. 55
Cocaine, introduction into bladder of cat producing distension, Laryng. 59
Cocainization of cardiac orifice or cardiac end of oesophagus, effect, Laryng. 59
Cochlea and labyrinth, sequestration, in case of necrosis of internal ear, Otol. 9
-, bending solids in, resistance of, how acting, Otol. 86
-, in bird, construction of, supporting Wrightson’s theory of hearing, Otol. 89
-, liquid of, multiplication of momeutary change of unit-pressure of air-wave in, Otol. 84
-of, resultant curves of pressure in. Otol. 86
-, microscopic examination in case of fracture of base of skull involving middle and inner
ear, Otol. 109
--, with fracture dislocation of incus and
rupture of roof of right mastoid antrum, Otol. 113
-, opening of, in labyrinthectomy, Otol. 102
-, part of, and semi-circular canals, obliteration by bone in case of vertigo (R. Lake),
Otol. 77
-, transmission of pressure through, Otol. 85
-, of sound wave in, Otol. 85
Cochleae, microscopic examination in case of otosclerosis associated with otitis media, Otol.
121
Cockayne, E. A.—Case of syphilitic bone disease, Child. 84
-, congenital absence of the lower portion of the left pectoralis major muscle and left
mammary gland, Child. 59
-, discussion on aplastic anaemia, Child. 75
-on case of adrenal growth and case of multiple glandular swellings, Child. 91
-on sclerodermia with calcification in mongol, Child. 98
-, trophoedema of leg, Child. 105
Cold and damp climates a factor in causation of adenoids, Child. 47
-, prevalence of adenoids in, Child. 36
- ; -of nasopharyngeal catarrh in, Child. 36
-, heat and pain, excited by same temperature, Neur. 10
Colds, infectious, exposure to, prevention of, in children, Child. 35
Cole, C. E. Cooper.—D iscussion on influenza, R.S.M. Disc. (Infl.) 85
Cole, Percival P.—Case showing result of resection of rectum for carcinoma, Proct. 45
-, discussion on the present position of spinal anaesthesia, Anaesth. 12
-, two cases illustrating the result of resection in complete prolapse of the rectum, Troct.
46
-, and Bubb, Charles H.—Bone-grafting in ununited fractures of the mandible, with
special reference to the pedicle graft (abstract), Odont. 13
Coley’s fluid, beneficial effect on sarcoma, Clin. 18
Colitis, treatment by diathermy, Electr. 34, 85
Collapse and shock, difference between, R.S.M. Disc. (Shock) 4
-, fatal, death from, how occasioned, R.S.M. Disc. (Shock) 30
XXX
Index
Collins, E. Treacher. —Discussion on diseases and injuries affecting orbit and accessory
sinuses, Ophth. and Laryng. Ixviii
Collis, E. L.—Discussion on cause and prevention of industrial accidents, Epid. 53
-, discussion on teaching of obstetrics and gynaecology, Obst. 63
Colloidal silver, injections of, beneficial effects on animals injected with pathogenic micro¬
organisms, Bain. 11
-solutions, therapeutic potency of, Bain. 11
Collosol argentum, injection, in chronic adhesive otitis, Otol. 96
Colon, distended, minute escape of gas from puncture during application of purse-string
suture to, Path. 73
Colostomy in treatment of gunshot wounds of rectum in all cases, Proct. 47
Colquhoun, case of pin inhaled into lung, quoted, Laryng. 16
Columnella, alse and tip of nose, restoration of, Laryng. 120
Colyer, A. R.— Discussion on adenoids, Child. 54
Colyer, J. P.—Variations in position of the teeth in New World monkeys, Odont. 39
Colyer’s method in treatment of gunshot wound of mandible with extensive loss of tissue
(P. N. Doubleday), Odont. 101
Combalousier, case of emphysema of intestinal wall, quoted, Path. 76, 77
Comforter, use of, factor in producing malformations of jaw, Child. 33
Commotion and emotion, combined operation in neurosis following detonation of high
explosives, Neur. 49
Complement deviation in malaria, experiments correlating large mononuclear count with,
Med. 46
__, experiments on in cases under various courses of quinine treatment,
Med. 46
_in malarial infection, experiments with, in 200 cases, results, Med. 43
_ f malarial, haemolytic doses of, Med. 42
Complex thinking, Psych. 18, 19, 20, 21
_and rational thinking, distinction between, Psych. 23
_processes ascribed to suggestion, examples of, Psych. 21
Concentrates, preparation for enumerative purposes, M.B.L. 12 »
Concentration methods in diagnosis of protozoal cysts in stools, statistical evidence for,
M.B.L. 12
Conceptions, infantile death-rate in relation to given number of, Obst. 56
Concussion, cervical, case with (E. Miller), Neur. 54
_, f direct, from high explosives, Neur. 37, 47
__ effects of, Neur. 47
_ f indirect, following detonation of high explosives, effects of, Neur. 48
_ t from high explosives, Neur. 37
Condensers, secondary, in diathermy apparatus, Electr. 22
-, use in diathermy, Electr. 19
Conditionalism, modern conception of aetiology, Psych. 70
Conduct, human, disorders of, following mental conflict, Psych. 6
_, effect of sexual impulse on, Psych. 5
_, normal and abnormal, force producing, Psych. 5
-science of, Psych. 4
Confusional states as war psychosis, Psych. 44
__ origin discussed, Psych. 44
_ f common occurrence of, in war, Psych. 44
_symptoms, development among soldiers drawn from farm labouring classes, Psych. 48
Conjunctiva, catarrh of, complicating influenza, Med. 27
Connaught Hospital, Aldershot, epidemic influenza at, clinical features, R.S.M. Disc. (Infl.)
97
Connecting wires in primary circuit joined to condensers and spark gap, in diathermy
apparatus, Electr. 21
Index
xxxr
Connective tissue, emphysema of, from entry of air, Path. 56
-, entrance of air into, pneumatoses due to, Path. 50
-, gas introduced into, question of intussusception by its cells in gaseous form,
Path 67
-, pigmented, immediately in front of and covering optic disk (L. V. Cargill and W.
J. Lindsay), Ophth. 57
- f immediately in front of, and covering optic disk, causation discussed,
Ophth. 58
Constipation in encephalitis lethargica, Med., Path, and Epid. xix, xxii
-in typhoid in inoculated soldiers, Epid. 2
-, treatment by diathermy, Electr. 34, 35
Contagion and miasma, struggle between, in history of epidemics, Epid. 71
Control, higher, disturbance of, as factor in failure in efficient performance of physical
efficiency tests, Epid 44
Conversion-hysteria, Freud’s theory of, Psych. 57
Cookery, early period of, supply of starch increased in, Child. 28
-, era preceding, changes in human diet during, Child. 28
-, salivation of starch in, Child. 28
Cope, V. Z.—Case of thoracic actinomycosis, Clin. 1
Coplans, M., Major, R.A.M.C., sanitary work during enteric fever epidemic in Flanders
(1914-15), Epid. 31
Copper preparations, failure in treatment of malignant growths, Laryng. 209, 210
Cornea, arches of opacity in, conditions under which appearing, Ophth. 2, 3
-, blood-vessels in, shapes assumed by, Ophth. 1
-, congenital pigmentation of (Miss R. Ford), Ophth. 34
Corner, E. M., and Cullingworth, C. J., case of carcinomatous appendix, quoted, Surg. 39
Corney, Bolton, I.S.O., first outbreak of measles in Fiji, quoted, R.M. Disc. (Inff.) 15
Corti, arches of, connexion with basilar membrane, Otol. 85
-, cells of, radial section of, Otol. 90
-, organ of, part taken by in production of heariug, Otol. SI
-, function, Otol. 83
-■ , position, Qtol. 82, 83
Costa, case of pin inhaled iuto lung, Laryng. 16
Costal cartilage graft, insertion of, profile of bridge of nose before and after, Laryng. 144, 146
Cough and expectoration, method of inducing by inhalation of oleum sinapis (J. Dundas
Grant), Laryng. 26
-, in malingerers, Laryng. 26
-, complicating influenza, Med. 26, 27
-, paroxysmal, cause of, Child. 34
Coughing, paroxysm of, followed by subcutaneous emphysema of face, Path. 59
Counter*suggestion in treatment of chronic cases of war neurosis, Psych. 55
Counting chamber, new, for cells, &c., in fluids (K. S. Bhat), Child. 4
Cows, milk fever of, treatment by pneumatosis, Path. 58
Cranial and orbital cavities, ivory exostosis growing from roof of frontal sinus into, removed
through osteoplastic opening in (William Lang and Donald Armour), Ophth. 16
Creighton, C., association between epidemics of influenza and of ague, quoted, Epid. 73
Crepitations in pulmdnary type of influenza, Med. 55, 56 0
Crile, G. W., cause of secondary shock, quoted, R.S.M. Disc. (Shock), 5
Crile’s clamps, compression of carotid arteries with, in removal of naso-pharyngeal angeio-
fibroma, Laryng. 175, 176
Criminality, type of ear associated with, Otol. 26
Crookshank, F. G.—Correlation between influenza and Heinc-Medin complex, quoted,,
Epid. 72
-, discussion on epidemic encephalitis, Med., Path, and Epid. iv, xii, xiv, xxi
-on influenza, R.S.M. Disc. (Infl.) 70
XXX11
Index
Cropper, J. W.— An enumcrative study of Entovueba coli cysts in stools, M.B.L. 1-14
Cross-circulation experiment to test presence of toxemia in experimental shock, R.S.M.
Disc. (Shock), 30, 34
Cullingworth, C. J. and Corner, E. M., case of carcinomatous appendix, quoted, Surg. 39
Cumberbatch, E. P.—Discussion on electrical methods of measuring body temperatures,
Electr. 62
-, discussion on treatment by diathermy, Electr. 39
Cunningham, J. F.—Case of tumour of the roof of the orbit, Ophth. 20
Curette forceps, single, for removal of foreign bodies from bronchi, Laryng. 20
Curettes, aural type, for removal of foreign bodies from bronchi, Laryng. 20
Currie family pedigree chart, showing otosclerosis associated with fragilitas ossium and blue
sclerotics (J. S. Fraser), Otol. 127
Cushing, Harvey, cranio-cerebro-nasal type of wound, quoted, Ophth. and Laryng. xxxix
Cutting shears (Irwin Moore’s), tooth-plate impacted in oesophagus divided by (Somerville
Hastings), Laryng. 7
Cyanosis in influenza, relief from oxygen administration, Med. 71
-in shock, R.S.M. Disc. (Shock), 33
-pronounced feature in pulmonary type of influenza, Med. 53
-, see also Heliotrope cyanosis
Cyclitis associated with septic trouble in nose, Ophth. and Laryng. xxxvi, xxxvii
-cured by intranasal operation, Ophth. and Laryng. lx
-treatment by diathermy, Electr. 33
Cyst of larynx, treatment by dissection, Laryng. 196
-by puncture, Laryng. 195, 196
Cysts, see Entamoeba coli cysts, E. histolytica cysts, Lamblia cysts
Czermak, J., clinical work done with laryngoscope first reported by, Laryng. 3
Dacryocystitis, chronic, and gunshot wounds of orbit, Ophth. and Laryng. xv, xix, xx
-, in injuries of orbit, Ophth. and Laryng. xv
-, wounds of bridge of nose causing, treatment, Ophth. and Laryng. xiii
Da Fano, C.—Discussion on epidemic encephalitis, Med., Path, and Epid. v
-, and Ingleby, Miss H. — Demonstration of preparations from cases of encephalitis
lethargica, Path. 42
Dale, H. H., F.R.S.—Discussion on shock, R.S.M. Disc. (Shock) 4
Daly, Ashley. —Successful massage in a case of heart failure due to shock, Amesth. 15
Darier’s disease (keratosis follicularis), case of (J. L. Bunch), Derm. 67
Daupeyroux, action of water of Choussv-Perriere on phenomena of anaphylaxis, quoted Bain. 8
Davidson, Sir James Mackenzie (the late).—Stereoscopic radiography, Electr. 1
Davies, D. Leighton. —Discussion on injuries and inflammatory diseases affecting the orbit
and accessory sinuses, Ophth. and Laryng. xlvi
Davis, E. D. D.—Case of extensive lupus of the alveolus, nose and larynx, Laryng. 212
-, discussion on case of laryngeal whistling, Laryng. 173
-of multiple epulides, Child. 71
-of nasopharyngeal growth, Laryng. 208
-on delayed breaking of voice, Laryng. 197
-on injuries and inflammatory diseases affecting the orbit and accessory sinuses,
Ophth. and Laryng. xxxviii, lxiv
-on instruments to simplify control of ^haemorrhage in difficult cases of enucleation
of tonsils, Laryng. 215
Davis, Haldin. —Discussion on case of Delhi boil, Derm. 72
Dawson, Sir Bertrand, G.C.V.O.—Spirochaetosis ictero-haemorrhagica (abstract), Med. 1
Dawson, G. W.—Adherent palate, Laryng. 150
-, angeioma of the left arytaenoid, Laryng. 150
-, bony nasal growth, Laryng. 213
-, case of chronic osteomyelitis of maxilla, Laryng. 212
Index
XXX111
Dawson, G. W., case of nasopharyngeal angeio-fibroma, Laryng. 174
---of perichondritis of larynx, Laryng. 176
-of sarcoma of tonsil, Laryng. 177
-, discussion on case for diagnosis, Laryng. 199
-on delayed breaking of voice, Laryng. 197
-on epithelioma of left tonsil, Laryng. 102
-on two cases of choanal polypi, Laryng. 154
-, mucocele of the frontal sinus, Laryng. 153
-, tumour of the base of the tongue, Laryng. 183
Deaf, the, proportion of defective auricles among, Otol. 19
Deaf-mutism with amnesia in case of war neurosis, treatment by hypnotism, result,
Psych. 58
Deafness, associated with adenoids, Child. 34, 48
-with stigmata of degeneration (Hugh E. Jones), Otol. 17
-, catarrhal, chronic, with rheumatoid arthritis due to latent sinusitis, Laryng. 220, 221
-, complete, production by closure of fenestra rotunda, Otol. 83, 188
-(degeneration), associated with defective auricles, Otol. 19
-, case illustrating, Otol. 19, 20
-, fatigue reaction in, Otol. 20
-, sites of main lesion in, Otol. 21
-, treatment, preventive, Otol. 24
-following radical mastoid operation, question discussed, Otol. 53, 55, 56, 57
-, hysterical, associated with organic blindness, caused by wound in occipital region,
followed by partial hysterical blindness, psychotherapy curing, Neur. 29
-in pulmonary type of influenza, Med. 55
-, an indication for operative treatment of adenoids, Child. 45
-, malformation of septum, nasopharynx, and middle-ear associated with, Otol. 23
-, mitigation by incitement to laughter, Otol. 25
-, mutism and amnesia in walking case of war neurosis, Psych. 54
Death, fear and desire for in war psycho-neuroses, Psych. 50
-rate, civilian, of England and Wales (1918) exceeds birth-rate, Obst. 53
-, infantile, in relation to given number of conceptions, Obst. 56
-, reduction of, by obstetrical operations, Obst. 56
Debility due to improper diet in malaria, Med. 37
Degeneration, deafness associated with stigmata of (Hugh E. Jones), Otol. 17 ; see also
Deafness (degeneration)
-, reaction of, conclusive sign of structural change in central nervous system, Neur. 25
Dejerine, explanation of persuasion by, Psych. 22, 24
Delhi boil, case of (H. MacCormac), Derm. 70
-, sources of infection, Derm. 71, 72
-, treatment, Derm. 72
Delirium in influenza, R.S.M. Disc. (Infl.), 71, 100
-in pulmonary type of influenza, Med.* 55
Delivery forced risk of, Obst. 103.
-, safest method of, in normal labour, Obst. 91
Dementia preecox, case of, effect on patient of religious conversion, Psych. 76
-effect on patient of remorse for past misdeed, Psych. 74, 75
-, psychological examination in, record of, Psych. 71-74
-, cases of, improvement ;or deterioration in response to psychological conditions,
Psych. 67, 69
-, confused classification of various forms of mental disease under, Psych. 65
-, hopeless and mild cases contrasted, Psych. 66
-, improvement in, under suitable surroundings, Psych. 69
-, largest percentage of war psychoses due to, Psych. 43
-, percentage of cases among war psychoses, Psych. 43
3
XXXIV
Index
Dementia prsecox, symptoms not organic, Psych. 65
-, psychological conflicts in, Psych. 70
- 1 worst cases, product of badly-administered and crowded asylums, Psych. 66, 69
Dench, E. B., results of hearing after radical mastoid operation, quoted, Otol. 42
Dendrons of nerve and cells of dental pulp, Odont. 12
Dental arch, typical in Cebus , Odont. 39, 40
-in Mycetes , Odont. 47, 48
-operations, local anaesthesia in (F. N. Doubleday), Odont. 1
-, cases illustrating, Odont. 4, 5
-plates removed from oesophagus, two cases (J. Gay French), Laryng. 12
-pulp, nerve-end cells of (J. Howard Mummery), Odont. 11
-standpoint, treatment of adenoids from, Child. 55
-technique before bone grafting of gunshot fractures of jaw, Odont. 57
Dentinal tubules, bacteria in, demonstrated in sections from cases of pyorrhoea, Odont.
107, 108
Dentine, histology and histo-pathology of dental pulp in normal relationship to, Odont. 31,
32, 33
Denture, attachment to prosthetic palate in case of total loss of premaxilla, alveolus and
palate, Odont. 90, 91
-used in case of loss of teeth only, in injuries to maxillae, Odont, 77, 79
Dentures and jaws, good development among German prisoners, Child. 40
-, construction bf, difficulties in taking impressions for, how overcome, Odont. 74, 75
-, fixation rendered difficult by local obliteration of sulci, Odont. 18
-, special construction in cases of loss of palatal portion of maxilla, Odont. 78-82
Depressive reactions, percentage among war psychoses, Psych. 43
Dercum’s disease, case (E. G. Graham Little), Derm. 35
Dermatitis herpetiformis, arsenical pigmentation and hyperkeratosis occurring in course of
(E. G. Graham Little), Derm. 31
-, (?) case (E. G. Graham Little), Derm. 19
-, case diagnosed as (A. Eddowes), Derm. 73
--, alternative diagnosis suggested, Derm. 73, 74
_, treatment suggested for, Derm. 73
_, septic, of nose, followed by sphenoidal sinus thrombosis, ending fatally, Ophth. and
Laryng. xxxvii
_ t X-ray, chronic, of anal region excised eighteen months previously (J. P. Lockhart-
Mummery), Proct. 45
Dermoid cyst, suppurating, removed from lower central region of forehead of child (Herbert
Tilley), Laryng. 193
-cysts, suppurating, treatment of cavity after removal of cysts, Laryng. 193
-fistula of nose (W. Stuart-Low), Laryng. 102
Dextrin and maltose, conversion of starch into, Child. 27
-stovaine solution in spinal ansesthesia, Ansesth. 2
_, mobility in cerebro-spinal fluid, Amesth. 2, 3
_in spinal anaesthesia, Anaesth. 2
Diagnosis, case for (H. W. Barber), Derm. 37
-(S. E. Dore), Derm. 46
_, bilateral ankylosis of vocal cords (Andrew Wylie), Laryng. 161
_ _ 9 chronic unilateral laryngitis (Andrew Wylie/and Archer Ryland), Laryng. 164
_oriental sore, possibly (H. G. Adamson), Derm. 33
_, sent from University College Hospital (J. H. Stowers, shown by H. C. Samuel),
Derm. 30
_, ? xanthelasmoidea (urticaria pigmentosa) (E. Bronson), Child. 21
Diaphragm, crura of, Laryng. 92, 97
Diaphragms, use of, in X-ray treatment of breast cancer, Electr. 47
Diarrhoea in typhoid fever in inoculated soldiers, Epid. 2
Index
xxxv
Diathermic effect in centre of body or limb, upon what dependent, Electr. 22
-puncture in treatment of enlarged or diseased tonsils, Laryng. 245
Diathermy, after-effects, Electr. 27
-and figuration, combined, in treatment of malignant disease, Electr. 25
- 1 distinction between, Electr. 24
-apparatus, inductance coil in, Electr. 21
-, resonance curve in, Electr. 21
-, secondary condensers in, Electr. 22
-used for treatment under (C. M. Dowse and C. E. Iredell), Electr. 18
-, caution in application in neighbourhood of large vessels, Electr. 27
-, dielectrics in, how to avoid injury to, Electr. 19
-, heating effect in, on what dependent, Electr. 22
-in gynaecology (C. E. Iredell, and others), Electr. 1G
-, technique, Electr. 17
-knife, use of, in staphylectomy, Laryng. 239
-, methods of connecting patient in, Elect. 19, 20
-, choice of, Electr. 19
-pads, temperature of, Electr. 39
-, resistance of body to electric current in, Electr. 24
-, treatment by, effecting general improvement in acne complicated by intestinal stasis
(H. W. Barber), Electr. 37
-, exophthalmic goitre developing during, Electr. 36
-, in abdominal disorders (C. E. Iredell), Electr. 34
-, length of treatment, Electr. 34
-, of acute rheumatoid arthritis, Electr. 35, 36
-, of asthma, Electr. 36
-, of cancer of breast, Electr. 29
-of cervix before Wertheim’s operation, Electr. 40
-(inoperable), Electr. 40
-, of constipation, Electr. 34, 35
-, of diseases of eye (C. E. Iredell and C. Meadows Ryley), Electr. 31
- 9 electrode used, Electr. 31
-, length of treatment and current used, Electr. 31
-, of dysmenorrhoea, Electr. 40
-, of epithelioma of epiglottis, case (R. A. Worthington), Laryng. 158
-of face or nose, Electr. 28
-of mouth or tongue, Electr. 27
-of palate, tonsil, tongue and floor of mouth, successful case (Norman
Patterson), Laryng. 182
-of tonsil, case shown two years and nine months after (Frank Rose),
Laryng. 170
-superimposed on lupus vulgaris, Electr. 28
-, of glaucoma, Electr. 32, 33, 39
- y method of conducting current to eye, Electr. 39
-, of inoperable cancer of cervix, application of small electrode in, Electr. 17, 18
-, application of radium after, Electr. 18
-, carried out under anaesthetic, Electr. 18
-, relief of pain in, Electr. 17, 18
-, technique, Electr. 17
-, of malignant disease (G. E. Iredell and Philip Turner), Electr. 24
-, application of electrodes in, Electr. 24, 25
-glands in neck, Electr. 26
-, of Raynaud’s disease, Electr. 36
-, of rodent ulcer, Electr. 25, 26, 28
-, of sarcoma of jaw, Electr. 29
XXXVI
Index
Diathermy, treatment by, of secondary growth in submaxillary region, fatal case, Electr. 26
-, of suppurating tuberculous glands, Electr. 27, 29
-, use of air core transformer in, Electr. 19
-of condensers in, Electr. 19
-of high frequency and low frequency alternating currents in, Electr. 19
Dickinson, Vincent. —Discussion on case of Delhi boil, Derm. 72
Dielectrics in diathermy, how to avoid injury to, Electr. 19
Diet, errors in, factor in causation of adenoids, Child. 26, 35, 45
-, human, changes in, since pre-cookery times, Child. 28
-, improper, in malaria causing debility, Med. 37
-of Highland and Lowland Scots, contrasted, Odont. 28, 29
Dietetic customs, change in, as means of diminishing prevalence of adenoids, Child. 30
Digestion, disturbance of, following migraine, Ophth. 54
-, salivary, Child. 27, 42, 56
-, importance of, Child. 27, 42
-, ingestion of starchy food without, Child. 28
Dighton, Adair, nerve deafness associated with fragility of bones and blue sclerotics, Otol. 130
Dilators, metal, risk of, in dilating cervix with, Obst. 203
Dinsley, A., and Carver, A.—Some biological effects due to high explosives, Neurol. 36
Diphtheria, gangrene following, Child. 89
——, prevalence during dry years, Med., Path, and Epid., xiii
-, tonsillitis during convalescence from, Child. 89
Diphtheroids demonstrated in sections of teeth, bone, and tissues from cases of pyorrhoea,
Odont. 107, 108, 112, 115
Diplopia, accompanying encephalitis lethargica, Neur. 58-60
-malignant disease of pituitary body, Ophth. 46, 47, 49
-due to injury, Ophth. and Laryng, ivii
-, special mode of treatment, Ophth. and Laryng. Ivii
Disease carriers, healthy, prevalence of, Laryng. 226
Disease, one, curative effect on another, Clin. 18
-, periodicity in, method of investigating, with examples, Epid. 100-111
Dissociation, mental, Psych. 4
-, conception of, Psych. 4
Diverticulopexy, case of, further notes on (William Hill), Laryng. 155
-, method described, Laryng. 155, 156
Diverticulum, pharyngeal, treated by dislocation and fixation in upper part of neck, case
(J. Dundas Grant), Laryng. 156, 166
-, two cases, one with removal under local anaesthesia (W. H Kelson), Laryng. 248
Dog, introduction of air, experimentally, into circulation through vein, without fatal result,
Path. 64
Donelan, James. —Combined tongue forceps and depressor for use in enucleation of tonsils,
Laryng. 188
-, discussion on adherent palate, Laryng. 152
-case of adhesions and contracture of faucial pillars, following complete enucleation
of tonsils, Laryng. 180, 181
-of chronic unilateral laryngitis, Laryng. 165
-of extensive lupus of alveolus, nose, and larynx, Laryng. 212
-of infiltration and ulceration of vocal cords, Laryng. 113
-of laryngeal whistling, Laryng. 174
-of nasopharyngeal angeio-fibroma, Laryng. 175
-of tongue for diagnosis, Laryng. 199
-on cyst of larynx, Laryng. 196
--on delayed breaking of voice, Laryng. 197,198
-on functional aphonia, Laryng. 31
-on injuries and inflammatory diseases affecting the orbit and accessory sinuses,
Ophth. and Laryng. lxii
Index
xxxvii
Donelan, James—D iscussion on instruments simplifying control of Luemorrhage in difficult
cases of enucleation of tonsils, Laryng. 215
-, discussion on naso-laryngeal growth, Laryng. 209, 210
_on non-surgical treatment of enlarged or diseased tonsils, Laryng. 245
_on pin in bronchiole of posterior lobe of right lung, Laryng. 11
’_on radiograms showing absence of right frontal sinus, Laryng. 168
_on removal of bone impacted in oesophagus, Laryng. 171
_on trans-sphenoidal operation for pituitary tumour, Laryng. 169
_on treatment of wounds of nose and nasal accessory sinuses, Laryng. 132, 133
-, large antral polypi, Laryng. 167
_ f paralysis of left vocal cord in a woman, aged 49, Laryng. 181
_’ President’s address (British laryngology and rhinology), Laryng. 1
_ f some suggested alternatives to operations for 44 adenoids ” and enlarged tonsils in young
children, Laryng. 216
Donors of transfused blood, after-effects absent in, Med. 9
_ t classification into groups, reason for, R.S.M. Disc. (Shock), 21
_ % freedom from certain diseases important in, Med. 9
_, relatives as, Med. 9
_ f repeated use of the same, Med. 9
_, selection, Med. 8
Dore, S. E.—Case for diagnosis, Derm. 46
_ discussion on alopecia of scalp and eyebrows associated with Graves’ disease, Derm. 41
_ on case of arsenical pigmentation and hyperkeratosis, Derm. 32
_of folliculitis decalvans, Derm. 14
_of lichen obtusus corneus, Derm. 17
__ of multiple benign tumour-like new growths, Derm. 23
_of mycosis fungoides, Derm. 24
_of trichorrhexis nodosa, Derm. 60
_on white-spot disease (morphoea guttata), Derm. 26
-, guttate morphoea, Derm. 3
Dorgan, Colonel, association between influenza and cerebro-spinal meningitis in military
camps, quoted, Epid. 72
Double images, perception of, how resulting, Ophth. 63
Doubleday, F. N. —Case of gunshot wound of the mandible, with extensive loss o tissue,
treated by Colyer method, Odont. 95
_ f on local aneesthesia in dental operations, Odont. 1
Dover’s powders in influenza, Med. 71
Dowse, C. M., and Iredell, C. E.—Notes on diathermy apparatus, Electr. 18
Drage, Lovell. Teaching of obstetrics and gynaecology from the point of view of a general
practitioner, Obst. 49
Drainage of cavity from which muscle for grafting is taken, Surg. 5
Draper’s sign in encephalitis lethargica, Med., Path, and Epid. xxii
Drew, Aubrey H., and Turner, J. G.—Experimental inquiry into the bacteriology of
pyorrhoea, Odont. 104
Dry weather, years of, prevalence of scarlet fever, diphtheria, and puerperal fever in, Med s
Path, and Epid., xiii
Dublin, measles epidemics in, amplitudes, Epid. 90, 92, 95
_, deaths from, average weekly prevalence for forty years, Epid. 98
Dubois, explanation of persuasion by, Psych. 22, 23
44 Dummy,” use of, forbidden to infants with rickets, Odont. 26
Dunn, Naughton, Major, R.A.M.C.—Discussion on bone-grafting, Surg. 23
Dura mater, penetration of, following gunshot injuries of orbit and nose, Ophth. and Laryng.
xxxvii i
Dysmenorrhoea, common cases of, inaccessible to students, Obst. 38
-, treatment by diathermy, Electr. 40
XXXV111
Index
Dyspepsia, intestinal, factor in causation of adenoids, Child. 26, 30
Dysphagia, associated with spasm at entrance to oesophagus, Laryng. 235
-, clinical type of, in women (D. R. Paterson), Laryng. 235
-, examination of oesophagus in cases of, Laryng. 236, 237, 238
Dystrophy, primary atrophic muscular (amyotonia congenita of Oppenheim), case (H. C.
Cameron), Child. 25
Eagle, see Sea eagle
Ear, discharge, chronic, among children, Otol. 55
-, treatment by paracentesis tympani, Otol. 55
-, diseases of, associated with adenoids, Child, 34, 48
-, loss of man power from, during the war, Otol. 51, 52
-, evolution of, Otol. 81
-, internal, necrosis of, causing sequestration of labyrinth, recovery (W. M. Mollison),
Otol. 8
--, nerve fibres of, Otol. 80, 81
-, left, microscopical examination of (chronic middle-ear suppuration with otosclerosis,
fistula in lateral canal, labyrinthitis, double vestibulotomy) (J. S. Fraser), Otol. 122-6
-, lobule of, embryological derivation, Otol. 22
-, malformations, Otol. 25
-, weakness in tuberculous subjects, Otol. 26
-, middle, and inner involved in fracture of the base of skull (J. S. Fraser), Otol. 104
-, microscopic examination of, Otol. 105-110
-, diseases of, associated with adenoids, Child. 34
-, inflammation, acute, chronic discharge following, causal factor, Otol. 52
-, septum and nasopharynx, malformations in association with deafness, Otol. 28
-, suppuration, chronic, and chronic mastoiditis, connexion between, Otol. 53
-, case (J. F. O’Malley), Otol. 13
-, question as to pension award, Otol. 13-16
-, following delay in operating for adenoids. Child. 39
-, implication of attic and antrum in, how indicated, Otol. 52, 60
- - - -, indications for modified radical mastoid operation in cases of,
Otol. 45, 46
-labyrinthine and intracranial complications of (J. S. Fraser and W. T.
Garretson), Otol. 29
-in school-children, recovery from without operation, Otol. 53, 55
-- f prevalence among poor school-children, Otol. 52, 53
-, rejection of candidates for admission to Royal Air Force on account of,
Otol. 52
-, treatment by ossiculectomy, Otol. 97
-, operative, sign indicating, Otol. 52
-, without operation, Otol. 60
-- - - - with otosclerosis, fistula in lateral canal, labyrinthitis, double
vestibulotomy (J. S. Fraser), Otol. 122-6
-, tension in, sudden alteration, effects of, Otol. 100
-, right, microscopical examination of (chronic adhesive process and otosclerosis), in case
of otosclerosis associated with otitis media (J. S. Fraser), Otol. 117-122
-, in case with fracture dislocation of incus and rupture of roof of right
mastoid antrum (J. S. Fraser), Otol. 110-115
-, see also Morel ear '
Ears, pricking up, during testing with tuning-fork, Otol. 26
Earthenware, fragments of, addition to boiling water, abuudant liberation of steam following,
Path. 69
Eaton, E. M.—Visual perception of solid form (abstract), Ophth. 63
Index
XXXIX
Eczema, disappearance during pyrexial infection, Child. 53
Eddowes, Alfred. —Association of blue sclerotics with hereditary tendency to fractures,
quoted, Otol. 129
-, case of dermatitis herpetiformis, Derm. 73
-, discussion on case for diagnosis, Derm. 34, 48
-on two cases of granulosis rubra nasi, Derm. 40
-on unilateral band sclerodermia and morphoeo-sclerodermia, Derm. 45
-, pigmented hairy mole benefited by impetigo contagiosa, Derm. 47
Eden, T. W.—Discussion on retroperitoneal bleeding after dilatation of cervix, Obst. 199
-, discussion on teaching of obstetrics and gynaecology, Obst. 58
-, report to Council on teaching of obstetrics and gynaecology to medical students and
graduates in London (Chairman), Obst. 108-184
Edinburgh, measles epidemic in, amplitudes, Epid. 90, 91, 95
-, measles in, deaths from, average weekly prevalence for forty years, Epid. 98
-, teaching of obstetrics and gynaecology in, Obst. 68, 69
Education, medical, report on teaching of obstetrics and gynaecology, in relation to
* Obst. 108-134
Effector mechanism, lower, behaviour in response to physical efficiency tests, Epid. 44
Egypt, venereal diseases in, management of, during the war (Sir James W. Barrett), R.S.M.
Lect. 1
Einhorn, M., inco-ordination theory of dilatation of oesophagus without anatomical stenosis,
quoted, Laryng. 70
Einthoven, invention of string galvanometer by, Electr. 64
Elastic tissue, extent of, on vocal cord, Laryng. 203, 204, 205
Electric current, high resistance of human body to, diathermic effect in centre of body or
limb dependent on, Electr. 22
-, path through body, use of thermo-couple thermometer in determining, Electr. 62
-, resistance of body to, in diathermy, Electr. 24
-currents, first instruments invented for indicating, Electr. 70, 71
—— flash resulting in obstruction of central retinal artery with patent branches (F. A. Juler),
Ophth. 58
-lamps, two, with red and green screens, use of, in apparatus for production of stereo¬
scopic pictures, Electr. 2, 3
-potentials, development in heart, deflection of sensitive galvanometer by, Electr. 64
-wave, transformation of sound wave into, Otol. 86
Electrical methods, in measurement of body temperatures in pulmonary tuberculosis,
Electr. 55-58
-, in trench fever, Electr. 58
-of measuring body temperatures (R. S. Whipple), Electr. 54
Electricity, in treatment of dilatation of oesophagus without anatomical stenosis, value
limited, Laryng. 39
Electrocardiogram, apparatus required to obtain, Electr. 64
Electrocardiograms, standardization of, Electr. 66
-, vibrations observed in, Electr. 69, 71
Electrocardiograph, application to clinical medicine, Electr. 65
-, electrodes in use with, Electr. 69, 71
-, light for use in connexion with, Electr. 70
-, notes on (R. S. Whipple), Electr. 64
-, rotary time-marker of, Electr. 70, 71
-, use of, demonstrated by clinical records, Electr. 65-68
Electro-cautery, application in treatment of enlarged or diseased tonsils, Laryng. 245
246, 247
Electrode, small, application in diathermy for inoperable cancer of cervix uteri, Electr. 17, 18
-used in diathermy treatment of eye diseases, Electr. 31, 39
Electrodes, application in diathermy in treatment of malignant diseases, Electr. 24, 25
xl
Index
Electrodes in use with electro-cardiograph, Electr. 69, 71
-, with porcelain sheath used in fulguration, Electr. 23
Electrolysis in treatment of enlarged or diseased tonsils, Laryng. 245
Elgood, Lieutenant-Colonel, C.M.G., prophylactic measures against venereal diseases among
Australian troops at Port Said carried out by, R.S.M. Lect. 8
Elliott, T.R., F.R.S., phosgene poisoning followed by pulmonary oedema and subcutaneous
oedema, quoted, Path. 58
Embleton, D., and Peters, E. A.—Sphenoidal sinus empyema in cerebro-spinal meningitis,
Laryng. 250
Embolism, cause of sudden death in childbirth, Obst. 83
Embolus, probable cause of gangrene of fingers, complicating chorea, Child. 88, 89, 90
-, pulmonary, complicating fatal case of mitral disease, Child. 89
Embryomata, complex, mixed tumours distinct from, Path. 3
Emotion and commotion, combined operation in neurosis following detonation of high
explosives, Neur. 49
-, intense, reinstatement of, effect on nervous system in war neurological cases with
amnesia, Psych. 57
Emotional systems, Psych. 17, 19
-in patients, stimulation and combination of, therapeutic value, Psych. 24, 25
Emotions, physical manifestations of, part played by, in determining form taken by war
neuroses, Psych. 59
Emphysema, artificial production, purposes for which employed, Path. 58
-, compensatory, of lung following “gassing,” Path. 58
-, intravascular, see Air embolism
-of connective-tissue from entry of air, Path. 56
-of forehead and left temple in case of fracture of outer wall of frontal sinus, Path. 62
-of intestinal wall, diffuse (C. A. R. Nitch and S. G. Shattock, F.R.S.), Path. 46
-, case of, clinical history and findings at operation, Path. 46-48
-, with stenosis of pylorus. Path. 46, 47, 48
-, examples recorded in earlier literature, Path. 75, 76
-, in swine, Path. 84
-, mechanical causation, evidence in favour of, Path. 78
-, pathogenesis, Path. 67-78
-, production post mortem, and in living subject, Path. 73, 74
-of neck, Path. 56
-complicating “gassing,” Path. 57
-influenzal pneumonia, R.8.M. Disc. (Infl.) 60, 64, 100; Path. 57
-, subcutaneous, in birds, Path. 60
-of wall of stomach occurring about site of simple ulcer, Path. 75
-, pulmonary, found post mortem in influenza, Med. 61
-, subcutaneous, complicating influenza, R.S.M. Disc. (Infl.) 100
-, pneumonia of influenza, R.S.M. Disc, 64
-, local, at site of punctured wounds, Path. 59
-, of lace following coughing, Path. 59
-, with pulmonary oedema, following phosgene poisoning, Path. 58
-, submucous, spreading, following injury to mucosa of Eustachian tube, Path. 59
-, of wall of caecum, case of, clinical history and details of operation, Path. 79
- - —, description of specimen, Path. 79
Employees, malaria in, means for diagnosis, Med. 15, 36
Empyema complicating influenza, treatment by mixed vaccines, R.S.M. Disc. (Infl.) 79
-, streptococeal, complicating influenza, R.S.M. Disc. (InfL) 69, 70
-, X-ray diagnosis of gall-stones from, radiogram showing, Electr. 82
Enamel organ of infant suffering from rickets, microscopical appearances, Odout. 34
Encephalitis lethargica, acute stage, accompanied by haemorrhage into vitreous, Neur. 64
-and poliomyelitis, association with prevalence of influenza, Med., Path, and Epid.
xii, xiii
Index
xli
Encephalitis letbargica and poliomyelitis, paralyses in, distinction between, Med., Path, and
Epid. xvii.
-, cases of (E. Farquhar Buzzard), Neur. 56
-, clinical histories, Neur. 57-62, Path. 42
-, lesions of central nervous system found post mortem, Path. 43-45
-, preparations from, demonstration (C. Da Fano and H. Iugleby), Path. 42
-, staining methods employed, Path. 43, 44, 45
-of slight severity and with trivial physical signs, Neur. 58-60
-with severe symptoms and disabling sequelae, Neur. 60, 61
-, cause of death in, Med., Path, and Epid. xx
-, cerebro-spinal meningitis and influenza, association between discussed, Epid. 72,
73, 75
-, diagnosis, Neur. 63, 64
-in early stage important, Neur. 60
-, diplopia accompanying, Neur. 5S-60
-, distinct from acute poliomyelitis and resulting encephalitis, Med., Path, and
Epid. x, xv
-, effect upon blood-vessels of brain, Neur. 63
-, epidemic, association with sweating sickness, Med., Path, and Epid. vii.
-at Birmingham, Med., Path, and Epid. xiv
-at Sheffield, Med., Path, and Epid. xv
-, causal organism, Med., Path, and Epid, iv, v
- f classification of cases, Med., Path, and Epid. xvii, xviii
--, diagnosis from botulism, Med., Path, and Epid. ii
-from haemorrhagic poliomyelitis, Med., Path, and Epid. ii
-from Heine-Modin disease, Med., Path, and Epid. ii, iii
-from sleeping-sickness, Med., Path, and Epid. ii
-, discussion on, Med., Path, and Epid. i-xxiii (E. Farquhar-Buzzard, xv;
F. G. Crookshank, iv, xii, xiv, xxi; C. Da Fano, v; A. J. Hall, xv ; W. H. Hamer, v ;
Miss Helen Ingleby, v ; S. P. James, viii; A. Salusbury MacNalty, xvii, xxiii; Sir F.
W. Mott, i; J. A. Murray, v; Sir Arthur Newsholme, xiii; P. N. Panton, iii; John
Robertson, xiv)
-, examination of cerebro-spinal fluid in, Med., Path, and Epid. iii, iv, xxi,
xxii
-, in London (1918), statistics relating to, Med., Path, and Epid. xxi, xxii
-, in New York and district (1916), Med., Path, and Epid. xxi, xxii
-, lesions of brain and spinal cord in, Med., Path* and Epid., i, ii
-, microscopical examination, Med., Path, and Epid. ii
-, points of difference from infantile paralysis, Med., Path, and Epid. ix
-, fatal case diagnosed as obscure cerebral condition, Med., Path, and Epid. xiii
-, incubation period, Med., Path, and Epid. xviii
-, involuntary movements of limbs following, Neur. 60, 61
-, prognosis, Neur. 63
-, lumbar puncture in, Med., Path, and Epid. xxi
-, mode of onset, Med., Path, and Epid. xxii
-, morbid anatomical features of, difficult to reconcile clinical phenomena with,
Neur. 63
-, notification made compulsory, Med., Path, and Epid. xi
-, paralysis arising from, prognosis, Neur. 63
-of cranial nerves in, Med., Path, and Epid. xv, xviii, xix, xx
-, prodromal period, Med., Path, and Epid. xvi, xviii
-, prognosis, Neur. 63
-, pyrexia in fatal case of, Neur. 57
-, relation to Heine-Medin disease, Med., Path, and Epid. xx, xxi
-, site of encephalitis in, Med., Path, and Epid. xv
xlii
Index
Eacephalifcis lethargies, sporadic distribution of, Med., Path, and Epid. xi
-, symptoms, Neur. 57-62
-and signs, Med., Path, and Epid. xv, xviii, xix
-, general, Med., Path, and Epid. xxii
-, treatment, Med., Path, and Epid. xxi, xxii
-, two cases in same household, Neur. 57, 58
-, untoward signs in fatal cases, Med., Path, and Epid. xx
Endocarditis, complicating influenza, R.S.M. Disc. (Infl.) 45
Endocrine glands, disturbances of, in relation to symptomatology of war neuroses, Psych. 59
-, in severe war neuroses in the field, Psych. 58
Endoscopy in diagnosis of dilatation of oesophagus with anatomical stenosis from functional
dilatation, Laryng. 34, 42
-in examination of oesophagus, in cases of dysphagia, Laryng. 236, 238
-, peroral, new instruments designed for, in removal of foreign bodies from lungs (Irwin
Moore), Laryng. 20
Endothelial cells, presence in malaria, Med. 31, 32
Endothelioma of appendix, case of, Surg. 39
-of left tonsil, operation performed (Andrew Wylie), Laryng. 101
Endotheliomatous tissue, removal of, with sellar decompression in pituitary tumour
(H. Lawson Whale), Laryng. 178
Energy, one fundamental, primary impulses as differentiations of, Psych. 8
England and France, treatment of amnesia of war neurological cases in, results compared,
Psych. 57, 58
- and Wales, annual death-rate from cerebro spinal fever (1881-1917), R.S.M. Disc.
(Infl.) 6
-from influenza (1847-1917), R.S.M. Disc. (Infl.) 6
-, birth-rate exceeded by civilian death-rate (1918), Obst. 53
-, maternal death-rate due to pregnancy and labour in, Obst. 64, 74
-, vital statistics in connexion with mortality from child-bearing, Obst. 75
-, Belgian refugees in, cases of enteric fever among, Epid. 16
-, parent home of laryngoscopy, Laryng. 2
-, prevalence of adenoids in, Child. 28
Entamoeba coli cyst content, count in stools, effect of concentration on, table showing,
M.B.L. 13
-cysts in stools, comparison of counts in same preparation made by two different
observers, table showing, M.B.L. 11
-, daily variation in number per gramme of stool, M.B.L. 6
-, diagnosis of presence or absence, means of, M.B.L. 5
-, enumeration, adjustment of light under microscope, M.B.L. 4
-, by new method, M.B.L. 1
-, experimental errors in, due to use of pipette, to
personal factor and to random sampling, M.B.L. 8-11
-, enumerative study of (J. W. Cropper), M.B.L. 1-14
-, rate of degeneration, table showing, M.B.L. 13
-, variability in content, M.B.L. 4, 5
-, variation, daily, in number, per gramme of dried stool, M.B.L. 8
-in number, excreted per day, M.B.L. 7
-in successive cubic millimetre volumes in same emulsion of stool, table show¬
ing, M.B.L. 11
Entamoeba histolytica cysts, method of counting, M.B.L. 11
Enteric fever, cases among Belgian refugees in England, 1914, Epid. 16
-epidemic in Flanders, among civilian population in area occupied by Allies, per¬
centage of fatality rate in typhoid and paratyphoid cases compared, Epid. 27
-among inhabitants of area occupied by Allies, Epid. 22
-, cases at Popcringhe and Ypres, Epid. 24, 25
hidex
xliii
Enteric fever, epidemic in Flanders, among inhabitants of area occupied by Allies, character
of cases, Epid. 22
-, complications, Epid. 24
- 1 rarity of perforation cases, Epid. 24
-.cessation, causes discussed, Epid. 32, 33
-, civilian cases, hospitals established for, Epid. 28
-, how provided for, Epid. 28
-in ar ea occupied by Allied Armies, Epid. 21
-, measures employed against, Epid. 27-32
-, by promotion of sanitary work of search parties, Epid. 31
-t -, by protection of healthy, Epid. 29
-, by provision for the sick, Epid. 28
-, by sterilization of water-supply, Epid. 30, 31
-, military cases, how provided for, Epid. 28
-, spread among civil population, Epid. 19
-, causes of, Epid. 16, 17
-, outbreak becoming epidemic, Epid. 19
-, date of, Epid. 18, 19
-(Presidential Address) (E. W. Goodall), Epid. 15
- 1 treatment and suppression of, work done by Friends’ Ambulance Unit,
Epid. 19, 20, 21, 28
-, varieties of, diagnosis varies according to laboratory methods, Epid. 27
-, See also Typhoid fever , Paratyphoid fever
Enteromere theory of congenital dilatation of oesophagus, Laryng. 70
Enuresis, case of, origin of habit, Neur. 18
-, nocturnal, cause of, Child. 34
Eosinophils, increase in chronic malaria, Med. 31
Epicardia, opening and closing of, under examination by cesophagoscope, Laryng. 50
Epidemic constitution, characteristic product of, Epid. 70
-, local nature of, Epid. 70
-constitutions, doctrine of, Med., Path, and Epid. viii
-of Sydenham, Epid. 58, 59, 60, 62
-, relation to epidemic diseases, Epid. 69
-, symbolic expression of, Epid. 61
-, theory of, attempted rationalization, Epid. 64
- f discussed, Epid. 63, 67, 68
- # support for, Epid. 64
-diseases, causation of, factors in, recently brought to light, Epid. 71
-, causation of, micro-organism a factor in, unknown to Sydenham, Epid. 71
-, Sydenham’s views as to, Epid. 70
-, changes in clinical type, Epid. 63
-observed by Sydenham, Epid. 67
-, relation of epidemic constitutions to, Epid. 69
-, special hospitals for, attachment of experts in laryngology and otology to, resolution
passed respecting, Otol. 31, 51
Epidemics appearing during 1661 and 1676, Sydenham’s observations on, Epid. 67
--, doctrine of, history of, how best summarized, Epid. 71
-, periodicity of, on what dependent, Epid. 79
-, seasonal prevalence as defined by Sydenham, Epid. 59, 60
Epidemiologist, Sydenham as (M. Greenwood), Epid. 55-76
Epidemiologists and bacteriologists, differing views of problem of disease taken by, Epid. 75
Epidermolysis bullosa hereditaria, two cases of (George Pernet), Derm. 64
Epiglottis, carcinoma, squamous-celled, in combination with a spindle-celled sarcoma,
Path. 23-27
-, epithelioma of (W. Stuart-Low), Laryng. 104
xliv
Index
Epiglottis, epithelioma of, treated by diathermy, case (R. A. Worthington), Laryng. 158
Epilepsy, attack of, automatic acts following, explanation, Neur. 7
-, war psychoses associated with, Psych. 49
-, see also Aura , epileptic
Epiphora following injury to lachrymal sac, Ophth. and Laryng. lv
-- treatment, Ophth. and Laryng. lv
Epistaxis accompanying case of malignant disease of pituitary body, Ophth. 48
-in early stage of gunshot wounds of orbit and accessory sinuses, Ophth. and Laryng. xxix
-in influenza, R.S.M. Disc. (Infl.) 62
-in pulmonary type of influenza, Med. 55
Epithelial cell, malignant, polymorphism of (E. H. Kettle), Path. 1-32
-, morphological elasticity, to be allowed for in interpretation of anomalous growths,
Path. 4
-inlay operation, followed by prosthetic treatment, in case of loss of premaxilla with
part of alveolus and palatal portion of maxillae, Odont. 86, 87, 88
-in loss of alveolar border of maxilla, Odont. 77, 78, 80
-inlays in treatment of obliteration of buccal sulci, Odont. 19
Epithelioma of auricle (left) after operation (W. Stuart-Low), Otol. 78
-of epiglottis (W. Stuart-Low), Laryng. 104
-, treated by diathermy, case (R. A. Worthington), Laryng. 158
-of face (J. L. Bunch), Derm. 2
-or nose, treatment by diathermy, Electr. 28
-of maxillary antrum, glaucoma associated with, Ophth. and Laryng. xxxvi
-of mouth or tongue, treatment by diathermy, Electr. 27
-of palate and anterior faucial pillar, with enlarged glands in neck (Norman Patterson),
Laryng. 183
-, tonsil, tongue and floor of mouth, treatment by diathermy (successful) (Norman
Patterson), Laryng. 182f
-of tonsil two years and nine months after treatment by diathermy, case (Frank Rose),
Laryng. 170
-superimposed on lupus vulgaris, treatment by diathermy, Electr. 28
-, squamous, on vocal cord, Laryng. 203, 205
-, protective against tuberculosis, Laryng. 207
Epulides, multiple, case of (W. Warwick James and D. Nabarro), Child. 65-72
-, models taken at age of four years, Child. 67
-, report on sections from (D. Nabarro), Child. 69
-, cases occurring in one family, Child. 68, 70
-, region of jaw most affected in, Child. 68
Eructations, swallowing easier after, in pbreno-cardiac stenosis, Laryng. 38
Erysipelas, beneficial effect on carcinoma of breast, Clin. 18
-following radical mastoid operation, Otol. 38
Erythema multiforme, circinate persistent, case (E. G. Graham Little), Derm. 7
- 9 cases already recorded, Derm. 8
Erythrodermia, with lymphatic leukaemia, case of (J. H. Sequeira), Derm. 54
-, blood-count in, Derm. 54, 55
Erythromelalgia, Raynaud’s disease and transient oedema, combined, complicating malaria,
Med. 29
Esquimaux, jaws of, strength, Child. 29
Ether, administration preceding spinal anaesthesia, for severe operations, Anaesth. 3
-, contra-indicated in cases of shock, R.S.M. Disc. (Shock) 23
-, sudden collapse under, during laparotomy, treatment by heart massage, case (F. E.
Shipway), Anaesth. 17
-warm, and oxygen, administration with Shipway’s inhaler in cases of abdominal surgery,
Anaesth. 16
-, induction of anaesthesia by, in case of tonsillectomy, Anaesth. 19, 20
Index
xlv
Ethmoid and frontal sinus communicating with orbit in severe injuries to frontal sinus
treatment, Ophth. and Laryng. xii
-and orbit, gunshot wounds involving, case histories and treatment, Ophth. and Laryng.
xiv, xvii
-and orbits, injury to, fatal cases, Ophth. and Laryng. vii
-, anterior, upper part, war injury to, resulting in anosmia, Ophth. and Laryng. xxxiii
-, antrum and orbit, injury to, Ophth. and Laryng. ix
-, orbit and frontal sinus, injury to, Ophth. and Laryng. viii
-, gunshot injuries, effects on neighbouring structures, Ophth. and Laryng. xl
-, wounds of, injuries to eye following, Ophth. and Laryng. xxxiii
-involving, intranasal drainage in, Ophth. and Laryng. xxvi
-, hypertrophy of, without suppuration, as cause of retrobulbar neuritis, Ophth. and
Laryng. xxvii
-, orbit and frontal sinus, injury to, Ophth. and Laryng. viii
-, wounds of, complicated by blindness, Ophth. and Laryng. lii
Ethmoidal cells, posterior, disease of, in relation to retrobulbar neuritis, Ophth. and
Laryng. lxiv
-, wounds involving, treatment, Ophth. and Laryng. xi
-region, gunshot wounds of, septic, Ophth. and Laryng. liii, liv
-, treatment, operative, favourable results, Ophth. and Laryng. liv
-, non-septic, Ophth. aud Laryng. liv
-, treatment, operative, Ophth. and Laryng. xxvi
-, sarcoma commencing in, invading orbit, Ophth. and Laryng. lv
-in, Laryng. 163
-sinuses, development in young children, Ophth. and Laryng. lx
Eucalyptus, inhalation in influenza, Med. 70
Eusol, in treatment of influenza, R.S.M. Disc. (Infl.) 186
Eustachian tube, atresia of, treatment by myringotomy, Otol. 96
-, catarrh of, associated with adenoids, Child. 34
-, findings in at radical mastoid operations, Otol. 37
-, injury to, followed by spreading submucous emphysema, Path. 59
-, method of dealing with, in radical mastoid operations, Otol. 35
-, microscopic examination in case of fracture of base of skull involving middle and
inner ear, Otol. 106
-, with fracture dislocation of incus and rupture of
roof of right mastoid antrum, Otol. 112
-, patent, with mastoid suppuration, treatment, Otol. 98
-tubes, microscopic examination in case of otosclerosis associated with otitis media, Otol.
118, 122
-, orifices of, masses of adenoid tissue around, Child. 34
Evans, Willmott.— Discussion on case of trichorrhexis nodosa, Derm. 60
Eve, Frank.—C ase of syringomyelia (alleged plumbism), Neur. 31
-, rising floor cell to facilitate microscopy of cerebro-spinal fluids, Neur. 32
Everidge, J., O.B.E.—Case of acute suppurative arthritis of the right knee, treated by
mobilization method, Clin. 16
-, model to demonstrate the methods carried out in the mobilization treatment of knee-
joints, Clin. 10
Evolution, spontaneous, foetus undergoing, removal of, by laparotomy during labour (Clifford
White), Obst. 135
Exaemia, R.8.M. Disc. (Shock), 2
-•, following shock, R.S.M. Disc. (Shock), 15, 21
-, treatment, R.S.M. Disc. (Shock), 15, 21, 22 ; see also Blood , deficiency in
circulation
Examination system, damaging effect on training in obstetrics and gynaecology, Obst. 47
-, in obstetrics and gynaecology, defects in, Obst. 66 •
xlvi
Index
Excoriations, neurotic, Derm. 73
Exercise, response of pulse to, as test of physical efficiency, Epid. 36
Exhaustion in post-operative shock, R.S.M. Disc. (Shook) S3
-, physical, intense, recuperative powers of soldiers after, Psych. 37, 38
-, psychoses not produced by, Psych. 37
-, psychoses, not due purely to war stress, Psych. 38
-, wrongly included under mental diseases, Psych. 38
Exophthalmos in malaria, Med. 38
Expectoration and cough, method of inducing by inhalation of oleum sinapis (J. Dundas
Grant), Laryng. 26
Explosive, definition of, Neur. 38
Explosives, fragmentation of container, Neur. 40
-, high, action of, Neur. 39
-, biological effects due to (Alfred Carver and A. Dinsley), Neur. 36
-, detonation, demoralizing effects produced by, Neur. 40
-, direct concussion following, Neur. 37, 47
-, neurosis following, due to mixed emotion and commotion, Neur. 49
-, disruptive effects of, Neur. 40
-, effect of, on animals, experimentally tested, Neur. 41-45
-, general characteristics, Neur. 39
-, zones exhibiting various degrees of injury from, Neur. 40, 43, 44
-, mixed, detonation, effects on men, experimentally tested, Neur. 45
-, pressure exerted by, Neur. 38, 39
Extremity, lower, fracture of, bone-grafting seldom necessary in, Surg. 23
-, upper, fractures of, splint for (J. R. Lee), Surg. 6, 9
-, ununited fractures of bones of, bone grafting in, Surg. 23, 24
Eye accidents more frequent in women at shell factory than at fuse factory, Epid. 52.
-, diseases of, treatment by diathermy (C. E. Iredell and C. Meadows Ryley), Electr. 31
-, electrode used, Electr. 31, 39
-, dropped, treatment by paraffin injection, Ophth. and Laryng. lvii
-—, contra-indicated, Ophth. and Laryng. lxvi, lxvii
-, enucleation in war injuries of orbit with damage to eyeball, Ophth. and Laryng. v
-, inflammatory diseases resulting from sinusitis rare, Ophth. and Laryng. xlvi
-, injuries to, in gunshot and other injuries to frontal sinuses, Ophth. and Laryng. xxxii
-, in gunshot wounds involving two or more accessory sinuses, Ophth. and Laryng.
XXX, XXXI
-, following gunshot wounds of maxillary antrum, Ophth. and Laryng. xxxiv
-, in gunshot wounds of sphenoidal sinus, Ophth. and Laryng. xxxi
-, injury to, complicating gunshot wounds of antrum, Ophth. and Laryng. liv
-, lesions in children possibly due to sinus suppuration, Ophth. and Laryng. lxi
-symptoms absent in suppuration of sphenoidal sinuses, Ophth. and Larynx, liii
-, in encephalitis lethargica, Med., Path, and Epid. xxii
-, rarely mentioned by patients, with sinus suppuration, Ophth. and Laryng. lx
Eyes, convergence and divergence of, respective association with near and distant objects,
Electr. 5, 6
-, application to physiological optics of stereo
scopic vision, Electr. 5, 6
-, examination, in case of obstruction of central retinal artery (F. A. Juler), Obst. 59
Eyeball, left, dropping through floor of orbit, case of, Ophth. and Laryng. xii
-, removal of, in severe injury to floor of frontal sinus with deficiency of roof of orbit,
Ophth. and Laryng. xii
Eyebrows and scalp, alopecia of, associated with Graves disease (H. W. Barber), Derm. 41
Eyelid, gunshot wounds of, treatment, operative, Ophth. and Laryng. xxvi
Eyre, John.—D iscussion on influenza, R.S.M. Disc. (Infl.) 93
Index
xlvii
Face, atrophy of, with telangiectasis, Derm. 64
-, epithelioma of (J. L. Bunch), Derm. 2
-, treatment by diathermy, Electr. 28
-by radium, Derm. 2, 3
-, gunshot wound of, treatment by chest-flap rhinoplasty, Laryng. 142, 144, 145
-, lost parts of, method for measuring and regulating size and shape of, Laryng. 133, 134
-, subcutaneous emphysema of, following coughing, Path. 59
Factories, different, accident frequency of men and women at, compared, Epid. 51, 52
Fainting, hysterical, in hot weather, euro after original cause ascertained by anamnesis,
Neur. 16, 17
Faibbairn, J. S.—Discussion on changes in uterus as result of procidentia, Obst. 21
-, discussion on extra-uterine pregnancy, Obst. 183
-- on retro-peritoneal bleeding after dilatation of ebrvix, Obst. 199
-on two cases of puerperal anuria, Obst. 31
-, teaching of obstetrics and gynsecology from the standpoint of preventive medicine,
Obst. 40
Familial tendency to migraine, Ophth. 50, 52
Farm labouring classes, development of confusional symptoms among soldiers drawn from.
Psych. 48
Farrar, C., exhaustion psychoses, quoted, Psych. 38
Fat embolism, supposed death from shock due to, R.S.M. Disc. (Shock), 30
Fatigue, due to effects of bombardments, Neur. 47
-in workers, estimation by physical efficiency tests, Epid. 43
-reaction in degeneration deafness, Otol. 20
Fatness of infants with rickets, Odont. 26
Fauces and tonsil, epithelioma of, in woman (W. Hill), Laryng. 210
Faucial pillar, anterior, and palate, epithelioma of, with enlarged glands in neck (Norman
Patterson), Laryng. 183
-pillars, adhesions and contracture of, following complete enucleation of tonsils (Irwin
Moore), Laryng. 180
Faulder, T. J.—Discussion on radiograms showing absence of right frontal sinus, Laryng.
169
Fear as source of psycho-neuroses, Psych. 7
-, protection of patients against, before being anaesthetized, Anaesth. 11
Feeding, artificial, infantile scurvy due to, Odont. 24
-, of congenital syphilitic infants, Obst. 10, 11
-in cardiospasnf, Laryng. 51, 52, 53
-through tube in dilatation of oesophagus without anatomical stenosis, Lnryng. 40, 46
Females, prevalence of dilatation of oesophagus without anatomical stenosis in, Laryng. 60
Femur, dried, radiographed with penetrometer scale, Electr. 80
-, fixation to acetabulum by means of bono-spike, in case of morbus coxte, Surg. 30, 31
-, fractures of, compound, in upper third (J. R. Lee), Surg. 6
-, in bad position, Surg. 7
-, septic condition, Surg. 7
-, treatment by application of pelvic-femur splint, Surg. 8
-, treatment, stereoscopic radiography in (James Metcalfe), Electr. 72
-, surgical, Electr. 73
Fenestra ovalis, closure of, effect on hearing by bone conduction, Otol. 83
-, position pf, Otol. 83
-rotunda, action of, Otol. 90
-, closure of, producing complete deafness, Otol. 83, 88
-, position of, Otol. 82
Ferdinand II, Grand Duke, prevention by, of plague invading Tuscany, Epid. 69, 70
Ferment, diastasic, in saliva, animals without, Child. 27
Ferreyrolles, Paul.—I mmunity and mineral water treatment (with an introductory note
by R. Fortescuo Fox), Bain. 1-12
xlviii
Index
Fever in encephalitis lethargica, Med., Path, and Epid. xvi, xix
-, obscure, in tropics, blood-cultures iu, Med. 40
-, examination of blood film for parasites before treatment, Med. 39, 40
Fevers, intercurrent, Sydenham’s theory of, Epid. 61, 68
-, non-stationary, differentiated by Sydenham, Epid. 68
-, stationary, characteristic product of epidemic constitution, Epid. 70
-, Sydenham’s theory of, Epid. 68
Fibrolipoma, weighing thirteen pounds, which invaded or originated in right broad ligament
(W. S. A. Griffith), Obst. 188
Fibroma of auricle at entrance of meatus, case (W. Stuart-Low), Otol. 79
Fibromata of uterus, removal, method adopted (1884), Obst. 6
Fibula, inner surface of, as bone graft, Surg. 25
Fiji, first outbreak of measles in, R.S.M. Disc. (Infl.) 15
Fingers, gangrene of, complicating chorea (Mrs. Chodak), Child. 87
Finzi, N. S.—Discussion on mode of spread of cancer in relation to its treatment by radia¬
tion, Electr. 50
Fish, effect of high explosives on, Neur. 41, 42
-, swim-bladder of, secretion of gas in, Path. 67
Fishes, lowest, otic vesicle in, Otol. 81, 82
-, semaphoric apparatus in, Otol. 81, 82
Fisheb, J. Herbert, case of sympathetic uveitis, quoted, Ophth. 28
-, discussion on case of (?) pituitary tumour, Ophth. 40
-on case of pituitary tumour (hypopituitarism), Ophth. 41
-on changes in the sella turcica in association with Leber’s atrophy, Ophth. 23
-on fold in internal limiting membrane of retina, Ophth. 16
-on malignant disease of pituitary body, Ophth. 49
-, drawing of a transverse section through the optic chiasma and sella turcica to show the
relations of the pituitary body, Ophth. 56
-, migraine, Ophth. 49
Fixation abscesses, attempted production in virulent cases of influenza, R.S.M. Disc. (Infl.)
101
Flack, Martin, Lieut.-Colonel, R.A.F.—Some simple tests for physical efficiency, Epid. 35
Flanders, enteric fever in, epidemic (1914-15) (E. W. Goodall), Epid. 15-34
-, West, physical conformation of, in relation to spread of enteric fever, Epid. 16,17
-, See also under Enteric fever
Flap method in treatment of obliteration of buccal sulci, Odont. 19
Flavine as antiseptic mouth-wash, Odont. 31
Fleiner, congenital dilatation of oesophagus, quoted, Laryng. 70
Fletcher, Sir Walter, F.R.S.—Discussion on some simple tests for physical efficiency,
Epid. 44
-, discussion on teaching of obstetrics and gynaecology, Obst. 60
Flexor spasms following injury to spinal cord, cause of, Neur. 7
Fluid, administration of, in avoidance of surgical shock, R.8.M. Disc. (Shock) 29
-, increase of volume in body in shock, importance of, R.S.M. Disc. (Shock), 18, 21, 22, 23
Fluids, new counting chamber for cells in (R. S. Bhat), Child. 4
Fluoroscope, stereoscopic, provisional form of, Electr. 4, 5
Fluoroscopy, stereoscopic, suggestions for future development of, Electr. 4, 5
Flying accidents, displacement of maxillae without loss of tissue, due to, Odont. 76
Fcetor due to rhinolith in nose, Laryng. 160
Foetus, death of, in extra-uterine pregnancy, one hundred cases, complications following,
Obst. 154
-, percentage of occurrence, Obst. 154
-, mature, lower limb of, contained in osseous cyst, and remaining in abdomen of mother
for fifty-two years, specimen (Herbert Williamson), Obst. 171
-, position of, diagnosis learnt in out-patient department, Obst. 37
Index
xlix
Foetus undergoing spontaneous evolution removed by laparotomy during labour (Clifford
White), Obst. 135
Folliculitis decal vans, and Brocq’s pseudo-pelade, distinction between, Derm. 14
-, case (E. G. Graham Little), Derm. 13
Food and nourishment, type of influenza produced by lack of, H.S.M. Disc. 65
-, deficiencies in, as factor influencing calcification and fixation of teeth (F. M. Wells),
Odont. 23
-passages, foreign bodies impacted in, recorded at Section of Laryngology since 1908
(Irwin Moore), Laryng. 14
——, regurgitation in dilatation of oesophagus without anatomical stenosis, Laryng. 42
-shortage, not a cause of fatality in influenza epidemic (1918), R.S.M. Disc. (Infl.), 23
Foot, sole of, pricking, reaction to, Neur. 5
Forceps, bronchial, dilating, for removal of foreign bodies, Laryng. 20
-, non-slipping, for removal of foreign bodies, Laryng. 20
-used in preparation of fragments in bone-grafting in fractures of mandible, Surg. 16
Fobd, Miss Rosa. —Congenital pigmentation of the cornea, Ophth. 34
Forearm, fracture of, ununited, treatment by bone-grafting, Surg. 24-27
Forehead and left temple, emphysema of, in case of fracture of wall of frontal sinus, Path. 62
-flap containing anterior division of superficial temporal artery, use of, in wounds of nose,
Laryng. 142, 143
-, reversed pedicle, use in gunshot wounds of nose and eye, Laryng. 142
-, lower central region of, suppurating dermoid cyst removed from, in child (H. Tilley),
Laryng. 193
Foreign bodies : fork accidentally impacted in oesophagus (W. Hill and K. Lees), Laryng. 110
-impacted in food passages, recorded at Section of Laryngology since 1908 (Irwin
Moore), Laryng. 14
--in oesophagus, methods of removal discussed, Laryng. 17
—--in respiratory passages, recorded at Section of Laryngology since 1908 (Irwin
Moore), Laryng. 15
- -in maxillary antrum, removal, Ophth. and Laryng. xxxix, lxv
-in orbit, Ophth. and Laryng. v
--, jagged piece of bone impacted in oesophagus (W. Jobson Horne), Laryng. 171
-, pin in bronchiole (Hunter Tod), Laryng. 10
-removal from lungs by peroral endoscopy, new instruments recently designed for,
demonstration (Irwin Moore), Laryng. 20
-, operations for, in gunshot wounds of antrum, Ophth. and Laryng. liv
-, scarf pin in stomach (C. E. Woakes), Laryng. 10
-, screen localization in stereoscopic radiography, Electr. 7, 8
- -, tooth plates impacted in oesophagus (S. Hastings), Laryng. 7 ; (E. Woakes),
Laryng. 8 ; (Hunter Tod), Laryng. 11 ; J. Gay French, Laryng. 12
-hody immersed in aerated water, appearance of gas bubbles on, explanation, Path. 69
-in gravid uterus, skiagram of (G. Drummond Robinson), Obst. 17
-in oesophagus ; case occurring at Royal Naval Base Hospital (J. Gay French),
LaryDg. 13
-, lodgment at back of orbit, sympathetic paralysis resulting from, Ophth. and
Laryng. vii
-removed from nose after thirteen years, case (R. A. Worthington), Laryng. 159
-retained in sphenoidal region in case of injury to orbit, sphenoid and antrum,
Ophth. and Laryng. x
-in case of injury to orbit and sphenoid, Ophth. and
Laryng. x
Fowler’s bed, use of, for patients after operations for gunshot wounds of nose and orbit
Ophth. and Laryng. xli
Fox, H. Clayton. —Discussion on case of chronic adhesive otitis, Ofcol. 96
-, discussion on case of laryngeal whistling, Laryng. 173
-on removal of bone impacted in oesophagus, Laryng. 172
4
1
Index
Pox, H. Clayton—D iscussion ou transsphenoidal operation for pituitary tumour, Laryng. 169
Fox, R. Fobtescue.—I ntroductory note to Dr. Paul Ferreyrolles’ paper on “ Immunity and
Mineral Water Treatment,” Bain. 1
Fox, T. Colcott, on lichen urticatus and urticaria, quoted, Derm. 74
Fracastor, Jerome, “ De Contagionibus, 1646,” epoch-making importance of, Epid. 71, 7*2
Fracture of bone-graft, Surg. 31, 32
Fractures, compound, of femur in its upper third (J. R. Lee), Surg. 6
-*-, position or displacement of fragments in, Surg. 7
--, treatment, correct, essentials in, Surg. 7
-, hereditary tendency to, association of blue sclerotics with, Otol. 129
-of upper extremity, splint for (J. R. Lee), Surg. 6, 9
-, ununited, of long bones, bone-grafting in, value of, Surg. 23
-, of mandible, bone-grafting in (P. Cole and C. H. Bubb), Odont. IS
-, transplant grafts in (C. Ernest West), Odont. 95
-, treatment in interval between wound healing and operation, Surg. 30
Fraenum linguae, long, case (Irwin Moore), Laryng. 108
Fragilitas ossium and blue sclerotics, nerve deafness associated with, Otol. 130
-, associated with otosclerosis, clinical report of cases (J. S. Fraser), Otol. 126-131
-, congenital, clinical picture, Otol. 129
-late, clinical picture, Otol. 129
France, American army in, meningitis in (1918), R.S.M. Disc. (Infl.) 29
- and England, treatment of amnesia of war neurological cases in, results compared.
Psych. 57, 68
-, British Army in, influenza epidemic in (1918), R.S.M. Disc. (Infl.) 27
-, paratyphoid fever A and B in before war, Epid. 27
Fbankau, C. H, S.—Discussion on shock, R.S.M. Disc. (Shock) 31
Fraser, J. S.—Fracture of the base involving right middle and inner ear, Otol. 104
-, fracture of the base with fracture dislocation of incus and rupture of roof of right
mastoid antrum, Otol. 110
-, otosclerosis associated with fragilitas ossium and blue sclerotics, with a clinical report
of three cases, Otol. 126-131
-with otitis media, Otol. 115, 133
-, two cases of fracture of the base followed by otitis media, meningitis and death,
Otol. 103
--and Garretson, W. T.—The radical and modified radical mastoid operations: their
indications, technique, and results, with notes on the labyrinthine and intracranial
complications of chronic middle-ear suppuration, Otol. 29
Fraser and Greenfield, method of preventing occurrence of ante-mortem intracardiac
thrombosis, R.S.M. Disc. (Infl.) 81
French, J. Gay.—P erithelioma of the right maxillary antrum, radium treatment
Laryng. 114
-, summary of case of foreign body in oesophagus, occurring at a Royal Naval Base
Hospital, Laryng. 13
-, two cases of dental plates removed from the oesophagus, Laryng. 12
French soldiers in Flanders, paratyphoid fever among, Epid. 24, 25
Frenkel’s methods, improvement of gait of tabetic patients under use of, a phase of psycho¬
therapy, Neur. 23
Freud, S., errors in doctrines of, Psych. 5, 6
-, suggestion and sex instinct, Psych. 20
-, support given to hedonism by, Psych. 6
—, theory as to origin of human conduct, Psych. 5
— , theory as to result of ungratified sexual desire, Psych. 43
-. theory of conversion hysteria, Ps)ch. 57
Friedliinder, A. and M’Cord, C. P., diagnosis of typhoid fever by atropine test, quoted,
Epid. 3
Index
li
Friedreich’s ataxy, hysterical element in, Neur. 23
Friends’ Ambulance Unit, antityphoid inoculation of Belgian civil population by, statistics,
Epid. 30
-, work done by, in treatment and suppression of enteric fever in Flanders (1914,
1915), Epid. 19, 20, 21, 28
Friesner mastoid rongeur in preparation of fragments in mandibular bone-grafting, Surg. 16
Frill operation in war injuries of orbit, Ophth. and Laryng. v
Frontal bone, ivory exostoses of, Ophth. and Laryng. lvi
-, osteomyelitis of, in children, causing orbital cellulitis, Ophth. and Laryng. liii, lv
-- sinus abscess, treatment by suction, Ophth. and Laryng. lviii
-and ethmoid communicating with orbit in cases of severe injury to frontal sinus,
treatment, Ophth. and Laryng. xii
-and orbit, gunshot wounds involving, case histories and treatment, Ophth. and
Laryng. xiii, xiv, xvi, xvii
-, deformity left after wound and operation on, method of overcoming, Laryng. 136
-, ethmoid and orbit, injury to, Ophth. and Laryng. viii
-antrum and orbit, injury to, Ophth. and Laryng. viii
-, floor of, severe injury to, with deficiency of roof of orbit, removal of eye for, Ophth.
and Laryng. xii
-, fracture of outer wall of, with emphysema of forehead and left temple, Path, 62
-, gunshot and other wounds of, injuries to eye in, Ophth. and Laryng. xxxii.
-injury, treatment, operative, Ophth. and Laryng. xxxix
-wounds of, intranasal drainage in, Ophth. and Laryng. xxvi
-, treatment, operative, Ophth. and Laryng. xxvi
-, injury to, causing cerebral abscess ; recovery, Ophth. and Laryng. vii
-, followed by acute frontal sinusitis, Ophth. and Laryng. liii
-- 1 difficulty of operating iu cases of, Ophth. and Laryng. liii
-, mucocele of (G. W. Dawson), Laryng. 153
-, osteomyelitis of, after operation, Otol. 3
-, right, absence of, radiograms showing (A. J. Hutchison), Laryng. 168
-, roof of, ivory exostosis growing from into orbital and cranial cavities, removed
through osteoplastic opening in cranium (William Lang and Donald Armour), Ophth. 16
-, wounds of, followed by blindness, Ophth. and Laryng. lii
-sinuses, both, shell wound of, case history, Ophth. and Laryng. xliv
-, suppuration, chronic, following gunshot wounds involving orbit and frontal sinuses,
Ophth. and Laryng. xi.
-sinusitis, acute, following on injury to sinus, Ophth. and Laryng. liii.
-, with swelling of middle turbinal, Ophth. and Laryng. lviii ; lavage of sinus
contra-indicated, Ophth. and Laryng. lviii, lx
-, treatment without operation, Ophth. and Laryng. lviii
Fruit, raw, consumption of, benefit from, Child. 30
Fry, W. Kelsey.—P rosthetic treatment of old injuries of the maxillse, Odont. 73-94.
Fulguration, after-effects, Electr. 27
-and diathermy combined, in treatment of malignant disease, Electr. 25
--, distinction between, Electr. 24
——, electrodes used in, Electr. 23
-in treatment of malignant disease (C. E. Iredell and Philip-Turner), Electr. 23
-, duration of, Electr. 24
-, process of, described, Electr. 23
-spark, erratic nature of, Electr. 23
-, treatment by, of epithelioma of mouth or tongue, Electr. 27
-of rodent ulcer, Electr. 28
Functions in abeyance expressed in anatomical arrangements of structure, Neur. 5
Fundus changes in sympathetic ophthalmitis (R. Foster Moore), Ophth. 25
-in sympathetic ophthalmitis, form assumed by, Ophtb. 29-32
lii
Index
Fundus changes resulting from war injuries (William Wallace), Ophth. 24
Fuse factory, eye accidents and burns more frequent among women in shell factory than in,
Epid. 52
-, sprains more frequent in women than men at, Epid. 51
Gall-bladder and bile-ducts, relations to surrounding structures, radiogram showing, Electr.
78
-and common bile-duct, situate in different planes, Elect. 78
-, portion below inferior border of liver, radiogram demonstrating, Electr. 78
-, projecting below liver with well-defined shadow of gall-stone, Electr. 79
-, radiography, absorption by tissues in first two or three inches, Electr. 80
-, with anatomical relationships, radiogram demonstrating, Electr. 78
Gallie, W. E., Captain, C.A.M.C. —Discussion on bone-grafting (abstract), Surg. 22
——, and Robertson, D.E., osteogenetic properties of transplanted bone, quoted, Surg. 13
Galloway, Sir James, K.B.E., C.B.—Discussion on case for diagnosis, Derm. 31
-, discussion on case of arsenical pigmentation and hyperkeratosis, Derm. 32
-, of Delhi boil, Derm. 71
--, of Dercum’s disease, Derm. 36
- , of dermatitis herpetiformis, Derm. 20
-, of epithelioma of face, Derm. 3
-, of erythrodermia with lymphatic leukaemia, Derm. 56
- f of multiple idiopathic haemorrhagic, sarcoma of Kaposi (miscalled), Derm. 51
-, of keratosis follioularis, Derm. 70
-, of lichen obtusus corneus, Derm. 18
-——-, of melanotic naevo-carcinoma, Derm. 43
-, of multiple benign tumour-like new growths. Derm. 23
-, of senile tuberculosis cutis, Derm. 19
--, of tuberculosis cutis of six years’ duration, Derm. 10
-on circinate persistent erythema multiforme, Derm. 9
-, on guttate morphcea, Derm. 5
-, on unilateral band sclerodermia and morphcea sclerodermia, Derm. 45
-, on urticaria pigmentosa, Derm. 1
-, on white-spot disease (morphcea guttata), Derm. 25
Gall-stone, liver substance casting denser shadow than, Electr. 79
Gall-stones and kidney, relationship between, radiogram showing, Electr. 82
-and renal calculi, X-ray diagnosis between, Electr. 81
-, chemical composition as affecting radiography, Electr. 83
-, cholesterin, and liver tissue, relative density, radiograms showing, Electr. 84
-, diagnosis, differential, Electr. 84
-, complications in, radiograms showing, Elect. 82
-- in gall-bladder of patient after taking opaque meal, Electr. 81
-, or bile-duct, correct diagnosis important, Electr. 76
-in patient, X-ray demonstration of, method shown, Electr. 80, 81
-, radiogram of, taken with penetration scale, Electr. 79
-, radiograms of, Electr. 84
-, kind of tube best suited for taking, Electr. 85
-, position of patient for taking, Electr. 83, 85
-, radiography, correctness and speed in exposure, Electr. 84
-, discussion on, Electr. 76-86 (Captain Backman, 85; F. Hernaman-Johnson, 85 •
Robert Knox, 76 ; Dr. Richardson, 85; R. W. A. Salmond, 83)
-, essentials for, Electr. 83
-, position for examination of patient, Electr. 78
-, value of doubtful shadows in, Electr. 77
-, suspected, inflation of intestine with air in case of, Electr. 85, 86
Index
Hit
Gall-stones, symptoms caused by, differential diagnosis from other conditions, Electr. 76
-, X-ray diagnosis from empyema, radiogram showing, Electr. 82
Galvano-cautery or puncture in treatment of enlarged or diseased tonsils, Laryng. 245, 247
-puncture of cyst of larynx, Laryng. 195
Galvanometer for recording body tefnperatures measured by electrical methods, Elect. 55
-, sensitive, deflection by electric potentials developed in heart, Electr. 64
-, string, complete series of deflections of, demonstrated by single heart-beat, Electr*
65, 66
- -, demonstrations of irregularities of heart's action by, Electr. 66, 67
-, invention of, felectr. 64
-, priority in, Electr. 70
-, microphone connected with, record of heart sounds obtained from, Electr. 67
Galyl, average number of doses necessary to bring aoout negative Wassermann reactions in
syphilitic infants, Obst. 10, 11
-in glucose, intramuscular injections in anti-syphilitic treatment of infants, Obst. 10
-, intravenous injections, in treatment of syphilis in mothers, Obst. 9
Gamgee, Arthur, study of body temperatures, quoted, Electr. 55
-, thermometers employed by, in testing body temperatures, Electr. 55, 56
Gangrene following diphtheria, Child. 89
-of fingers complicating chorea (Mrs. Chodak), Child. 87
-, cause of gangrene discussed, Child. 88, 89, 90
Gargles, in treatment of influenza, R.S.M. Disc. (Infl.), 92
Gargling, as prophylactic against influenza, R.S.M. Disc. (Infl.) 102
Garuetson, W. S., and Fraser, J. S.—The radical and modified radical mastoid operations ;
their indications, technique and results, with notes on the labyrinthine and intracranial
complications of chronic middle-ear suppuration, Otol. 29
Garrulitas vulvas, Path. 53
Gas blebs, covering wall of small intestine, from case of pyloric stenosis, Path. 46, 47, 48, 65, 66
- f pathogenesis, Path. 67
—— bubbles, appearance upon foreign body immersed in aerated water, explanation, Path.
69
-cellulitis, Path. 49
-. discharge from stomach in gout and hysteria, Path. 71
-, formation following perforation of vermiform appendix, intestine or stomach, and
producing pneumo-peritoneum, Path. 50
-gangrene, Path. 49
-, deaths from, attributed to shock, B.S.M. Disc. (Shock), 17
-gland of Ophidium, Path. 67
-in peritoneal cavity without perforation of stomach or intestine, Path. 71, 72
—*— introduced into connective tissue, question of intussusception by its cells in gaseous
form, Path. 67
-meter, as means of measuring vital capacity of pilots, Epid. 38
-, minute escape from each puncture during application of purse-string suture to
distended colon, Path. 73
-production in vaginal wall in vaginitis emphysematosa, Path. 49
-, cause of. Path. 49
-, question of liberation from tissue-lymph. Path. 68
-, secretion of, in swim-bladder of .fish, Path. 67
-, supposed visible secretion from skin during submersion of body, Path. 68
Gases liberated in blood in caisson disease, origin of, Path. 68
-, passage from lumen into intestinal wall, and from intestinal wall into lumen, Path. 70
Gassing at Front, symptoms produced by, similar to those of heliotrope cyanosis in influenza,
R.S.M. Disc (Infl.), 99 '
-complicated by emphysema of neck, Path. 57
--followed by compensatory emphysema of lung, Path. 58
liv
Index
Gastro-infcestinal tract, infection of, relationship of amount of shock and its consequences to,
R.S.M. Disc. (Shock), 26, 27
Gastroscopy for scarf-pin in stomach, expelled by vomiting (C. G. Woakes), Laryng. 10
Gastrostomy in case of dilatation of oeesophagus without anatomical stenosis, death from
shock, Laryng. 62
-in treatment of cardiospasm, Laryng, 56
Gauze masks, wearing of, by all in attendance on influenza cases, R.S.M. Disc. (Infl.) 102
Gelignite, charge of, explosive effect on fish in tank, Neur. 41, 42
General practitioner, midwifery fees of, underpaid, Obst. 96, 103, 104
-, teaching of obstetrics and gynaecology from point of view of (Lovell Drage), Obst. 49
Generative organs, physiology, teaching of, Obst. 34
Genital tract, female, infections of, knowledge of, highly important, Obst. 50
Genito-urinarv tract, entrance of air into, pneumatoses due to, Path. 50
-, presence of air in, Path. 52
Genius, association of bodily malformations with, Otol. 23, 24
German children, breast fed, Child. 41
-prisoners, good development of jaws and dentures among, Child. 40
-shells, with mixed and layered fillings, demoralizing effects of, Neur. 46
Germany, paratyphoid fever A and B in, before war, Epid. 26
-, poorer classes of, main article of diet, Child. 41
Gibb, J. A.—Discussion on naso-pharyngeal growth, Laryng. 209
Gibbons, R. A.—Discussion on high maternal mortality of child-bearing, Obst. 106
Giddiness following labyrinthectomy, cause of, Otol. 102
Giles, Arthur, E.—Discussion on extra-uterine pregnancy, Obst. 181
Gilliatt, W.—Obstructed labour due to ventrifixation, Obst. 216
-, two cases of full-term extra-uterine gestation, Obst. 177
Gillies, H. D.—Discussion on injuries and inflammatory diseases affecting the orbit and
accessory sinuses, Ophth. and Laryng. xliv
Gingivitis, hypertrophic, septic, Child. 71
Glandular swellings, multiple, case of, blood-count in, Child. 91
-(? lymphadenomatous) (Edmund Cautley), Child. 91
Glasgow, measles epidemics in, amplitudes, Epid. 90, 91, 95
-(1872-1917), course of, Epid. 93, 94, 95
Glaucoma associated with epithelioma of antrum, Ophth. and Laryng. xxxvi
-with haemorrhages in retina, Ophth. and Laryng. xxxviii
-, treatment by diathermy, Electr. 32, 33
-, method of conducting current to eye, Electr. 39
Globoid bodies, associated with encephalitis lethargica, Med., Path, and Epid. iv, v
Glucose-stovaine solution in spinal anaesthesia, Ansesth. 12
-, specific gravity, Ansesth. 13
-, superiority of saline-stovaine solution over, Anaesth. 13
Glycerine and liquid glucose, application in treatment of atrophic rhinitis with ozaena,
Laryng. 227, 229
-, application in treatment of atrophic rhinitis with ozaena, results in ten
cases, Laryng. 231
-and liquid perchloride of iron, application as paint to adenoids, Child. 43
-and sugar, application in treatment of atrophic rhinitis, with ozaena, previous records of,
Laryng. 230
-, application, in treatment of atrophic rhinitis with ozaena, scientific basis of, Laryng.
228, 233
Glycophylic method of treating atrophic rhinitis, with ozaena (C. H. Hayton), Laryng. 1S4
(T. H. C. Benians and C. H. Hayton), Laryng. 227-234
-, four cases undergoing (C. H. Hayton), Laryng. 184
Goadby, Sir Kenneth, O.B.E.—Discussion on influenza, R.S.M. Disc. (Infl.) 32
Godlec, Sir Rickman, cases of gas in peritoneal cavity, without perforation of stomach or
intestine, quoted, Path. 71, 72
Index
lv
Goitre, exophthalmic, alopecia of scalp and eyebrows in association with (H. W. Barber),
Derm. 41
-, developing during treatment by diathermy, Electr. 36
Goldsmith, Harvey.— Angioma of retina, Ophth. 3
Goldsmith, PerRy G.—Discussion on adherent palate, Laryng. 151
-on alternatives to operations for adenoids and enlarged tonsils in young children,
Laryng. 218
-on bilateral ankylosis of vocal cords, Laryng. 161
-on case of acute mastoiditis followed by thrombosis of internal jugular vein,
Otol. 10 .
---of acute osteomyelitis of right temporal bone, Otol. 3
-of double facial paralysis, due to bilateral tuberculous mastoiditis, Otol. 7
-— of sarcoma of nose, Laryng. 163
-on chronic middle-ear suppuration, Otol. 14
-on dermoid fistula of nose, Laryng. 103
-on functional aphonia, Laryng. 31
-on two cases of radical mastoid operation for cholesteatoma, Otol. 12
Gonorrhoea, cases in early stages, reception into department for diseases of women, Obst. 43
Goodall, E. W. —Discussion on Sydenham as an epidemiologist, Epid. 66
-, enteric fever in Flanders, 1914 and 1915 (Presidential Address), Epid. 15-34
Gottstein’s balloon in treatment of cardiospasm, Laryng. 53, 54
-, method of determining whether in position, Laryng. 54
Gout, discharge of gas from stomach in, Path. 71
Graham, George. —Case of severe rickets in a child of three years, Child. 103
-, discussion on case of trophoedema of leg, Child. 106
Graham, Captain.—Discussion on influenza, R.S.M. Disc. (Infl.) 57
Gram’s method, modified, used in staining sections from cases of pyorrhoea, Odont. 105, 106
Grant, J. Dundas. —Case of functional aphonia cf ten months’ duration with laryngitis,
Laryng. 30
-, case of functional aphonia of three months’ duration, Laryng. 29
-of incipient singer’s nodules in a vocalist, Laryng. 25
-of mutism of ten months' duration, Laryng. 29
—-of pharyngeal diverticulum, treated by dislocation and fixation in the upper part of
the neck, Laryng. 156, 166
-of polypus of larynx, removed with snare, Laryng. 165
-, discussion on case of chronic adhesive otitis, Otol. 96
-of paralysis of left vocal cord, Laryng. 182
-on chronic middle-ear suppuration, Otol. 14
-on four cases of atrophic rhinitis with ozeena undergoing treatment by glycophylic
method, Laryng. 185
-on dilatation of the oesophagus without anatomical stenosis, Laryng. 62
-on gunshot wounds of nasal accessory sinuses, Laryng. 242
-on mastoid operations, Otol. 56
-on new theory of hearing, Otol. 91
-on non-surgioal treatment of enlarged or diseased tonsils, Laryng. 245
-on tumour at base of tongue, Laryng. 184
-on sarcoma of left tonsil, Lairyng. 27
-, method of producing cough and expectoration by the inhalation of oleum sinapis,
Laryng. 26
-—, two cases of radical mastoid operation for cholesteatoma, with preservation of the
matrix (fourteen years and six months after operation respectively), Otol. 12 /
Granulomata from apices of teeth, micro-organisms in, demonstrated in sections from cases
of pyorrhoea, Odont. 114
Granulosis rubra nasi in boys, two cases (H. W. Barber), Derm. 40
-, treatment, Derm. 40
lvi
Index
Graves* disease, see Gfoitre, exophthalmic
Gray, A. M. H., C.B.E.— Case of angioma serpiginosum, Derm. 60
-of lupus erythematosus, Derm. 62
Gray, A. A.—Discussion on new theory of hearing, Otol. 88
-on otosclerosis associated with fragilitas ossium and blue sclerotics, Otol. 131
Gray, Charles, results of vaccine treatment of influenza, quoted, R.S.M. Disc. (Infl.) 82
Great Britain and Ireland, death rates per 1,000 births, from accidents and diseases of child¬
birth other than sepsis, Obst. 78
-from puerperal sepsis, Obst. 77
—-, epidemics of measles in, periodicities of {J. Brownlee), Epid. 77-120
-, large towns of, periodicities of epidemics of measles in (John Brownlee), Epid.
77, 120
Greenfield, J. Godwin. —Case of cervical concussion, shown for E. Miller, Lieut. R.A.M.C.,
Neur. 64
-, case of pachymeningitis,cervicalis of syphilitic origin, shown for E. Miller, Lieut.
R.A.M.C., Neur. 56
Greenfield and Fraser, method of preventing occurrence of ante-mortem intraoardiac
thrombosis, R.S.M. Disc. (Infl.) 81
GsnsNWOOD, M.—Discussion on causation and prevention of industrial accidents, Epid. 52
-on influenza, R.S.M. Disc. (Infl.) 21
_on periodicities of epidemics of measles, Epid. 119
_on some simple tests for physical efficiency, Epid. 45
-, Sydenham as an epidemiologist, Epid. 55
Gregarious impulse, Psych. 7, 20
Griffith, W. S. A.—Discussion on changes in uterus as result of procidentia, Obst. 20
-, discussion on treatment of natal and ante-natal syphilis, Obst. 13
-, a fibro-lipoma, weighing 13 lb. which invaded or originated in the right broad ligament,
Obst. 188
-, a general survey of subjects to be taught in obstetrics and gynaecology and methods of
teaching them to medical students, Obst. 33
Grimsdale, Harold. —Pulsating tumour of the orbit, of uncertain nature, Ophth. 35
Guinea-pig kept on scorbutic diet, fibrosis of dental pulp in, Odont. 32, 35
Guinea-pigs, intra-peritoneal injection of Choussy-Perrtere water into, effect, Bain. 4, 5
-, pregnant, effect of scorbutic diet on, Odont. 34
-suffering from scurvy resulting from scorbutic diet, teeth of, histological appearances,
Odont. 31, 32, 35
Gum saline, defects, R.S.M. Disc. (Shock) 26
-, injection in shock, R.S.M. Disc. (Shock) 3, 18, 19, 26, 33, 34
-, intravenous, in shock, R.S.M. Disc. (Shock) 18, 19
Gums, hypertrophy of, diffuse, Child. 70, 71
-, micro-organisms in, demonstrated in sections from cases of pyorrhoea, Odont. 110
Gunewardenb, T. H., and Weber, F. Parkbs. —New case of lipodystrophia, Child. 13
Gunshot fractures of jaw; bone-grafting in (W. Billington, A. H. Parrott and H. Rouud),
Odont. 55
-injuries of orbit and nose, dangerous nature of, Ophth. and Laryng. xxxviii
-injury of lachrymal apparatus, Ophth. and Laryng. lix
-wound of mandible with extensive loss of tissue treated by Colyer's method, oase
(F. N. Doubleday), Odont. 95
-of nose and eye, use of reversed pedicle forehead flap in, Laryng. 140, 142
-of sphenoid, cases of, Ophth. and Laryng. xii
-wounds involving antrum and orbit, case histories and treatment, Ophth. and Laryng.
xiv, xv, xviii, xix
-ethmoid and orbit, case histories and treatment, Ophth. and Laryng. xiv, xvii
-frontal sinus and orbit, case histories and treatment, Ophth. and Laryng.
xiii, xiv, xvi, xvii
Index
lvii
Gunshot wounds involving orbit and frontal sinuses, Ophth. and Laryng. xi
-of buttock, through and through, Proct. 48
— -of ethmoid region, Ophth. and Laryng. liii
-of great bowel and rectum (Arthur Keith), Proct. 47
-of jaw causing obliteration of buccal sulci, Odont. 18
-of maxillary antrum, Ophth. and Laryng. liv
-— of nasal accessory sinuses (J. F. O'Malley), Laryng. 241
-- of nose and nasal accessory sinuses, epidiascopic demonstration of methods of
treatment of (G. Seccombe Hett and D. Guthrie), Laryng. 135
-of orbit, Ophth. lvi
-with chronic dacryocystitis, case histories aud treatment, Ophth. and
Laryng. xv, xix, xx
Guthrie, Douglas.— Gases shown illustrating methods of treatment of gunshot wounds of
the nose and nasal accessory sinuses, Laryng. 135
-, choanal polypi in children : (1) a boy, aged 9, and (2) a girl, aged 12, Laryng. 153
-, discussion on epithelioma of left tonsil, Laryng. 102
Guthrie, Leonard. —Discussion on case of oxycephaly with symmetrical polysyndactylia.
Child. 9
- -discussion on case of achondroplasia with hydrocephalus, Child. 10
-on shortening of limbs on one side of body, Child. 7
-on deafness associated with stigmata of degeneration, Otol. 26
Gutta-percha, black, insertion, in case of openings of palate into nasal cavities, Odont. 74, 75
Guy’s Hospital, museum of, specimens of dilatation of oesophagus without anatomical
stenosis exhibited from (W. M. Mollison), Laryng. 72-74, 84, 85
Gynecological operations, performance by general surgeons, Obst. 50, 54
-surgery, relation to that of rest of abdomen, Obst. 7
Gynecology and obstetrics should not be separated for purposes of teaching and research,
Obst. 59
-, teaching of, simultaneously, Obst. 72
-, importance of, Obst. 42
-and physiology, connection between, Obst. 61, 74
-, case-taking in, Obst. 36
-. diagnosis, prognosis and treatment in, personal responsibility for forming correct
opinions as to, Obst. 37
-, diathermy in (C. E. Iredell and others), Electr. 16*
-, minor, importance of study of, to students, Obst. 38
-, obstetrics, maternity and child welfare, teaching in one lying-in hospital, Obst. 57
-. should be taught as part of course in surgery, Obst. 50
-, teaching of from standpoint of preventive medicine (J. S. Fairbairn), Obst. 40
-, in outpatient departments of hospitals, Obst. 36
-, methods, Obst. 35
— --■, order in which subjects should be taken, Obst. 35
-, to medical students and graduates in London, Obst. 108-134
--, scheme for, Obst. 122-129
-, training in, defective, consequences, Obst. 118-120
-, f efficient, bases of, Obst. 120-122
Haeckel, value of pinna in lower animals and man contrasted, quoted, Otol. 23
Hematuria in influenza complicating pneumonia, R.S.M. Disc. (Infl.) 69
Hemoglobin, combination of transport carbon dioxide of blood with, Path. 70
Hemolysis, doses of malarial complement producing, Med. 42
Hemorrhage, cause of death of mother in extra-uterine pregnancy, Obst. 155
-, control of, in difficult cases of enucleation of tonsils, exhibition of instruments to
simplify (Sydney Scott), Laryng. 215
Iviii
Index
Hemorrhage, control of, in gunshot wounds of nasal accessory sinuses, Laryng. 242
-during traumatic shock, R.S.M. Disc. (Shock) 31, 32
-, foci of, in brain and spinal cord in epidemic encephalitis lethargica, Epid. ii
-from lateral sinus after mastoidectomy, what is indicated by, Otol. 73
-from mastoid wound, treatment, Otol. 72
-in shock, treatment, R.S.M. Disc. (Shock) 16
- 1 post-operative, R.S.M. Disc. (Shock) 33
-into orbit in early stage of gunshot wounds of orbit and accessory sinuses, Ophth. and
Laryng. xxix
- into vitreous in acute stage of encephalitis lethargica, Neur. 64
-, intravaginal, of optic nerve in head injuries without fracture of orbit or optic foramen,
Ophth. and Laryng. lxiii
-, one cause of maternal mortality in childbirth, Obst. 83
-, retinal, slight, with glaucoma, Ophth. and Laryng. xxxviii
-, retroperitoneal (severe), after dilatation of cervix (H. R. Andrews), Obst. 199
-, risk of, in operations for full-time extra-uterine pregnancy, Obst. 183
-, secondary, cause of death of mother in extra-uterine pregnancy, Obst. 155
Haemorrhages in pulmonary type of influenza, Med. 55
-, multiple, punctate, in substance of brain, Neur. 36
Hair-cells, auditory, Otol. 81
Hairlets, auditory, bending of, how produced, Otol. 86
-, phases in completed movement of, Otol. 83
Haldane, J. S., condition termed “ anoxaemia,” by, R.S.M. Disc. (Infl.) 99
Half., A. J.— Discussion on epidemic encephalitis, Med., Path, and Epid., xv
Hall, F. de Havilland. —Discussion on paralysis of left vocal cord, Laryng. 182
- discussion on spasm at entrance to oesophagus, and clinical type of dysphagia,
Laryng. 236
Haller, case of emphysema of intestinal wall, quoted, Path. 76
Hallows, N., Captain, R.A.M.C.—Discussion on influenza, R.S.M. (Infl.) 41
Hamer, W. H.—Discussion on epidemic encephalitis, Med., Path, and Epid. v
-, discussion on influenza, R.S.M. Disc. (Infl.) 24
-on periodicities of epidemics of measles, Epid. 118
-on Sydenham as an epidemiologist, Hist. 72
Hammer-toe and otosclerosis, inheritance in one family, Otol. 131
Hand, left, loss of sensation in, injury to parietal region with (Henry Head, F.R.S.), Neur. 53
-, right, weakness and wasting of, in case of cervical ribs (Henry Head, F.R.S.),
Neur. 53
Handfield-Joneb, M.—Discussion on treatment of ante-natal and post-natal syphilis,
Obst. 14
Handley, W. S.—Case of recurrence in the posterior vaginal wall three years after abdomino¬
perineal excision for carcinoma recti, Proct. 46
-, case of tuberculous lymphangitis following injury to a tuberculous wart of long
standing ; complete excision in continuity of primary focus, infected vessels and
glands, Clin. 19
-, on the mode of spread of cancer in relation to its treatment by radiation, Electr. 41
Hapale , variations in position of teeth in, Odont. 54
Hapalidae, variations in position of teeth in, Odont. 53
Harmer, W. Douglas. —Case of tongue for diagnosis, Laryng. 198
-, discussion on case of epithelioma of tonsil after diathermy, Laryng. 170
—-of naso-pharyngeal angeiofibroma, Laryng. 175
-on dilatation of the oesophagus without anatomical stenosis, Laryng. 63
- and Jockes, T.— Specimens of Aspergillus fumigatus from nasal sinuses, Laryng. 187
Harris, results of hearing after radical mastoid operation, Otol. 42
Harrison, C. J., results of vaccine treatment of influenza, quoted, R.S.M. Disc. (Infl.) 82
Hart, Bernard. —Methods of psychotherapy, Psych. 13
Index
lix
Harvey, D.. Lieutenant-Colonel, C.M.G., B.A.M.C.— Discussion on outbreak of typhoid
fever in inoculated soldiers, Epid. 12
Hastings, Somerville. —Case showing method of repair of right side of nose, Laryng. 110
-, discussion on deafness associated with stigmata of degeneration, Otol. 26
-, discussion on foreign bodies impacted in food and respiratory passages, Laryng. 19
-, discussion on mastoid operations, Otol. 58
-on treatment of wounds of nose and nasal accessory sinuses, Laryng. 133
-, a tooth-plate impacted in the oesophagus divided by Irwin Moore’s cutting shears,
Laryng. 7
Haversian canals, open mouths of osteoblasts on, Surg. 22
-, osteoblasts in, Surg. 13, 16
Hawn, Clinton, B.—An outbreak of typhoid fever in inoculated soldiers, clinical study,
Epid. 1
Hayton, C. H.—Four cases of atrophic rhinitis with ozama undergoing treatment by the
glycophylic method, Laryng. .184
-, a method of treating atrophic rhinitis with ozaena based on an alteration in composition
and reaction of the substrate on which the bacterial ferments are acting, Part II,
Clinical, Laryng. 228
Hazeline cream, application, in treatment of burning, due to secondary radiation, Electr. 15
Head, Henry, F.R.S.—Cases with signs of neurological interest, Neur. 53
-, discussion on some simple tests for physical efficiency, Epid. 43
-, some principles of neurology (Presidential Address), Neur. 1
Head and limbs, forced movements of, due to sudden alteration of tension in middle-ear,
Otol. 100
-, operations on, dilution of blood during, in subjects of traumatic shock, R.S.M. Disc.
(Shock) 32
Headache, following stovaine amesthesia, Antesth, 6
-method of relieving, Ansestli, 7
--, frontal, complicating inflammatory diseases of orbit and accessory sinuses, Ophth. and
Laryng. xxvi, xxvii
-, malarial, Med. 25
-, area affected by, Med. 25
-, hyperalgesic lines and areas in, Med. 26
-, unilateral, in migraine, Ophth. 49
Health, Ministry of, maternity and childhood posts under, Obst. 52
-visitor, work of, in relation to pregnancy, Obst. 44
Hearing, before and after radical mastoid operation, Otol. 43
-condition of, an indication for modified radical mastoid operation in cases of chronic
middle-ear suppuration, Otol. 45, 46
-, effect of ossiculectomy on, Otol, 97
--of radical mastoid operation on, discussed, Otol. 53, 55, 56, 57
-. fixation of stapes in relation to, Otol. 90
-. good, associated with well-formed auricles, Otol. 18, 19
-, without tympanic membrane and ossicles, Otol. 91, 92
-. Helmholtz’s theory of, Otol. 81, 88
---, difficulties in acceptance of, Otol. 81, 83, 87, 88
-. mass-movement theory of, Otol. 92
-, new theory of (Professor Arthur Keith), Otol. 80
-(Sir Thomas Wrightson), Otol. 84
-, only opening in inner ear necessary for, Otol. 87
-, organ of, transformation of otic vesicle into, conditions necessary for, Otol. 82
-, sound and defective, respective proportions of well-formed and defective auricles in
those with, Otol. 19
-, state of, after modified radical mastoid operation, Otol. 47
-, before radical mastoid operation, Otol. 33, 45
lx
Index
Hearing, state of, in labyrinthitis complicating chronic middle-ear suppuration, Otol. 48
- tests employed in three cases of otosclerosis associated with fragilitis ossium and blue
sclerotica, Otol. 126
-, transmission of nerve-impulses in, Otol. 88
-, Wrightson’s theory of, Ophth. 81, 88
-, difficulties in acceptance of, stated, Otol. 88
-, objections to, Otol. 89, 92
-, supported, Otol. 89
He arson, Brigadier-General J. C.—Discussion on some simple tests for physical efficiency,
Epid. 44
Heart, action of, irregularities, demonstration by string galvanometer, Electr. 67
-, rapidity, extreme, in profound shock, R.S.M. Disc. (Shock) 11
-, unimpaired, with vascular contraction, in shock, R.S.M. Disc. (Shock) 11, 12
-and lungs, disease of, mental changes associated with, Neur. 4
-, “base” beat, record of, method of obtaining, shown experimentally, R.S.M. Disc.
(Shock), 26
-beat, single, demonstration of complete series of deflections of string galvanometer by,
Electr. 65, 66
-block, explanation of, Electr. 66
-blood, cultures from, in influenza, R.S.M. Disc. (Infl.) 52
-, capacity to All with blood during diastole, influence of bodily posture on, R.S.M. Disc.
(Shock) 25
-, congenital lesion in case of obstruction of central retinal artery (F. A. Juler), Obst.
59, 60
-, contraction, intense, in shock, R.8.M. Disc (Shock) 11
-, development of electric potentials in, deflecting sensitive galvanometer, Elect. 64
-, dilatation, accompanying muscular hypertrophy of oesophagus without dilatation y
Laryng. 99, 100
-, in fatal cases of influenza, R.S.M. Disc. (Infl.) 54, 56
-disease, indications and contra-indications for spinal anaesthesia in, Anaesth. 10
-, posture preferred by subjects of, R.S.M. Disc. (Shock) 25
-failure due to shock, successful massage in case of (Ashley Daly), Anaesth. 15
---, following change of position, case (R. E. Apperly), Anaesth. 17
--, fatty degeneration, complicating influenza, R.S.M. Disc. (Infl.) 56
-, inability to fill during diastole, experiments on sheep dealing with, R.S.M. Disc. (Shock y
24, 25
-, owing to deficient volume of blood in circulation, R.S.M. Disc.
(Shock) 24
-, massage of, in treatment of sudden collapse during laparotomy under ether, case
(F. E. Shipway), Anaesth. 17
- 1 successful case (Llewellyn Powell), Anaesth. 17
-, treatment by, of sudden collapse during laparotomy under ether, case ;(F. E.
Shipway), Anaesth. 17
-, pathological-anatomical changes in influenza, Med. 65
-, position in chest, influence of bodily posture on, R.S.M. Disc. (Shock) 25
-, post-mortem appearances in pneumonia complicating influenza, R.S.M. Disc. (Infl.
36, 37
-, right, air driven experimentally from, through lungs into left, experimentally, in cat.
post-mortem. Path, 64
-sounds, detection by auscultation, Electr. 68
-, record of, obtained by string-galvanometer, connected with microphone, Electr. 67
Heat, cold and pain, excited by same temperature, Neur. 10
Heath, Charles J.—Discussion on mastoid operations, Otol. 53
-, discussion on septic infection of lateral sinus injured during mastoidectomy, Otol. 75
Heath, Christopher, case ofimultiple epulides, quoted, Child, 68, 69
Index
lxi
Heatstroke as factor in production of mental disease in war, Psych. 39
-, comatose malaria wrongly diagnosed as, Med. 39
Hbdley, J. P.—Discussion on extra-uterine pregnancy, Obst. 183
Hedonism, definition of. Psych. 3
-, support given to, by Freud, Psych. 6
Height, bodily, in relation to length of normal oesophagus, Laryng. 49
Heine-Medin disease, diagnosis of encephalitis lethargica from, Med., Path, and Epid. ii
-, relation of encephalitis lethargica to, Med., Path, and Epid. xx. xxi
Heliotrope cyanosis in influenza, R.S.M. Disc. (Iufl.) 59, 98, 99
-, extreme fatality of, R.S.M. Disc (Infl.) 99
-, nature discussed, R.S.M. Disc. (Infl.) 98, 99
-, similarity to anoxaemia, R.S.M. Disc. (Infl.) 99
---to gassiDg at Front, R.S.M. Disc. (Infl.) 98, 99
- 1 treatment by any measure hppeless, R.S.M. Disc. (Infl.) 101
Helmholtz’s theory of hearing, Otol. 27, 80, 81, 88
Hemiplegia, hysterical and organic combined, following gunshot wound of skull, great
improvement with psychotherapy, case, Neur. 27
-, as war neurosis, Psych. 55
-, with persisting signs of organic disease following concussion by shell explosion
cured by psychotherapy, Neur. 27
-, involuntary movements in, explanation, Neur. 7
-, spastic rigidity in, Neur. 9
Hrpbubn, Malcolm.—D iscussion on fundus changes resulting from war injuries, Ophth. 25
Herd instinct, Psych. 7, 20
Hereditary tendency to adenoids, Child. 38, 40, 45, 47
-to otosclerosis, Otol. 126, 127, 130, 131, 132, 133
Heredity in relation to prevalence of dental caries, Odont. 27
-, problem of, clinical psychology in relation to, Psych. 11
Hebnaman-Johnson, F.—Discussion on radiography of gall-stones, Electr. 85
-, discussion on stereoscopic radiography in fractures of femur, Electr. 75
-, experiments on secondary radiation, quoted, Electr. 14
Hernia cerebri complicating osteomyelitis of temporal bone after operation, Otol. 1, 2
Heroin in influenza, Med. 71
Herpes complicating influenza, R.S.M. Disc. 62
-labialis in malaria, Med. 33
-zoster associated with arsenical poisoning among beer-drinkers, Clin. 18
Hetero-suggestion in hysterical tabes dorsaliB, Neur. 22
Hett, G. Secgombe.—C ases, casts, photographs, and diagrams, illustrating some methods of
repair of wounds of the nasal cavities aud nasal accessory sinuses, Laryng. 115
-, discussion on injuries and inflammatory diseases affecting the orbit and accessory
sinuses, Ophth. and Laryng. xi, lxv
-, epidiascopic demonstration of methods of treatment of gunshot wounds of the nose
and nasal accessory sinuses, Laryng. 135
-, methods of repair of wounds of the nose and nasal accessory sinuses, Laryng. 117, 136
Hiatus GBsophageus, contraction at rest, Laryng. 36
-, enlargement during swallowing, Laryng. 36
Hicks, J. Bbaxton.—R eport on specimen of carcinoma of uterus-cervix, in case of abnormally
long supra-vaginal cervix decreased in length, Obst. 20
High-frequency alternating currents, use in diathermy, Electr. 18
-currents, use in raising temperature of different parts of body, Electr. 62
Highland crofters, excessive tea drinking becomiog common among, Odont. 28
-, increase of tuberculosis among, presumed cause, Odont. 29
Highland Scotch, recruits from, state of teeth in those above and below 20 years of age
compared, Odont. 29
Hill, William.—D iscussion on adenoids, Child. 50
lxii
Index
Hill, William. —Discussion on bilateral ankylosis of vocal cords, Laryng. 161
-on case of adenoma of .vocal cord removed by thyro-fissure, Laryng. 148
-----of epithelioma of epiglottis treated by diathermy, Laryng. 158
-of pharyftgeal diverticulum treated by dislocation and fixation of upper part of
neck, Laryng. 157
-sarcoma of nose, Laryng. 163
--on choanal polypi in two children, Laryng. 154
-on dilatation of the oesophagus without anatomical stenosis, Laryng. 33, 66
-on epithelioma of left tonsil, Larynx. 102
-on foreign bodies impacted in food and respiratory passages, Laryng. 18
-on glycophylic method of troating atrophic rhinitis with ozuena, Laryng. 232
-on latent sinusitis in relation to systemic infectious, Laryng. 225
-on mastoid operations, Otol. 54
-on new theory of hearing, Otol. 91
-on non-surgical treatment of enlarged or diseased tonsils, Laryng. 246
-on pin in bronchiole of posterior lobe of right lung, Laryng. 11
-on sarcoma (?) of left tonsil, Laryng. 27
-- on sellar decompression for pituitary tumour, Laryng. 254
-on spasm at entrance to oesophagus aud clinical type of dysphagia, Laryng. 236
-, epithelioma of the tonsil and fauces in a woman aged 57, Laryng. 210
-, further notes of a case of diverticulo-pexy, Laryng. 155
-and Lees, R. A.—Fork accidentally swallowed and impacted in the pylorus, Laryng. 110
Hillier, W. T.-Discussion on specimens from case of purpura and on speoimen of liver
abscess, Child. 109
Hine, M. L.—Unusual case of ptosis with bilateral ophthalmoplegia externa, Ophth. 61
Hip disease, fixation of femur to acetabulum in case of, by means of bone spike, Surg. 30, 31
Hippocrates, a believer in miasma as opposed to contagion in epidemics, Epid. 71
Hirschsprung's disease, see Mega-colon
Histamine, action of, R.S.M. Disc. (Shock), 7, 8
-, nature of, R.S.M. Disc. (Shock) 7
-poisoning, experimental, changes in brain cells in, R.S.M. Disc. (Shock) 20
-, toxic agent, in surgical shock, R.S.M. Disc. (Shock) 3
Holland, Eardley. —Discussion on teaching of obstetrics and gynaecology, Obst. 59
-, the syphilitic placenta, Obst. 204-215
Holmes, Gordon. —Discussion on migraine, Ophth. 57
Hooke, Robert, law of clastic solids, Otol. 86
Hooks, safe patterns, for removal of foreign bodies from bronchi, Laryng. 20
Hope, C. W. M.—Discussion on delayed breaking of voice, Laryng. 197
Hopital du Sacre Cceur, Ypres, treatment of civilian cases of enteric fever at, Epid. 28
Hdpital Elisabeth, Poporinghe, fatality rate of typhoid and paratyphoid among cases
admittod to, compared, Epid. 27
-, proportion of cases of typhoid and paratyphoid fever admitted to, Epid. 25
-, treatment of civilian cases of enteric fever at. Epid. 28
Hopkins, J. G-— Discussion on influenza. R.S.M. Disc. (Infl.) 50
-, outbreak of typhoid fever in inoculated soldiers, Epid. 9
Hormone, production in blood of donor in transfusion, Med. 9
Horne, W. Jobson.— Case of delayed breaking of the voice, Laryng 196
-, cyst of larynx, Laryng. 195
-, discussion on case of laryngeal whistling, Laryng. 174
---of nasopharyngeal growth, Laryng. 209
---of tuberculous laryngitis, Laryng. 214
-— on foreign body removed from nose, Laryng. 160
-on normal histology of vocal cord and ventricle of larynx, considered in connexion
with development of adenomata, Laryng. 207
--on sarcoma (?) of left tonsil, Laryng. 27
Index
lxiii
Horne, W. Jobson.—D iscussion on submucous lipoma of palate and ilarynx, Laryng.
192
-, removal by the indirect method of a jagged piece of l>one impacted in the oesophagus,
Laryng. 171
Horse, aerophagy in, Path. 55
-, human acute infective polio-enceplialo-myelitis in, manifestations, Path. 39
-, mode of transmission, Path. 39
Horsford, Cyril.—D iscussion on case of adhesion and contracture of faucial pillars following
complete enucleation of tonsils, Laryng. 180
-, discussion on cyst of larynx, Laryng. 196
-on delayed breaking of voice, Laryng. 197
Hospitalization, immediate, of military cases of influenza, R.S.M. Disc. G3, 66
Hospitals, establishment of matorriity centre in, Obst. 43
-for diseases of women in London, utilization of clinical material at, Obst. 71
-, labour conducted in, low mortality from, Obst. 81
-, out-patient departments of, teaching of gynaecology in, Obst. 36
Host bone, close contact of bone graft to, important, Surg. 32
-, unilateral fixation of bone-graft to, Surg. 33
Hot weather, hysterical fainting in, cure, after original cause ascertained by anamnesis,
Neur. 16,17
Howarth, W. G.—Discussion on case *of epithelioma of epiglottis treated by diathermy,
Laryng. 159
-, discussion on complete removal of soft palate (staphylectomy), Laryng. 240
-on dilatation of the oesophagus without anatomical stehosis, Laryng. 64
-on gunshot wounds of nasal accessory sinuses, Laryng. 242
--on sarcoma (?) of left tonsil, Laryng. 27
-on sphenoidal sinus empyema in cerebro-spinal meningitis, Laryng. 252
-. sellar decompression for pituitary tumours, Laryng. 253
-, specimens of dilatation of oesophagus, Laryng. 71, 72
Howell, B. Whitchurch.--D iscussion on case of syphilitic bone disease, Child. 84
-, lymphangioma of the tongue, Child. 78
Hudson, A. C.—Folds in the internal limiting membrane of the retina, Ophth. 15
Hughes, Professor, action of microphone, quoted, Otol. 86
Humerus, fracture of, ununited, treatment by bone-grafting, Surg. 24, 27
--, method, Surg. 34
-, right, chronic suppurative osteomyelitis of, with contraction of visual fields, Ophth.
and Laryng. 1
Hunter, John, air-sacs of birds, quoted. Path. 61
-, description of closed tympanitic abscess due to gas-forming bacteria without perforation
of intestinal or respiratory tract, quoted, Path. 49
-, discharge of gas from stomach in gout and hysteria, Path. 71
-, question of assistance of air-sacs to birds during singing, quoted, Path. 63
-, specimen of intostinal emphysema in swine, Path. 84
Hunter, W., researches on inflammation, quoted, Med. 17
Hurst, A. F.—Cardiac achalasia, quoted, Laryng. 35
-, cause of cesophagectasia, quoted, Laryng. 37
- 9 and Symns, J. L. M.—The hysterical element in organic disease and injury of the
central nervous system, Neur. 21
Hutchison, A. J.—Discussion on non-surgical treatment of enlarged or diseased tonsils,
Laryng. 245
-, exhibition of electrodes for the treatment of ozsena of the nose by ionic medication,
Laryng. 257
-■, radiograms showing absence of right frontal sinus, Laryng. 168
Hydrocephalus in achondroplasia, case (H. C. Cameron), Child. 9
Hydronephrosis, mistaken for ovarian tumour, Obst. 7
lxiv
Index
Hygiene, public, requirements of otology in relation to, Otol. 52, 59
Hyoscine, see Morphine and hyoscine
Hyperesthesia in cardiospasm, Laryng. 50, 58
Hyperalgesia, cutaneous, in malaria, areas and lines of, clinical chart showing, Med. 28, 24
-, method of testing, Med. 24, 25
-, in trench fever, Med. 25
Hyperidrosis complicating chronic malaria, Med. 27
Hyperkeratosis and arsenical pigmentation occurring in course of dermatitis herpetiformis
(E. G. Graham Little), Derm. 31
Hypertrichosis in mentally defective child (E, Bronson), Child. 22
Hypnosis, light, in treatment of amnesia occurring in war neurological cases, Psych. 56, 60
Hypoleucocytosis and hyperleucocytosis, alternation of, under influence of thermal treat¬
ment, Bain. 8
Hypoblastic structure, defective development, Otol. 22
Hypopituitarism (pituitary tumour) (L. V. Cargill), Ophth. 41
Hysterectomy, death-rate from, at Samaritan Free Hospital (1884), Obst. 7
Hysteria and neurasthenia, no fundamental difference between, Neur. 14
-developing into neurasthenia, Neur. 14, 15
-, discharge of gas from stomach in, Path. 71
-, manifestations of, spontaneous cure followed by appearance of neurasthenic manifesta¬
tions, case illustrating, Neur. 15
-, pure, mistaken diagnosis of sarcoma of membranes of spinal cord in case of, Psych. 64, 65
-, worst and mild cases, contrasted, Psych. 66
-, see also Conversion-hysteria
Hysterical element, development in subjects amenable to suggestion causing perpetuation of
organic paralysis, Neur. 24, 25
-in organic disease and injury of central nervous system (Arthur F. Hurst and J.
L. M. Symns), Neur. 21
- paralysis of arm in soldier, therapeutic superiority of analysis over suggestion and
persuasion in dealing with, indicated, Psych. 29, 80
Ice, melting, immersion of cold junction of thermo-couple thermometer in, Electr. 61, 63
lchthyol and vaseline, application in atrophic rhinitis with ozsBna, Laryng. 186
Ideas, communication of, grounds for belief of, Psych. 15, 16
ldeo-motor action, theory of. Psych. 3
Ileal stasis, X-ray diagnosis, Electr. 11
Ileum, wall, emphysematous condition, experimentally produced at autopsy, Path. 73
Iliac crest as mandibular bone-graft, Surg. 18
-, suitability, Surg. 16, 17
-, as transplant graft in ununited fractures of mandible, Odont. 96, 97
-, method of obtaining for grafting, Surg. 17
-, site for obtaining bone-graft, for gunshot fractures of mandible, Odont. 61
-, gland, metastases in, microscopical appearance. Path. 18 »
Illness, acute, predisposing cause of war psychoses, Phych. 39
Illumination, artficial defective, as factor in causation of industrial accidents, Epid. 51
Immobilization in ununited fractures, Surg. 30
Immunity and mineral water treatment (Paul Ferreyrolles), Bain. 1-12
Implantation-epithelioma of lip following malignant disease of palate, Laryng. 170, 171
Impression tray, made in two parts, Odont. 74
Impulses, primary, as differentiations of one fundamental energy, Psych. 8
Incisors, irregularity in position in Caliithr%x t Odont. 51
——, mandibular, filling under submucous anaesthesia, Odont. 2
-, occlusion in specimens of Lagothrix , Odont. 45
-, maxillary and mandibular, irregularity in position in Nyetipithecus (unclassified),
Odont. 52
Index
lxv
Incisors, upper, distance of hiatal oesophagus from, Laryng. 48, 49
Incus, fracture dislocation of, in case of fracture of the base of skull (J. S. Fraser), Otol. 110
Indian mutilation type in loss of alae, tip and columnella, operation for, Laryng. 120
India-rubber container of thermo-electric couple thermometer, Electr. 60
Inductance coil in diathermy apparatus, Electr. 21
Industrial work, capacity of women for, Obst. 63, 64
-, during pregnancy, Obst. 64
Infant, congenital teratoblastoma (rhabdomyoma) of vulva in, Obst. 190
-, rickety, enamel organ of, microscopical appearances, Odont. 34
Infant Welfare Centres, Obst. 113
-, departments, Obst. 54, 55
Infants, artificial feeding, instruction in, Obst. 35
-, calcification of teeth in, effect of artificial light on, Odont. 36
-, congenital syphilitic, artificial feeding of, Obst. 10, 11
-, mortality under treatment at Thavies Inn Venereal Centre, Obst. 11, 12
-, percentage dying within first year of life, Obst. 9
-, treatment at Thavies Inn Venereal Centre, Obst, 9
--, results, Obst. 11, 12’
---, Wassermann reaction in, becoming negative under treatment, Obst. 11, 12, 15
-, female, idiopathic distension of bladder in, museum specimens showing, Laryng. 58
-, hygiene and diseases of, teaching of, combination with teaching of obstetrics, Obst.
45, 46
-, mortality of, high, associated with Leber’s disease, Ophth. 23
-, in relation to given number of conceptions, Obst. 56
-, reduction by obstetrical operations, Obst. 56
-, new-born, narrowness of nasal passages and naso. pharynx in, Child. 32
-, of Scottish Lowlanders, rickets and scurvy prevalent among, Odont. 29
-, scurvy among, cause of, Odont. 24
-*, unborn, prevention and treatment of syphilis in, by means of anti-syphlitic treatment
of mothers, Obst. 9
-, Wassermann reaction in, positive becoming negative quicker than in older children,
Obst. 15
-, with rickets, fatness of, Odont. 26
-, to be forbidden use of “ dummy,” Odont. 26
-, young, pathology in, teaching of, Obst. 35
Infanticide, medical responsibility in, teaching of, Obst. 55
Infantile, mortality, high, associated with Leber’s disease, Ophth. 23
Infections, systemic, latent sinusitis in relation to (P. Watson-Williams), Laryng. 220
Infectious diseases, increasing control of, R.S.M. Disc. (Infl.) 17
Infiltration-anthsthesia, submucous, in dental operations, Odont. 2
Inflamed part, heat in, never above that of other parts of body, Med. 17
Influenza, aetiology, R.S.M. Disc. (Infl.) 1
-, afebrile, fatal type, R.S.M. Disc. (Infl.) 65
-and cerebro-spinal meningitis, association between in military camps, Epid. 72
-, identity of origin, Med., Path, and Epid. vi
-, relationship between, R.S.M. Disc. (Infl.) 25
-and other epidemic diseases, connecting link between, dispute as to, R.S.M. Disc. (Infl.)
25
-and poliomyelitis, relationship between, R.S.M. Disc. (Infl.) 24
-and pulmonary tuberculosis, relationship between, R.S.M. Disc. 69
-, annual death-rate in England and Wales (1847-1917), R.S.M. Disc. (Infl.) 6
-as clinical entity, R.S.M. Disc. (Infl.) 3
-, Bacillus influenza associated with, R.S.M. Disc. (Infl.) 31, 38, 44, 45, 47, 51, 55, 57, 80,
93, 94
-, bacteriology of, R.S.M. Disc. (Infl.) 30, 31, 32, 35, 44, 50, 55, 79, 80, 94
5
lxvi
Index
Influenza, bacteriology of, in fatal cases, R.S.M. Disc. (Infl.) 44, 45
-and non-fatal cases, R.S.M. Disc. (Infl.) 33
-, blood cultures in, results, R.S.M. Disc. (Infl.) 35
——, blood examination in, R.S.M. Disc. (Infl.) 33, 43
-, bronchitis and pneumonia, deaths from, in London compared, 1889-92, 1915-18, R.S.M.
Disc. (Infl.) 4, 5, 69
-, broncho-pneumonic, consolidation in, Med. 63-65
-, cases of, charts illustrating, Med. 52, 57-64, 67-69, 73
-, causes of death in, R.S.M. Disc. (Infl.) 85 ; Med. 70
-, cerebro-spinal meningitis and encephalitis lethargica, association between discussed,
Epid. 72, 73, 75
-, clinical aspects, R.S.M. Disc. (Infl.) 59-67
-manifestations, Med. 51
-, complicated and followed by pulmonary tuberculosis, R.S.M. Disc. (Infl.) 67, 68
-by acidosis, R.S.M. Disc. (Infl.) 69
-by adenitis, Med. 68, 69
-by bronchitis, R.S.M. Disc. (Infl.) 61
-, purulent, R.S.M. Disc. (Infl.) 91, 97
-by broncho-pneumonia, R.S.M. Disc. (Infl.) 34, 45, 49, 55, 57, 61, 64, 65
—--by dilatation of heart, R.S.M. Disc. (Infl.) 54, 56
-by endocarditis, R.S.M. Disc. (Infl.) 45
——-by fatty degeneration of heart, R.S.M. Disc. (Infl.) 56
-by haemoptysis, R.S.M. Disc. (Infl.) 99
-by herpes, R.S.M. Disc. (Infl.) 62
-by leucopenia. R.S.M. Disc. (Infl.) 81
-by meningitis, R.S.M. Disc. (Infl.) 54
-by nephritis, R.S.M. Disc. (Infl.) 69, 100
-by peribronchial abscesses, R.S.M. Disc. (Infl.) 48
-by pericarditis, R.S.M. Disc. (Infl.) 56
-by pharyngitis, R.S.M. Disc. (Infl.) 62
-by pneumonia, R.S.M. Disc. (Infl.) 32, 36, 44, 45, 49, 57, 61, 63, 98, 99
-by serous haemorrhages in pericardium and pleura, R.S.M. Disc. (Infl.) 56
-by streptococcal empyema, R.S.M. Disc. (Infl.) 69, 70
-by subcutaneous emphysema, R.S.M. Disc. (Infl.) 60, 64, 100; Path. 57
-by vomiting, R.S.M. Disc. (Infl.) 78
-, complications, cause of, R.S.M. Disc. (Infl.) 92
-, consolidation of lung tissue in, Med. 62-65
-, cultures from lungs, post mortem in influenza, R.S.M. Disc. (Infl.) 52
-from organs other than lungs in influenza, R.S.M. Disc. (Infl.) 52
-from, sputum in, R.S.M. Disc. (Infl.) 53
-, definition of, R.S.M. Disc. (Infl.) 92
-, delirium in, R.S.M. Disc. (Infl.) 100
-, difficulty of preventive measures in war time, R.S.M. Disc. (Infl.) 2
-, diplococcus infection in, R.S.M. Disc. (Infl.) 31, 33
-, diplostreptococcus associated with, R.S.M. Disc. (Infl.) 41, 42, 80
-, discussion on, R.S.M. Disc. (Infl.) 1-102 (R. G. Abercrombie, 91 ; A. Abrahams, 97 ;
P. W. Bassett-Smith, C.B., C.M.G., R.N., 30-83; C. E. Cooper Cole, 85; F. G. Crook-
shank, 70; Sir Bertrand Dawson, 59; John Eyre, 93 ; Sir Kenneth Goadby, 32 ; Capt.
Graham, 57 ; M. Greenwood, 21; Capt. N. Hallows, 41; W. H. Hamer, 24 ; J. G. Hopkins,
50; R. Murray Leslie, 67; T. R. Little, 36; Col. Longcope, 64 ; G. Roche Lynch, 44 ;
T. A. Malloch, 45 ; Fred. M. Meader, 71; J. T. C. Nash, 92; Sir Arthur Newsholme,
1; G. Newton Pitt, 84 ; Sir Humphry Rolleston, 84 ; A. B. Soltau, 27 ; B. H. Spilsbury,
55; T. H. C. Stevenson, 19; Col. Stock, 29; W. S. Thayer, 28, 31, 61 ; H. Tilley, 67 !
E. B. Turner, 76, 87 ; H. E. Whittingham, 34)
-, epidemic, 1782, R.S.M. Disc. (Infl.) 32
Index
lxvii
Influenza, epidemic (1918), fatality, causes discussed, R.S.M. Disc. (Infl.) 23
-epidemic at Aldershot (June, 1918), R.S.M. Disc. 41
-, September, 1918, R.S.M. Disc. (Infl.) 41
-at Connaught Hospital, Aldershot, clinical features, R.S.M. Disc. (Infl.) 97
-, symptoms, R.S.M. Disc. (Infl.) 99, 99
-at Munich, 1889-90, R.S.M. Lect, (Infl.) 22
-, historical memoranda relating to, R.S.M. Disc. 21, 22
--, hopelessly fatal cases in, R.S.M. Disc. (Infl.) 84, 85
-i n American Army, (1918), R.S.M, Disc. (Infl.) 61
-in France (1918), R.S.M. Disc. (Infl.) 28
-, complicated by pneumonia, R.S.M. Disc. (Infl.) 29
-in British Army in France (1918), R.S.M. Disc. (Infl.) 27
-, effect on troops, R.S.M. Disc. (Infl.) 28
-, spread by re-distribution of troops, R.S.M. Lect. 28
-in London (1891, 1892, 1895, 1900), excess mortality due to respiratory diseases
occurring in, R.S.M. Disc. 20
-and Paris (1918), excess mortality due to influenza only, R.S.M. Disc. 20
-, intensity compared with that of previous epidemics, R.S.M. Disc. 19
-, mortality, age-distribution in, R.S.M. Disc. 20
-, date of appearance and disappearance, R.S.M. Disc. 21
-in Macedonia (Julius Burnford), Med. 49
-, cause of death in, Med. 61
-. course and termination, Med. 57
-, path of infection, Med. 51
-, pathological findings, Med. 61
-, pleural effusion in, Med. 57
-, respiratory compensation, Med. 59
-, treatment of cases, Med. 70, 71
-, ulceration of vocal cords in, Med. 59
-in Royal Air Force (1918), R.S.M. Disc. (Infl.) 22
-in Royal Navy stationed at Plymouth (1918), R.S.M. Disc. 30
-, complicated by acute pleuro-pneumonia and empyema.
R.S.M. Disc. 30
-in South Africa (1918), R.S.M. Disc. (Infl.) 29
-in 1918, incidence of workers in National Munition factories, R.S.M. Disc. 22, 23
-, severity variable, R.S.M. Disc. (Infl.) 84, 85
-, similarity to that of 1889-90, R.S.M. Disc. 64
-epidemics, 1889-90, 1891, 1892, 1893, 1895, cases simulating typhoid fever, R.S.M. Disc.
(Infl.) 18, 77
-- clinical features, R.S.M. Disc. 76-78
-, nervous sequelae of, R.S.M. Disc. (Infl.) 77
-, clinical convergence towards grave type of pneumonia in, Epid. 64
-, primary and secondary, R.S.M. Disc. 22
-, successive, time interval between, R.S.M. Disc. (Infl.) 23
-, epistaxis in, R.S.M. Dist. (Infl.) 62
-, fatal cases, post mortem appearances, R.S.M. Disc. (Infl.) 53-58
-, first general use of term, R.S.M. Disc. (Infl.) 22
-, followed by acute tuberculous broncho-pneumonia, R.S.M. Disc. (Infl.) 68
-, friability of lung tissue in, Med. 65, 66
-, heliotrope cyanosis in, R.S.M. Disc. (Infl.) 59
-, R.S.M. Disc. (Infl.) 98, 99
--, intercurrent, attack of, temporarily benefiting malignant disease of liver, Clin. 18
-, investigation of, desiderata in, R.S.M. Disc. (Infl.) 17
-, leucopenia in, R.S.M. Disc. (Infl.) 33
-, malaria diagnosed as, Med. 26
lxviii
Index
Influenza, Micrococcus catarrhalis and, R.S.M. Disc. (Infl.) 93
-, military cases, immediate hospitalization, B.S.M. Disc. (Infl.) 63, 66
---, isolation and segregation, diminishing prevalence of pneumonia, R.S.M. Disc.
(Infl.) 66
-, important, B.S.M. Disc. (Infl.) 66
-, mortality, age and sex distribution, B.S.M. Disc. (Infl.) 55
-, from, course of, in London (1890-1917), B.S.M. Disc. (Infl.) 7-10
-, from, since 1847, B.S.M. Disc. (Infl.) 5
-, muscle pains in, B.S.M. Disc. (Infl.) 65
-, nature of poliomyelitis allied to that of, Med., Path, and Epid. vi.
-, pandemic (1918), B.S.M. Disc. (Infl.) 10
-, pandemics, unknown causes of, B.S.M. Disc. (Infl.) 14
-, pathological anatomical changes in, Med. 65
-, pathology, B.S.M. Disc. (Infl.) 53
-, pneumococcus in, B.S.M. Disc. (Infl.) 31, S3, 44, 66, 93
-, pneumonia and bronchitis, relationship between, B.S.M. Disc. (Infl.) 24
-, post-mortem appearances in central nervous system, B.S.M. Disc. (Infl.) 57
-, prevalence of, association of poliomyelitis and encephalitis with, Med., Path, and
Epid. xii., xiii.
-, primary and secondary sources of infection in, B.S.M. Disc. (Infl.) 41, 43
-, problem of preventive measures in times of peace, B.S.M. Disc. (Infl.) 13
-, prognosis, B.S.M. Diso. (Infl.) 101
-, uncertain even in mild cases, B.S.M. Disc. (Infl.) 101
-, prophylactic inoculations against, B.S.M. Disc. (Infl.) 96
-, prophylaxis against, B.S.M. Disc. (Infl.) 102
-, by vaccines, R.S.M. Disc. (Infl.) 83, 84
-, pulmonary, complicated by emphysema of neck, Path. ^7
-type of, cause of death in, Med. 70
-, pathological findings, Med. 61
-, physical signs, Med. 55
-, significance of, Med. 56
--, symptoms in detail, Med. 53
-, relation of malaria to, Med. 71
-, of whooping-cough and measles to, B.S.M. Disc. (Infl.) 25
., secondary wave, question of, R.S.M. Disc. (Infl.) 11
-, secretions in, cultures from, R.S.M. Disc. (Infl.) 94
-, septiccemic factor in, R.S.M. Disc. 59, 60
-, spontaneous rupture of rectus abdominis muscle in, B.S.M. Disc. (Infl.) 100
-, staphylococcus associated with, R.S.M. Disc. 46, 50, 53, 80, 93, 94
stench from body in, R.S.M. Disc. (Infl.) 100
streptococcus infection in, R.S.M. Disc. (Infl.) 31, 33, 38, 44, 55, 66, 94
-, Streptococcus pyogenes longus associated with, R.S.M. Disc. (Infl.) 42
-, suddenness of onset, R.S.M. Disc. (Infl.) 61
symptoms, R.S.M. Disc. (Infl.) 59-66, 76
treatment, Med. 70
_by antipneumococcal and antistreptococcal sera, useless in virulent cases, R.S.M.
Disc. (Infl.) 101
___ 9 by antistreptococcic serum, R.S.M. Disc. (Infl.) 85, 86
_, by drugs, Med. 70, 71; R.S.M. Disc. (Infl.) 92, 93
_, by eusol, R.S.M. Disc. (Infl.) 86
_ 9 by gargling with izal and permanganate solution, R.S.M. Disc. (Infl.) 92
--, by mercury perchloride injection, R.S.M. Disc. (Infl.) 85
__, by salicin, R.S.M. Disc. (Infl.) 87-90, 92
___ 5 by salicylate of soda, R.S.M. Disc. (Infl.) 87
_ _, by specific drugs without action in, R.S.M. Disc. (Infl.) 100
Index
lxix
Influenza treatment, by vaccines, R.S.M. Disc. (Infl.) 29, 30, 35, 36, 78, 82, 83
--, unavailing in virulent cases, R.S.M. Disc. (Infl.) 101
-, by venesection, useless in virulent cases, R.S.M. Disc. (Infl.) 101
--, curative, R.S.M. Disc. (Infl.) 87
-dietetic, Med. 70
-, virulence of, influence of war upon, R.S.M. Disc. (Infl.) 16
-, virulent, prognosis, R.S.M. Disc. (Infl.) 101
—-, toxaemia of, Med. 67
-, treatment by attempted production of “ fixation abscesses/’ R.S.M. Disc. (Infl.) 101
- f of every kind hopeless, R.S.M. Disc. (Infl.) 101
- t unexpected recoveries from, R.S.M. Disc. (Infl.) 101
-, see also Respiratory disease, acute
Influenzal diseases, group of, spread of, application of law of parsimony to, R.S.M. Disc.
(Infl.) 26
-, common infective agency in, argument for, R.S.M. Disc. (Infl.) 26
Infra-orbital region, oedema of, treatment by lymphangioplasty, Ophth. and Larvng. lxii.
Ingals, cases of pins inhaled into the lung, quoted, Laryng. 16
Ingesta, reflex in stomach preventing entry of, Laryng. 99
Ingleby, Miss Helen.—D iscussion on epidemic encephalitis, Med., Path, and Epid. v.
-and Da Fano, 0.—Demonstration of preparations from cases of encephalitis
lethargica, Path. 42
Insanity, previous attacks concealed by recruits at medical examination, Psych. 37
-See also Mental disease
Instruments, new, recently designed for removal of foreign bodies from lungs by peroral
endoscopy ; demonstration (Irwin Moore), Laryng. 20
Internal organs, afferent impressions from, sensations produced by, under abnormal
conditions, Neur. 6.
International Medical Congress (1913), Sections of Laryngology and Otology of, resolution
carried by, Otol. 31, 51
Intestinal obstruction, acute, operation for, shock following, how combated, R.S.M. Disc.
(Shock) 27
-, administration of stovaine in, Anaesth. 10
-, fatal, following opium administration after abdominal operations, Obst. 4
-, operations for, when undertaken early, good results, Obst. 6
-, stasis, chronic, operation for, method of avoiding shock after, R.S.M. Disc. (Shock) 27
- -, complicating acne, general improvement effected by diathermy (H. W. Barber),
Electr. 37
Intestine, distension of, extreme, caecum presenting gaping rents in peritoneum, Path. 75
-, gunshot wounds of, closure or resection, undertaken early, good results of, Obst. 6, 7
-, human, mucosa of, non-sensitive. Path. 78
-, inflation with air for examination in case of suspected gall-stones, Electr. 85, 86
-, large, and rectum, gunshot wounds of (A. Keith, F.R.S.), Proct. 47
-, complete resection of, for multiple adenomata, case (J. C. Lockhart-Mummery),
Proct, 43 ; see also Bowels great
-, lumen of, effect on gases of air introduced into, Path. 70
-, mucosa of, air forced into the other tunics after damage to, Path. 73
-, passage of gases from lumen into wall and from wall into lumen, Path. 70
-, perforation of, gas in peritoneal cavity without, Path. 71
-, pneumo-peritoneum from gas formation following, Path. 50
-, rare among cases of enteric fever in civilian inhabitants of Flanders (1914-15),
Epid. 24
-, rupture of, operation for, when undertaken early, good results, Obst. 6
-, small, carcinoma of, primary, resemblance of carcinoma of appendix to, Surg. 41
-, evacuation of, as precaution against shock following operation for chronic
intestinal stasis, R.S.M. Disc. (Shock) 27
Ixx Index
Intestine, small, evacuation from, of toxic material to combat shock following operation for
acute intestinal obstruction, R.S.M. Disc. (Shock) 27
-, portion of excised, in case of pyloric stenosis, macroscopical and microscopical
appearances, Path. 65, 66
-, toxicity of portal blood in, R.S.M. Disc. (Shock) 26
-, wall of, diffusibility of carbon-dioxide, oxygen and nitrogen through, Path. 70
--—-, emphysema of, diffuse (C. A. R. Nitch and S. G. Shattock, F.R.S.), Path. 46
-in case of stenosis of pylorus, Path. 46, 47, 48
-, clinical history, and findings at operations, Path. 46, 47
-, examples recorded in earlier literature, Path. 75, 76.
--, pathogenesis, Path. 67-78
-, production post mortem and in living subject, Path. 73, 75
- : , in swine, Path. 84
-, local emphysematous or bullous condition after death at site of intestinal ulcer,
Path. 73
Intestines, binding up by opium injections to avoid risk of peritonitis (1884), Obst. 3, 4
-, micro-organisms present in, Obst. 102
—-, operations on, under spinal anaesthesia, Anaesth. 13
-, removal from pelvis, under influence of gravity (1884), Obst. 6
Intracranial complications of chronic middle-ear suppuration (J. S. Fraser and W. S.
Garretson), Otol. 29, 50
-, cholesteatoma in, Otol. 50
-, operations for, delay in, Otol. 50
. Intralaryngeal growth, laryngofissure with removal of, performed under gas and oxygen, case
(H. E. G. Boyle), Anaesth. 20
Intranasal drainage in operations on frontal sinus and ethmoids, Ophth. and Laryng. xxvi
——-in perforating wounds of antrum, Ophth. and Laryng. xi
—- infections, acute, treatment by radical measures, contra-indicated, Ophth. and Laryng. lx
-operations, eye diseases cured by, Ophth. and Laryng. lx
-treatment, relief following rapid, Ophth. and Laryng. lx
Intra-ocular growth, case (J. F. Carruthers), Ophth. 36
Intra-oral appliances in treatment of old injuries of maxillae, difficulties in taking impressions
for, and means of overcoming, Odont. 73-75
Intratracheal route, injection of new anti-tuberculous medicament in pulmonary tuberculosis
by, Therap. 3, 5
Intussusceptions, ileo-csecal, rupture of peritoneum investing ctecum during reduction.
Path. 75
Iodide, mercuric, painting with, in treatment of keratosis follicularis (Darier's disease),
Derm. 70
Iodine, application, in treatment of enlarged tonsils, Laryng. 244, 246
-, tincture of, gargling as prophylactic against influenza, R.S.M. Disc. (Infl.) 102
Iodoform worsted, packing cavity with, after radical mastoid operation, Otol. 39
Ionization of soft parts, as adjuvant in treatment of ununited fractures of mandible,
Odont. 58
-with sodium hypochlorite in treatment of Delhi boil, Derm. 71
Irk dell, C. E.—Diathermy in abdominal disorders, Electr. 34
-and Dowbe, G. M.—Notes on diathermy apparatus, Electr. 18
-and Ryley, C. Meadows. —Diathermy in diseases of the eye, Electr. 31
-and Turner, Philip.—T he treatment of malignant disease by diathermy and
fulguration, Electr. 23
- , MAB8TON, A. D., and Smi?h, G. Bellingham. —Diathermy in gynaecology, Electr. 16
Irido-cyclitis accompanied by pan-sinusitis, Ophth. and Laryng. xlvi.
-associated with septic trouble in nose, Ophth. and Laryng. xxxvi.
-, treatment by diathermy, Electr. 32, 33
Iritis associated with septic trouble in nose, Ophth. and Laryng. xxxvi, xxxvii
Index
lxxi
Iritis, cured by intra*nasal operation, Ophtb. and Laryng. lx
-, gonorrhoeal, treatment by diathermy, Electr. 32
-, rheumatic, treatment by diathermy, Electr. 32
-, treatment by diathermy, Electr. 32
Iron, liquid perchloride of, and glycerine, application as paint to adenoids, Child. 43
Ivory exostoses, growing from roof of frontal sinus into orbital and cranial cavities, removed
through osteoplastic opening in the cranium (W. Lang and D. Armour), Ophth. 16
-of frontal bone, Ophth. and Laryng. lvi
Izal, gargling with, in influenza, R.S.M. Disc. (Infl.) 92
Jackson, Chevalier, cases of inhalation of pins into the lung, quoted, Laryng. 15, 16
-, treatment of cardio spasm by mechanical divulsor, Laryng. 54
Jaeger, intestinal emphysema in swine, quoted, Path. 84
Jambs, S. P., Lieutenant-Colonel, I.M.S.—Discussion on epidemic encephalitis, Med., Path,
and Epid. viii
Jambs, W. Wabwick.— Case of multiple epulides (with report on sections by David Nabarro),
Child. 65
Janet, Pierre, belief as factor in treatment of neuroses, quoted, Neur. 13, 14
-, conception of mental dissociation, Psych. 4
-, synthetic energy of mind, quoted, Psych. 4
—, unconscious mental processes, quoted, Psych. 8, 9
Jaundice in malaria, Med. 33
-in spirochetosis icterohaemorrhagica, Med. 3
Jaw, gunshot fractures of, treatment by bone-grafting (W. Billington, A. H. Parrott and
H. Round), Odont. 55
-Injuries Centres, discharge form, necessity for unification, Odont. 9
-—-, short review of another year’s work at (George Northcroft), Odont. 7
-injuries, treatment under military service, lack of continuity in, Odont. 8
-, sarcoma of, treatment by diathermy, Electr. 29
-by radium, Laryng. 164
Jaws and dentures, good development among German prisoners, Child. 43
-, early use of, method of obtaining in ununited fractures of mandible, Surg. 12
-, gunshot wounds of, causing obliteration of buccal sulci, Odont. 18
-, fracture of, time of discharge after operation for, Odont. 8, 9
-, maldevelopment of, types associated with rickets, Child. 33
-, malformation of, types associated with nasal obstruction. Child. 32
-, various types of, causes, Child. 33
-of British, defective development, cause, Child. 29
-of Esquimaux, strength. Child. 29
Jenkins, G. J.—Discussion on new theory of hearing, Otol. 92
Jenkins, operation on thyroid followed by alopecia areata, quoted, Derm. 42
Jewell, W. H.—Case of infiltration and ulceration of the vocal cords (previously shown),
Laryng. 113.
-, tumour of right submaxillary region and floor of mouth ; ? actinomycosis, Laryng. 215
Jewesbury, R. C.—Discussion on case of adrenal growth, and case of multiple glandular
swellings; Child. 93
Jockes, T., and Habmer, W. Douglas —Specimens of Aspergillus fumigatus from nasal
sinuses, Laryng. 187
Johns Hopkins Hospital, Baltimore, teaching of obstetrics and gynaecology at, Obst. 70
Johnstone, R. W.—Discussion on teaching of obstetrics and gynaecology, Obst. 68
Joint, air entering, Path. 55
Jones, A. Rocyn. —Two cases illustrating effect of severance of the brachial artery, Neur. 33
Jones, Ernest, fear and desire for death in war psychoneuroses, quoted, Psych. 59
lxxii
Index
Jones, Hugh E.—Deafness associated with the stigmata of degeneration, Otol. 17
-, discussion on case of ‘acute mastoiditis followed by thromboses of internal jugular
vein, Otol. 11
-, of acute osteomyelitis of right temporal bone, Otol. 2
- f of circumscribed labyrinthitis, Otol. 100
— -, of double facial paralyses due to bilateral tuberculous mastoiditis, Otol. 7
— -. on necrosis of internal ear causing sequestration of labyrinth, Otol. 9
-, on new theory of hearing, Otol. 87, 93
-, on septic infection of lateral sinus injured during mastoidectomy, Otol. 75
Jones, Lawrence and Rolleston, Sir Humphry, cases of primary malignant disease of vermi¬
form appendix, quoted, Surg. 41
Jones, Sir Robert, case of fracture of bone-graft, quoted, Surg. 31-82
Jordan, A. C.—Discussion on examination of vermiform appendix by X-rays, Electr. 11
Jugular vein (internal), thrombosis of, as far as clavicle, following acute mastoiditis, recovery
(W. M. Mollison), Otol. 10
Juler, Frank.— Discussion on sympathetic ophthalmitis with fundus changes, Ophth. 32
-, obstruction of central retinal artery with patent branches, following electric flash,
Ophth. 58
Jung, C. J.— Advances in clinical psychology made by, Psych. 8
-, the problem of psvchogenesis in mental diseases, Psych. 63
Kangaroo tendon sutures, use in bone-grafting, Surg. 25
Kaposi, sarcoma of multiple idiopathic haemorrhagic (miscalled) (J. J. Pringle), Derm. 48
Katatonia, worst cases, product of badly administered and crowded asylums, Psych. 66
Katatonic seizures, sudden and violent, with sane intervals, cases illustrated, Psych. 67, 68
Keegan method of operation for loss of ala?, tip and columnella of nose, Laryng. 120, 121
Keegan-Smith method of operation for loss of alse, tip and columnella of nose, Laryng. 122
Keith, Arthur, F.R.S.—Demonstrations on a new theory of hearing, Otol. 80, 87, 89'
-, gunshot wounds of the great bowel and rectum, Proct. 47
-, capacity of blood-vessels for taking up fluid in shock, quoted, R.S.M. Disc. (Shock) 18
Kkllock, T. H.—Discussion on case of thoracic actinomycosis, Clin. 1
-, sarcoma of scapula, treated by radium, Clin. 3
Kelly, A. Brown.—C ase of cardiospasm, Epid. 56
-, condition possibly representing compensated achalasia or cardiospasm, quoted,
Laryng. 99, 100
-, discussion on dermoid fistula of nose, Laryng. 103
-, on dilatation of the oesophagus without anatomical stenosis, Epid. 48, 67
-, on recurring spheno-choanal polypus in child, Laryng. 107
—-, on removal of bone impacted in oesophagus, Laryng. 171
-, spasm at the entrance to the oesophagus, Laryng. 235
-, specimen of dilatation of oesophagus, Laryng. 78
-, three dental plates removed from oesophagus, Laryng. 27
Kelly’s speculum for cystoscopy of female bladder and ureteral catheterization, modus operandi ,
upon what dependent, Path. 53
Kklson, W. H.—Discussion on adenoids, Child. 51
-, discussion on adherent palate, Laryng. 151
-on case of acute osteomyelitis of right temporal bone, Otol. 3
-of chronic adhesive otitis, Otol. 97
-of laryngeal whistling, Laryng. 174
-on four cases of atrophic rhinitis with ozrena undergoing treatment by glycophylic
method, Laryng. 186
--on deafness associated with stigmata of degeneration, Otol. 26
-on dermoid fistula of nose, Laryng. 103
-on double facial paralysis due to bilateral tuberculous mastoiditis, Otol. 8
Index
lxxiii
Kelson, W. H.—Discussion on non-surgical treatment of enlarged or diseased tonsils,
Laryng, 247
-, disoussion on treatment of ante natal and post-natal syphilis, Obst. 15
-, pharyngeal diverticula with notes of two cases—in one of which the pouch was removed
under local anaesthesia, Laryng. 248
Keratitis, interstitial, formation of clear lines in nebulae following, Opth. 2
-punctata complicating sympathetic ophthalmitis, with fundus changes, Ophth. 26, 27
Keratoma, senile, case of (H. C. Semon), Derm. 65
-, treatment, Derm. 65
Keratosis follicularis (Darier’s disease), case of (J. L. Bunch), Derm. 67
-, first description of, Derm. 68
-, f treatment, Derm. 67, 69, 70
Kettle, E. H.—On polymorphism of the malignant epithelial cell, Path. 1-32
Kidney and gall-stones, relationship between, radiogram showing, Elect. 82
-capsule, incision of, in puerperal anuria, removal of portions of kidney substance for
examination, two cases (Clifford White), Obst. 27
-. cortex, necrosis in cases of puerperal anuria, Obst. 29, 30, 31
-disease, facial aspect of symmetrical generalized oedema simulating that of, Derm. 27
-, normal, section of, compared with sections from kidney in cases of puerperal anuria,
Obst. 29
-, radiography of, absorption by tissues in first two or three inches, Electr. 80
-, split open, with calouli and various deposits in interior, radiogram showing, Electr. 79
King, Miss C. A.—Discussion on syphilitic bone disease, Child. 84, 86
Knee and ankle jerks, loss of, conclusive sign of structural change in central nervous system,
Neur. 25
-, right, acute suppurative arthritis of, treated by mobilization method, case(J. Everidge),
Clin. 16
-joint, after-stiffness absent in treatment of fractures of femur, Electr. 73
—_ joints, suppurating, mobilization treatment of, model to demonstrate methods carried out
in (J. Everidge), Clin. 10-15
Knox, Robert. —Discussion on radiography of gall-stones, Electr. 76
Krompecher, basal-celled tumour of, resemblance of carcinomata of appendix to, Surg. 41. 42
Krister’s mastoid operation, Otol. 54
Laboratory methods employed, diagnosis of different varieties of enteric differs according to,
Epid.‘27
-, research work in ante-natal clinics, Obst. 55
Labour and pregnancy, dangers of, underrated by public, Obst. 65
-, maternal death-rate due to, in England and Wales and Scotland, Obst. 64
-, application of principles of surgical cleanliness during, Obst. 44.
-, case of, in paraplegic women (G. Drummond Robinson), Obst. 22
-, clinical instruction in, Obst. 110
-, conduct of, rubber gloves not a sufficient protection against infection at, Obst. 88, 90
-, conducted in hospitals, low mortality from, Obst. 81
-, considered as operation, Obst. 88, 104
-, dangers of, little regarded by the public, Obst. 85
-, discovery of contracted pelvis before, important, Obst. 73
-, foetus undergoing spontaneous evolution removed by laparotomy during (Clifford White),
Obst. 135
-in extra-uterine pregnancy, 100 cases, complications following on, Obst. 154
—-, percentage of occurrence, Obst. 153
-in women suffering from paraplegia, cases recorded, Obst. 25
-, major wound of, treatment by war methods, why unsuitable, Obst. 94, 95
-, natural termination of, should be waited for, Obst. 103
lxxiv
Index
Labour, normal, safest method of delivery in, Obst. 91
—obstructed, due to ventrifixation (W. Gilliatt), Obst. 216
-, method of delivery adopted, Obst. 217
-, pathology, teaching of, Obst. 35
-, physiological stimulus to, experimental work on, desirable, Obst. 26
-, presence of anaesthetist at, Obst. 90
-, severe, sterility following, Obst. 92
-, special points with regard to, teaching of, Obst. 35
-, wounds in, liability to infection, Obst. 92
La Bourboule, waters of, anti-anaphylactic power of, Bain. 8
-, lesions following experimental injection, Bain. 10
Labyrinth and cochlea, sequestration, in case of necrosis of internal ear, Otol. 9
-, auditory portion, analysing function discussed, Otol. 91
-capsule, origin of, Otol. 129
-, primitive, balancing apparatus of, evolution of ear from, Otol, 81
-, sequestration of, caused by necrosis of internal ear, recovery (W. M. Mollison), Otol. 8
-windows, microscopic examination in case of fracture of base of skull, involving middle
and inner ear, Otol. 108
-, with fracture dislocation of incus
and rupture of roof of right mastoid antrum, Otol. 113
-, ethmoidal, disease of, accompanying atrophic rhinitis with ozaena, Laryng. 233
Labyrinthectomy, case of (J. F. O’Malley), Otol. 101
-, technique employed, Otol. 101
-, giddiness following, cause of, Otol. 102
-, opening cochlea in, Otol. 102
Labyrinthine complications of chronic middle-ear suppuration (J. S. Fraser and W. T.
Garretson), Otol. 29
Labyrinthitis, associated with intracranial complications of chronic middle-ear suppuration,
Otol. 51
-, circumscribed, case of (J. F. O’Malley), Otol. 99
-, treatment suggested, Otol. 100
-, complicating chronic middle-ear suppuration, operation performed and result, Otol. 49
-, state of hearing in, Otol. 48
-, symptoms, Otol. 48
-, types of, Otol. 49
-, vestibular symptoms in, Otol. 48
-, purulent, following radical mastoid operation, fatal cases, Otol. 38
Labyrinthotomy in vertigo, obliteration of semi-circular canals and part of cochlea by bone,
case, Otol. 77
Lachrymal apparatus, gunshot injury of, Ophth. and Laryng. lix
-gland, primary nocardiasis of, caused by species of Nocardia hitherto undescribed,
case (J. B. Christopherson and R. G. Archibald), Ophth. 4
-, clinical history and description of case, Ophth. 4
— passages, gunshot injuries involving, Ophth. and Laryng. xxxv
- sac removed by intranasal route (H. Lawson Whale), Laryng. 179
-, suppuration, chronic, treatment, operative, Ophth. and Laryng. lxvi
-, following injury, Ophth. and Laryng. liv, lv
--, resulting from wounds of nose, Ophth. and Laryng, xii
Lactation, conditions interfering w'ith, demonstration to students, Obst. 38
-, function of, in rabbits, Obst. 27
- -, observations on, Obst. 26
-, knowledge as to, teaching of, Obst. 55, 61
Lagothrix (Woolly monkeys), variations in position of teeth in, Odont. 44
- Bumboldtii , misplacement of maxillary third premolar in, Odont. 44
- infumatus , asymmetrical growth of maxillae in, Odont. 44, 45
-, unclassified, misplacement of left third maxillary premolar in, Odont. 45
Index
lxxv
Lagrange, on fractures of skull, quoted, Ophtli. and Laryng. lxiii, lxiv
Lake, Bichard.—D iscussion on new theory of hearing, Otol. 90
-, particulars of a case of vertigo, labyrinthotomy, obliteration of the semi-circular canals
and part of cochlea by bone (R. Lake), Otol. 77
Lamblia cysts, method of counting, M.B.L. 11
Lane, Sir W. Arbuthnot.—N on-touch technique in preparation of operation field for mandi¬
bular bone-grafting, quoted, Surg. 15
-, discussion on shock, R.S.M. Disc. (Shock), 26
Lane’s gouge forceps for preparation of fragments in mandibular bone-grafting, Surg. 16
-metallic plate, Surg. 23
Lang, W.—Extraction of lens and iridectomy in old sympathizing eye, quoted, Ophth. 28, 29
-and Armour, Donald, C.M.G.—Ivory exostoses, growing from the roof of the frontal
sinus into the orbital and cranial cavities, removed through an osteoplastic opening in
the cranium by Mr. Donald Armour, Ophth. 16
Langmead, F. S.—Discussion on apyrexial symptoms in malaria, Med. 37
-, discussion on case of adrenal growth and case of multiple glandular swellings, Child. 98
-of aplastic anaemia, Child. 75
-of multiple epulides, Child. 70
-of trophcedema of leg, Child. 103
-on specimens from case of purpura, Child. 109
-on syphilitic bone disease, Child. 85, 86
-, sclerodermia with calcification in a mopgol, Child. 94
Lankester, Sir E. Ray, F.R.S., on useless structural characters, quoted, Otol. 23
Lapage, C. P.—Discussion on adenoids, Child. 44
-, discussion on case of myoclonus multiplex, Child. 19
Laparotomy, foetus undergoing spontaneous evolution removed by, during labour (Clifford
White), Obst. 135
-, under ether, sudden collapse during, treatment by heart massage (F. E. Shipway),
Anaesth. 17
Laryngitis, chronic unilateral, case for diagnosis (Andrew Wylie and Archer Ryland), Laryng.
164
-in functional aphonia of ten months’ duration, case (J. Dundas Grant), Laryng. 30
-, tuberculous, case of (T. B. Layton), Laryng. 214
Laryngo-fissure, with removal of intralaryngeal growth performed under gas and oxygen case
(H. E. G. Boyle), Anaesth. 20
Laryngologists, British, work of, Laryng. 3-6
Laryngology, advances in all branches of, in recent years, Laryng. 5, 6
-and otology, experts in, attachment to special hospitals for epidemic diseases, resolution
passed respecting, Otol. 31, 51
,-, Section of. Summer Congress, May 2 and 3, 1913 : Papers, demonstrations (in abstract),
with discussions, Laryng. 216-257
-, Museum Exhibitions: (1) Instruments and apparatus and
specimens, Laryng. 257 ; (2) Scientific relics of Morell Mackenzie, Laryng. 258
-, visit of H.H. Princess Marie Louise, May 3, 1919, Laryng. 258
Laryngoscopy, first clinical work done with, Laryng. 3
-, parent home of, Laryng. 2
Laryngospasm, cause of, Child 34
Larynx, cyst of (W. Jobson Horne), Laryng. 195
-, (Norman Patterson), Laryng. 194
-, mucosa, histology of, importance of knowledge as to, Laryng. 207, 208
-, perichondritis of, case (G. W. Dawson), Laryng. 176
-, polypus of, removed with snare, case (J. Dundas Grant), Laryng. 165
-, removal of, for malignant disease (W. S. Syme), Laryng. 109
-, ventricle of, and vocal cord, normal histology of, considered in connexion with develop¬
ment of adenomata, epidiascopic demonstration (Irwin Moore), Laryng. 199
lxxvi
Index
Larynx, ventricle of, adenoma of wall of (Hunter Tod), Laryng. 201
-, ventricular band of, adenoma of, Laryng. 201
-, whistling through, case of (L. H. Pegler), Laryng. 173
-, how performed, Laryng. 173, 174
Lateral sinus, accidentally injured during operation of mastoidectomy, septic infection*
Otol. 62
-, case-histories, Otol. 62-71
--, criticism of procedure in treatment of
cases, Otol. 64, 67, 69
-----, indicated by pyrexia, Otol. 64, 65 , 68,
72, 73
-operative treatment, Otol. 63-73
-, symptoms indicating, Otol. 63-72
-, exposure during mastoid operation, inspection, in case of injury, Otol. 72
-, haemorrhage from, after mastoidectomy, what is indicated by, Otol. 73
-, injuries to, anatomy of mastoid region in relation to, Otol. 62
-to, groups of, Otol. 62
-, injury during mastoid operation, procedure recommended, Otol. 72
Laughter, incitement to, mitigation of deafness by, Otol. 25
Lavage, in dilatation of oesophagus without anatomical stenosis, Laryng. 40
Lawrence, T. W. P.--Microscopical report on a case of tuberculosis cutis of six years*
duration, Derm. 9 •
-and Bradford, Sir J. Rose.—P ost-mortem findings in cases of puerperal anuria, Obst.
29, 31
Layton, T. B.—Case of tuberculous laryngitis, Laryng. 214
-, discussion on alternatives to operation for adenoids and enlarged tonsils in young
children, Laryng. 218
-, on latent sinusitis in relation to systemic infections, Laryng. 224
Leber’s disease, changes in sella turcica in association with (James Taylor), Ophth. 22
-, high infantile mortality associated with, Ophth. 23
-, origin of, Ophth. 23
Lee, John Robert.—C ompound fractures of the femur in its upper third, with demonstration
of new pelvic-femur splint, also a splint for fractures of the upper extremity, Surg. 6
Lees, K. A., and Hill, William.—A fork accidentally swallowed and impacted in the pylorus*
Laryng. 110
Leg, left, unilateral band sclerodermia and morphoeo-sclerodermia of, case (George Pemet),
Derm. 43
-, trophoedema of (E. A. Cockayne), Child. 105
---. and Milroy’s disease, connexion between, Child. 106
Leishman, Sir W., K.C.M.G.—Discussion on outbreak of typhoid fever in inoculated soldiers*
Epid. 10
-, excess of cases of paratyphoid over typhoid fever in British Army, quoted, Epid. 33
Leonard, demonstration of best position for taking radiograms of gall stones, quoted, Electr.
85
Lepine, alcoholism as factor in production of mental disease in war, quoted. Psych. 39
-, anxious insanity, quoted, Psych. 43
Leptomeningitis, complicating chronic middle-ear suppuration, Otol. 51
-following double acute otitis media in case of fracture of base of skull (J. S. P’raser),
Otol. 110
-, purulent, following fracture of base of skull involving right, middle and inner ear
(J. S. Fraser), Otol. 104
Leslie, R. Murray.—D iscussion on influenza, R.S.M., Disc. (Infl.) 67
Lethargy in pulmonary type of influenza, Med. 55
-, of encephalitis lethargica, Med., Path, and Epid. xv, xvi, xviii, xix, xxii
Leucocyte count, differential, in diagnosis of malaria, Med. 39
Index
lxxvii
Leucocyte oount in typhoid fever in inoculated soldiers, Epid. 2.
-, large mononuclear, experiments correlating with complement deviation, Med. 46
Leucocytes, effect of sodium chloride bath on, Bain. 4
Leucooytosis giving place to leucopenia in malaria, Med. 31
-in pneumonia complicating influenza, Med. 67
-, reaction, defined, Bain. 3
-, following external application of mineral waters, Bain. 4
Leucodermia and melanodermia associated with leuconychia (H. C. Samuel), Derm. 58
Leuconychia, case of (J. H. Sequeira), Derm. 57
-, leucodermia and melanodermia associated with, case of (H. C. Samuel), Derm. 58
-, striata arsenicalis, Derm. 29
-, multiple, associated with leuconychia totalis of one thumb-nail, case (George
Pernet), Derm. 28
Leucopenia complicating influenza, R.S.M. Disc. (Infl.) 81
-, treatment, R.S.M. Disc. (Infl.) 33, 81
-, streptococcal infection in influenza, R.S.M. Disc. (Infl.) 81
-, in pneumonia complicating influenza, Med. 67
-■ , leucocytosis giving way to, in malaria, Med. 31
Leukaemia, acute, case of, diagnosed post-mortem, Child. 92
-, diagnosis, failure in, cause, Derm. 56
-, lymphatic, erythrodermia with, case of (J. H. Sequeira), Derm. 54
-, myelogenous, case of, blood-count in, Derm. 56
-, myeloid, tranfusion of blood in case of, Med. 12
Lewis, Thomas, F.R.S.—Discussion on the electrocardiograph, Electr. 65
Ley, Gordon.—C ase of congenital teratoblastoma of the vulva (rhabdomyoma), Obst. 190
--, discussion on high maternal mortality of child-bearing, Obst. 106
-, two cases of full-time extra-uterine pregnancy, with a tabulated abstract of 100 cases
from the literature, Obst. 140
Leyton, A. S. and H., effect of injection of morphine and hyoscine, quoted, Med. 10
Leyton, O.—Transfusion in diseases of the blood, Med. 5
Liaison officer between child-welfare clinics and maternity ward, Obst. 46, 47
Lichen corneus, relation to lichen planus, Derm. 17
-obtusus corneus, case of (W. Knowsley Sibley), Derm. 14.
-, pathological report on, Derm. 16
-planus, and lichenization due to infective conditions, difficulty of diagnosis between,
Derm. 16
--, annularis, case of (J. H. Sequeira), Derm. 57
-, treatment by x-rays, Derm. 17, 18
-urticatus, not identical with urticaria, Derm. 74
I .ight, artificial, effect on calcification of teeth in infants, Odont. 36
Limb, immobilization of, in bone-grafting, Surg. 34
-, lower, of mature foetus contained in osseous cyst and remaining in abdomen of mother
for fifty-two years, specimen (Herbert Williamson), Obst. 171
Limbs, involuntary movements of, following encephalitis lethargica, Neur. 60, 61
--- 1 -, prognosis, Neur. 63
-, shortening of, on one side of body (? osteogenesis imperfecta unilateralis) (Joseph E.
Adams), Child. 5
Lime, slaked, see Soda , caustic and slaked lime
Lindsay, W. J. and Cargill, L. V.—Pigmented connective tissue immediately in front of
and covering the optic disk, Ophth. 57
Lip, implantation-epithelioma of, following malignant disease of palate, Laryng. 170, 171
Lipase, sensibilization of tubercle bacillus by, Therap. 1
Lipodystrophia progressiva, new case of (P. Parkes Weber and T. H. Gunewardene), Child. 13
Lipoma, large submucous, of palate and pharynx (Herbert Tilley), Laryng. 189
-of broad ligament (C. Lockyer), Obst. 195
lxxviii
Index
Lipoma, large submucous, rarity, Obst. 188
-, pharyngeal, causing death during meal, Laryng. 192
-, pre-vertebral characters of, contrasted with those of broad ligament and omentum,
Obst. 198, 199
-, submucous, large, of palate and pharynx, histological report on (S. G. Shattock),
Laryng. 191
-, subperitoneal, weighing 16J lb., specimen (T. G. Stevens), Obst. 189
Lips, pigmentation of, complicating malaria, Med. 28
Lister, antiseptic methods, abdominal operations at Samaritan Free Hospital conducted upon,
Obst. 2
-, maternal mortality from child-bearing not diminished after introduction of,
Obst. 80
- f opposition to, Obst. 2, 3
--, application of principles of, abolishes sepsis in civil surgical practice, R.S.M. Disc.
(Shock) 28, 29
-, definition of antiseptic treatment, Obst. 3
-, essential fact taught by, with regard to infection of tissues, Obst. 3
Little, E. G. Graham.—C ase for diagnosis, Derm. 47
-, case of actinomycosis, Derm. 12
--of arsenical pigmentation and hyperkeratosis occurring in the course of dermatitis
herpetiformis, Derm. 31
-of circinate persistent erythema multiforme, Derm. 7
— -of Dercum’s disease, Derm. 35
- -of (?) dermatitis herpetiformis, Derm. 19
-of extensive pigmented nsevi, Derm. 13
-of folliculitis decalvans, Derm. 13
-of multiple idiopathic haemorrhagic sarcoma of Kaposi, Derm. 5
-of multiple neuromata of the skin, Derm. 35
-of mycosis fungoides, Derm. 24
-, discussion on case of epithelioma of face, Derm. 2
-of erythrodermia with lymphatic leukaemia, Derm. 56
-of idiopathic multiple haemorrhagic sarcoma of Kaposi (miscalled), Derm. 50
— ---of lichen obtusus corneus, Derm. 16
-of “multiple, benign, tumour-like new growths,” Derm. 23
-of senile tuberculosis cutis, Derm. 19
--on two cases of granulosis rubra nasi, Derm. 40
-on guttate morphcea, Derm. 4
Little, T. R., Major C.A.M.C.—Discussion on influenza, R.S.M. Disc. (Infl.) 36
Liver, abscess of, specimen (Eric Pritchard), Child. 108
-, cultures from, in influenza, R.S.M. Disc. (Infl.) 52
-, function of, inhibited by mental stimulus, R.S.M. Disc. (Shock) 27
-, inferior border of, portion of gall-bladder below, radiogram demonstrating, Electr. 78
-, malignant disease of, case of, temporarily benefited by attack of intercurrent influenza,
Clin. 18
-, metastatic deposit in, microscopical appearances, Path. 19
-, post-mortem appearances in influenza, R.S.M. Disc. (Infl.) 56
-, substance casting denser shadow than gall-stone, Electr. 79
-tissue and cholesterin gall-stones, relative density, radiograms showing, Electr. 84
-, with gall-bladder projecting below, with well defined shadow of gall-stone, radiogram
showing, Electr. 79
-, X-ray examination of, important, Electr. 76
Liverpool, measles epidemics in, amplitudes, Epid. 90, 92, 95
--in, deaths from (1870-1912), Epid. 93, 95
--—--, average weekly prevalence for 40 years, Epid. 98
Lockhart-Mummery, J. P.—Case of chronic X-ray dermatitis of the anal region, excised
eighteen months ago, Proct. 45
Index
lxxix
Lockhabt-Mummery, J. P.—Case of complete resection of the large bowel for multiple
adenomata, Proct. 43
-of mega-colon (Hirschsprung’s disease), Proct. 44
-, with secondary carcinoma, Proct. 44
-, discussion on the present position of spinal anaesthesia, Anaesth. 11
-on shock, R.S.M. Disc. (Shock) 27
IiOckyer, Cuthbert.—L ipoma of the broad ligament, Obst. 195
Logical reasoning, part played by, in process of persuasion, Psych. 22, 23
London, absence of large maternity hospitals in, Obst. 62
-, clinics of, percentage of rickets in, Odont. 25
-, encephalitis lethargies epidemic in (1918), statistics relating to, Med., Path., and Epid.
xxi, xxii
-, epidemics of measles in 1840*1912, special investigation. Epid. 80
-, extension of maternity hospital system in, on large scale, Obst. 67
-hospitals for diseases of women, utilization of clinical material in, Obst. 71
-of, giving clinical instruction in conduct of labour, Obst. 110
-of, having midwifery ward for students, Obst. 118
-, influenza epidemics in (1891, 1892, 1895, 1900), excess mortality due to respiratory
diseases occurring in, R.S.M. Disc. (Infl.) 20
-(1918), excess mortality due to influenza only, R.S.M. Disc. (Infl.) 20
-, intensity compared with that of previous epidemics, R.S.M. Disc.
(Infl.) 19
-, mortality, age-distribution, R.S.M. Disc. (Infl.) 20
-—-, course of (1890-1917), R.S.M. Disc. (Infl.) 7-10
-, date of appearanoe and disappearance, R.S.M. Disc. (Infl.) 21
-, maternity hospitals in, amalgamation of, Obst. 63
-, measles epidemics in (1340-1912), Epid. 77
-, amplitudes, Epid. 80, 81
-, chief period between, Epid. 78, 79, 110, 111
-, special investigation, Epid. 80
——, measles in (1840-1912), deaths from, diagram showing, Epid. 78
-, average weekly prevalence, Epid. 98
-, in each quarter year, Epid. 78
-.- # special investigation, Epid. 80
-, South; measles in, appearance to be expected when two epidemics intermix,
Epid. 85, 86, 87
-, spread of epidemic from one district to another, Epid. 85
London Hospital, Pathological Institute of, specimen of dilatation of oesophagus without
anatomical stenosis from (Sir H. Rigby and H. Turnbull), Laryng. 77, 90
Longcope, Colonel.—Discussion on influenza, R.S.M. Disc. (Infl.) 64
Lotions, alkaline, detergent, in treatment of adenoids in young children, Laryng. 219, 220
Low-frequency alternating currents, use in diathermy, Electr. 19
Lowlanders, Scotch, children of, prevalence of rickets and scurvy among, Odont. 29
-, diet among, Odont, 29
-, prevalence of dental caries among, Odont. 29
Lucae, impossibility of distinguishing between otosclerosis and chronic adhesive process,
quoted, Otol. 12*2
Luker, S. G.—Discussion on high maternal mortality of child-bearing, Obst. 105
Lumbar puncture in encephalitis lethargica, Med., Path, and Epid. xxi
-in relief of headache following stovaine anaesthesia, Anaesth. 7
Lung, choked, in pulmonary type of influenza, Med. 56
-, collapse of small areas, in influenza, R.S.M. Disc. (Infl.) 50
-, emphysema of, compensatory, following •• gassing,” Path. 58
-tissue, consolidation in influenza, Med. 62-65
-, diffuse congestion and oedema of, in influenza, R.S.M. Disc. (Infl.) 49
lxxx
Index
Lung tissue, universal friability of, in influenza, Med. 65, 66
Lungs, air driven through, from right heart into left experimentally, in cat post-mortem.
Path. 64
-and heart, disease of, mental changes associated with, Neur. 4
-, cultures from, post-mortem, in influenza, R.S.M. Disc. (Infl.) 52
-.from cases of pneumonia complicating influenza, post-mortem appearances, R.S.M.
Disc. (Infl.) 53, 54
-, histology of, in influenza, R.S.M. Disc. (Infl.) 47
-, pathological anatomical changes found post mortem in influenza, R.S.M. Disc. (Infl.) 47;
Med. 62, 63
-, pins accidentally inhaled into, some statistics and results of (Irwin Moore), Laryng. 15
-, removal of foreign bodies from by peroral endoscopy, new instruments designed for,
demonstration (Irwin Moore), Laryng. 20
-, roots of, presence of lymphadenomatous glands at, occurrence of acute pneumonia in
connection with, Clin. 18.
-, sections of, from cases of pneumonia complicating influenza, microscopical examinations,
R.S.M. Disc. (Infl.) 37, 54
-, source of air in air-sacs of birds, Path. 61
Lupus, extensive, of alveolus, nose and larynx, Laryng. 212
-erythematosus, case of (A. M. H. Gray), Derm. 62
-, diagnosis, Derm. 64
-, symmetrical, extensive, of auricle (W. Stuart-Low), Otol. 5
-vulgaris, epithelioma superimposed on, treatment by diathermy, Electr. 28
Luschka’s tonsil, enlargement in adenoids, Child. 48, 50, 51
-, hypertrophied, so-called atrophy of, explained, Child. 48
-, hypertrophy of, adenoids a condition of, Child. 47, 48
- 1 affecting connective as well as lymphoid tissue, Child. 48
-, masses of adenoid tissue around, Child. 34
Lying-in chamber, preparation as for surgical operation, Obst. 89
-hospitals, training in, Obst. 112, 115
-, combined teaching of obstetrics, gynaecology, maternity and child welfare in,
Obst. 57
-, large, establishment of, Obst. 96, 100
-ward, students’ work in should precede attendance on extern midwifery cases,
Obst. 66
Lymph gland, cervical, metastatic deposit ih, in case of tumour of thyroid, Path. 5, 8
Lymphadenoma, case, with arsenical pigmentation (Miss Eliz. O’Flynn), Clin. 17
-, with arsenical pigmentation, case of, blood count in, Clin. 18
Lymphadenomatous glands at roots of lungs, connexion of acute pneumonia with, Clin. 18
Lymphangiectodes, case of'(George Pernet), Derm. 64
Lymphangioma of tongue (B. Whitchurch Howell), Child. 78
Lymphangioplasty in treatment of oedema of infra-orbital region, Ophth. and Laryng. lxii.
Lymphangitis, tuberculous, following injury to tuberculous wart of long standing ; complete
excision of primary focus, infected vessels and glands (W. Sampson Handley), Clin. 19
Lymphatic plexus, fascial, Electr. 42, 43
-tissue, bactericidal function, Child. 41
-, how rendered less efficient, Child. 41
-, upon what dependent, Child. 41
-, hyporplasia of, Child. 41, 46, 47
-, conditions on which dependent, Child. 41, 42
-, naso-pharyngeal, work of, how encumbered, Child. 42
-vessels permeated by cancer cells, disappearance of, Electr. 44
-, permeation by cancer cells, Electr. 42, 43
Lymphatics, anatomy of, Electr. 42
-, fibrosing, irradiation, effect on cancer cells, Electr. 50
Index
lxxxi
Lymphoderraia perniciosa, Derm. 55, 56
Lymphoid character of cells of tumours yielding best results under radium treatment, Clin. 5, 6
-tissue, large proportion in well-nourished children, Child. 52
Lynch, G. Roche. —Discussion on influenza, R.S.M. Disc. (Infl.) 44
Lyster, Cecil R. C. —Discussion on stereoscopic radiography in fractures of femur, Electr.
74, 75
--, opening remarks at joint meeting of Section of Electro-Therapeutics with Institution of
Electrical Engineers, Electr. 53
McCann, F. J.—Discussion on high maternal mortality of child-bearing, Obst. 105
-, discussion on extra-uterine pregnancy, Obst. 184
-on retro-peritoneal bleeding after dilatation of cervix, Obst. 199
-on teaching of obstetrics and gynaecology, Obst. 62
-, the clinical teaching of post-graduates in midwifery, Obst. 134
MacCormac, Henry, C.B.E., M.D.— Case of Delhi boil, Derm. 70
-, case of the condition described as “multiple, benign, tumour-like new growths’’
(shown for Dr. J. J. Pringle), Derm. 21
-, discussion on case of keratoma senile, Derm. 65
-, histological report on Dr. Pringle’s probable early case of the miscalled multiple
idiopathic haemorrhagic sarcoma of Kaposi, Dorm. 48
McCrea, H. Moreland, results of vaccine treatment of influenza, quoted, R.S.M. Disc. (Infl.) 83
McDougall, W.—Definition of suggestion, quoted, Psych. 15
--, present position in clinical psychology (Presidential Address), Pysch. 1
-, theory of the physiological factors of association and hypnosis, quoted, Psych. 57
Macedonia, epidemic of influenza in (Julius Burnford), Med. 49
McKrnzie, Dan.— Absorption of the pre-maxilla in tertiary syphilis of nose, Laryng. 2S
-, discussion on adherent palate, Laryng. 151
-on case of epithelioma of epiglottis treated by diathermy, Laryng. 158
— -of sarcoma of nose, Laryng. 163
-on dilatation of the oesophagus without anatomical stenosis, Laryng. 61
— -on latent sinusitis in relation to systemic infections, Laryng. 225
-on mastoid operations, Otol. 59
-on recurring spheno-choanal polypus in child, Laryng. 107
---on septic infection of lateral sinus injured during mastoidectomy, Otol. 73
-on spasm at entrance to oesophagus and clinical type of dysphagia, Laryng. 237
-, an operation for the complete removal of the soft palate (staphylectomy), Laryng. 239
Mackenzie, Sir Morell, application of caustic soda and slaked lime to enlarged or diseased
tonsils, by, Laryng. 244, 245, 246
-, case of adenoma of vocal cord, quoted, Laryng. 200
-, “ Diseases of the Throat and Nose,” Laryng. 3, 4
-, and other writings of, Laryng. 3, 4
-, pioneer work in laryngology of, Laryng. 4
-, scientific relics of, exhibited at museum of Summer Congress of Laryngology, Laryng. 258
Macleod, A. L.—Microscope specimens and reports of a case of adenoma of the vocal cord
removed by thyro-fissure, Laryng. 148
MacLeod, J. M. H.—Discussion on case for diagnosis, Derm. 33
-, discussion on case of trichorrhexis nodosa, Derm. 60
-of multiple idiopathic haemorrhagic sarcoma of Kaposi (miscalled), Derm. 50
MacNalty, A. Salusbury. —Discussion on epidemic encephalitis, Med., Path, and Epid.
xvii, xxiii
Macula, concussion changes at, resulting from fragments driven into region of orbit and face
by shell-explosions, Ophth. and Laryng. vii
-, symmetrical disease of (with drawing of lpft eye) (Rayner Batten), Ophth. 35
-, occurrence at puberty in both sexes, Ophth. 35
6
lxxxii
Index
Macular atrophy, multiple benign tumour-like new growths, passing into state of, Derm. 22, 23
Malar-coronoid screw fixation in treatment of posterior fragment in fractures of mandible,
Surg. 12
Malaria, apyrexial rigors in, Med. 38
-, charts from five cases showing, Med. 22
-symptoms in (Gordon Ward), Med. 15
-as factor in production of mental disease in war, Psych, 39
-, attack of, Wassermann reaction for syphilis not affected by, Med. 47
-, benign and malignant, possibility of preparation of specific antigens for, experiments to
determine, Med. 44
-, blood-picture in, Med. 31
-, cases under various courses of quinine treatment, experiments on complement deviation
in, Med. 46
-, chronic, application for increase of pension on account of suffering from, Med. 1
-, complicated by hyperidrosis, Med. 27
-, increase of eosinophils in, Med. 31
-, tremor in, Med. 33
-, comatose, confusion with heatstroke in, Med. 39
-, complicated by conjunctival catarrh, Med. 27
-by cough, Med. 26
-by pharyngitis, Med. 26, 27
-by pigmentation of lips, Med. 28
-by Raynaud’s symptoms, Med. 28, 29
-by transient oedema, Med. 29, 30
-, complement deviation in, experiments correlating large mononuclear count with,
Med. 46
-, experiments on, with antigens prepared from cultures of malarial parasites
(Plasmodium falciparum and Plasmodium vivax) (J. Gordon Thomson), Med. 39
-experiments on, with antigens prepared from cultures of malarial parasites
(Plastnodium falciparum and Plasmodium vivax), conclusions, Med. 47
-, course of, in case of patient taking quinine, Med. 20, 21
-, cure of, cannot be diagnosed with accuracy, Med. 40
-, cutaneous hyperalgesia in, areas and lines of, clinical chart showing, Med. 23, 24
-, debility due to improper diet in, Med. 37
-, defective action of suprarenal and thyroid glands in, Med. 38
-, diagnosed as influenza, Med. 26
-. diagnosis by differential leucocyte count, Med. 39
-, value of negative blood film in, Med. 81
- $ of pigmented blood corpuscles in, Med. 31
-, endothelial cells in, Med. 31, 82
-, enlarged spleen in, diagnosis, Med. 20
-, rarity, Med. 34
-, exophthalmos in, Med. 38
--, headache in, Med. 25
-, herpes labialis in, Med. 33
-, immunity to, Med. 40
-, in employees, diagnosis of, means for, Med. 15, 36
-, jaundice in, Med. 33
-, minor, relapse in, Med. 17, 18, 19
-, preceding major, chart showing, Med. 22
-. pain in side in, Med. 23
--, perisplenitis in, Med. 20
--, pigmentation resembling Addison’s disease in, Med. 38
-, Plasmodium rxvax in blood of patients with, Med. 18, 19
-, poison of, connexion with origin of confusions! states in war, Psych. 44
Index
lxxxiii
Malaria, proof of disease being, signs required, Med. 16
-, pyrexia and minor relapses in, tertian periodicity of lesser degrees of, charts showing,
Med. 22
-, quartan and tertian periodicity, chart showing, Med. 18, 19
-, relapses in, how to avoid, Med. 40
-, relation of, to influenza, Med. 71
-, secondary infection in, Med. 37
-, tachycardia in, Med. 33, 34
-, clinical forms of, Med. 38
-, tertian, benign (Plasmodium vivax) compound antigen composed of ten cultures of,
series of cases done with use of, Med. 46
-, preliminary experiments carried out in known cases of, with Plasmodium
vivax present in blood, with use of antigen, from single strain of parasites, Med. 43
-, spleen from and cultures of Plasmodium vivax , antigens prepared respectively
from experiments with, Med. 45
-, periodicity, chart showing, Med. 19, 20, 21
-, tremors in, Med. 38
-, wasting in, Med. 34
-, weakness in, estimation of, Med. 34, 35
Malarial infection, two hundred cases of, results of experiments on complement deviation in,
Med. 43
Malcolm, J. D.—Case of extra-uterine pregnancy, Obst. 179
-, constriction of arteries in clinical shock, quoted, R.S.M. Disc. (Shock) 6, 9
-, developments in abdominal surgery since 1884 (Presidential Address), Obst. 1
-, discussion on obstructed labour due ta ventrifixation, Obst. 218
-on shock, R.S.M. Disc. (Shock) 9
-on teaching of obstetrics and gynaecology, Obst. 20
Malformations, bodily, association with genius, Otol. 23, 24
Malignant disease of pituitary body, case (G. Maxted), Opth. 42
-of soft palate, indication for staphylectomy, Laryng. 239
-, removal of larynx for (W. S. Syme), Laryng. 109
-, treatment by diathermy (C. E. Iredell and Philip Turner), Electr. 24
-and fulguration combined, Electr. 25
-by fulguration (C. E. Iredell and Philip Turner), Elect. 23
-epithelial cell, polymorphism of (E. H. Kettle), Path. 1-32
-, growths, most active portion when spreading. Elect. 43, 46
-, treatment by copper preparations, failure in, Laryng. 209, 210
Malloch, T. A., Major C.A.M.C.—Discussion on influenza, R.S.M. Disc. (Infl.) 45
Maltose and dextrin, conversion of starch into, Child. 27
Mammals, effects of explosives on, Neur. 43
Mammary gland, left and lower portions of, and left pectoralis major muscle, congenital
absence of (E. A. Cockayne), Child. 59
Manchester, measles epidemics in, amplitudes, Epid. 90, 92, 95
Mandible and maxilla, fractures of, ratio of fractures of mandible to, at Jaw Injuries Centre,
Odont. 7
-, fractures of, bone-grafting in, results, Burg. 18
-, examination,* extraction and preservation of teeth in, Burg. 12
-, percentage of non-union in, Odont. 13
-, prevention of displacement and control of edentulous posterior fragment in,
method employed, Surg. 12
-, ratio to fractures of mandible and maxilla at Jaw Injuries Centre, Odont. 7
-, ratio to fractures of maxilla at Jaw Injuries Centre, Odont. 7
-, treatment by bone-grafting (C. W. Waldron and E. F. Risdon), Surg. 7
--, preparation of fragments. Surg. 15, 16, 19
-, time when to be undertaken, Surg. 13
lxxxiv
Index
Mandible, fractures of, ununited anterior, Odont. 56
-, lateral, Odont. 56
-- f method of obtaining early use of jaws in, Surg. 12
-, non-union, cases discharged from Jaw Injuries Centre with, Odont. 8
-, posterior, Odont. 56, 57
-, difficulty of control of edentulous posterior fragment in, Odont. 56, 57
-, transplant grafts in (C. Ernest West), Odont. 95
-, essentials for satisfactory results, Odont. 98
-, operative technique, Odont. 96
-, treatment, Odont. 56, 57
-by bone-grafting (P. Cole and C. H. Bubb), Odont. 13
-, results tabulated, Odont. 14
-by massage and ionization of soft parts, Odont. 58
-, dental technique in, Odont. 57, 58
-, re-adaptation of splints in, Odont. 58
-, gunshot fracture, splitting of scar tissue before bone-grafting, Odont. 61
--, treatment by bone-grafting, cases illustrating, Odont. 64-66
-, operation described, Odont. 60-63
-, preliminary preparation for, Odont. 60
-, removal of dental fixation splint before, Odont. 60
-, results, Odont. 63-66
--, skiagrams illustrating, Odont. 66-72
-, wound of, with extensive loss of tissue, treated by Colyer’s method (F. N. Double¬
day), Odont. 101
-, regional anaesthesia in, method, Odont. 3
Manic depressive psychosis, percentage in war, Psych. 43
-type of reaction, infrequent occurrence of, in war, Psych. 44
Manometer, 0-tube, tests with, Epid. 39
--, measurement of pulse-rate during performance, Epid. 39
-, performance of, for admission to Royal Air Force, Epid. 39
Marasmus, fatal, attacking bulldogs fed on unsuitable diet, Odont. 37
Margate, climate of, in treatment of adenoids, Child. 51
Marie Louise, H.H. Princess, visit to Summer Congress of Section of Laryngology, May 8
1919, Laryng. 258
Marinesco, G., microscopical examination of brains from cases of epidemic encephalitis
lethargica, Med., Path, and Epid. i, ii, x
Marriage, H. J., spreading submucous emphysema following injury to mucosa of Eustachian
tube, quoted, Path. 59
Marriage, early, obstacles to, a bar against chastity. R.S.M. Lect. 11
Marriott, Cecil.—S pecimen from case of extra-uterine pregnancy (shown by J. D. Malcolm),
Obst. 180
Marris, H. F., diagnosis of typhoid fever by atropine test, quoted, Epid. 3
Marston, A. D.—See Iredell , C. E., diathermy in gynaecology
Mason, E. H., diagnosis of typhoid fever by atropine test, quoted, Epid. 3, 4
Massage in ununited fractures, Surg. 30
-of ossicles, Otol. 96
-of soft parts as adjuvant in treatment of ununited fractures of mandible, Odont. 58
-, successful, in case of heart failure due to shock (Ashley Daly), Anoesth. 15
Mastication, defective, as factor in causation of adenoids, Child. 27
-, effect of, Child. 27
-, vegetable food of British requires little, Child. 29
-, vigorous, value of, in prevention of adenoids, Child. 27, 35, 55
Mastoid and external and auditory meatus, microscopic examination in case of fracture of
base of skull with fracture dislocation of incus and rupture of roof of right mastoid
antrum, Otol. 110
Index
lxxxv
Mastoid cortex, findings in, at radical mastoid operation, Otol. 36
-operation, cortical, indicated for children, Otol. 66
-, exploration of sphenoidal sinuses before, Otol. 98
- -, Kiister’s, Otol. 54
- , radical, after-treatment of operated cases, Otol. 39, 40, 56
--, association of appearances present on otoscopy with state of hearing
c • iditions at, and result obtained by, Otol. 43, 44
__, condition of meatus and membrane on operated and non-operated sides
compared, Otol. 32
- 1 contra-indicated in children, Otol. 55
-, curettage of tympanic cavity in, Otol. 34
- , diseases developing after, Otol. 37, 38
- 9 duration of stay in hospital after, Otol. 40
-, effect upon hearing discussed, Otol. 53, 55, 56, 57
_ ___ ? findings in various regions of internal and middle ear at, Otol. 36, 37
___ f for cholesteatoma, with preservation of matrix, two cases (J. Dundas Graut),
Otol. 12
—-, hearing after, Otol. 41, 42
-before, Otol. 32, 33
-and after, Otol. 43
___ t in cases of labyrinthitis complicating chronic middle-ear suppuration, Otol. 49
--, indications for, Otol. 33
-, intra-tympanic syringing before, Otol. 33
-, line of incision in, Otol. 34
- , method of dealing with Eustachian tube in, Otol. 35
---, of removal of bone in, Otol. 34
- -, modified, Otol. 44, 58
- — --, advocated, Otol. 53, 58
__ -_, comparative hearing after operation, Otol. 47
- , hearing before, Otol. 45
___, indications for, in cases of chronic middle-ear suppuration, Otol. 45, 46
_in cases of chronic middle-ear suppuration as affected by hearing,
Otol. 45, 4G
_in cases of labyrinthitis complicating chronic middle-ear suppuration,
Otol. 49
--, mortality, Otol. 39
- , objections to, Otol. 52
- 9 results, Otol. 47 ,
-, statistics relating to cases, Otol. 44
_, testing of vestibular apparatus after, Otol. 45
-, mortality, Otol. 38, 39
___, erroneous statements respecting, Otol. 38, 39
_, persistence of discharge after, explanation, Otol. 96
__, preliminary treatment, Otol. 56
-, progress of patients after, Otol. 37
_, purulent labyrinthitis following, Otol. 38
_, question of performance, Otol. 58
_, of removal of aural polypi before, Otol. 33
__ f removal of floor or of convexity on anterior wall of bony meatus, Otol.
--— 5 results, Otol. 40
_in non-skin grafted cases, Otol. 41
-in skin-grafted cases, Otol. 41
-, scarlet fever following, Otol. 37
-, skin-flap used in, Otol. 37
-, skin-grafting in, Otol. 35.
lxxxvi
Index
Mastoid operation, radical, question of skin-grafting in, method employed, Otol. 37
-, statistics relating to cases, Otol. 30
-, technique in, points for discussion, Otol. 34, 35
---, treatment suggested in case of circumscribed labyrinthitis, Otol. 100
-, Schwartze’s, Otol. 52, 54, 57, 58, 59
-, Stacke’s, Otol. 54
-operations (radical and modified radical) indications, technique and results of (J. S. Fraser
and W. T. Garretson), Otol. 29
-process, findings in, at radical mastoid operations, Otol. 36
-processes, preliminary radiograms before operation, Otol. 34
-region, anatomy of, in relation to injury to lateral sinus, Otol. 62
-suppuration, with patent Eustachian tube, treatment, Otol. 98
Mastoidectomy, haemorrhage from wound after, treatment, Otol. 72
——, intermittent pyrexia, septic, without rigors, commencing ten days after, what is
indicated by, Otol. 73
-, operation of, septic infection of lateral sinus accidentally injured during (Hunter Tod),
Otol. 62
Mastoiditis, acute, complicated by peri-sinus abscess, Otol. 10
-, followed by thrombosis of internal jugular vein as far as clavicle, recovery (\V. M.
Mollison), Otol. 10
-chronic, and chronic suppuration of middle-ear, connexion between, Otol. 53
-, tuberculous, in children, due to infected milk, Otol. 7, 8
-, bilateral, double facial paralysis due to (W. M. Mollison), Otol. G
Materialism and spiritualism, controversy between, Psych. 11
Materialistic dogma in psychiatry, validity of, on what dependent, Psych. 63, 64
Maternal mortality, continued high, of child-bearing (Victor Bonney), Obst. 175
- f decline of, after passing of Midwives Act not maintained, Obst. 101
Maternity and child welfare, obstetrics and gynaecology, teaching in one lying-in hospital,
Obst. 57
-and gynaecological department, fully equipped, aspect from preventive standpoint, Obst. A 2
-hospital, central, establishment in principal teaching centres, Obst. 74
-and Infant Welfare Centres, Obst. 113
-benefit^ suggested outlay in purchasing obstetric outfit, Obst. 105
-cases, extern, attendance of students on, importance of, Obst. 42
-centre, establishment of, in hospitals, Obst. 43
- 1 staff for working, Obst. 43
-centres, supervision of, by medical profession, Obst. 52
-, results, Obst. 53
-district practice, value of, to student, Obst. 45
-hospital system, extension on large scale in London advocated, Obst. G7
-hospitals in London, amalgamation of, Obst. 63
-, none of large size, Obst. 62
-, posts connected with, under Ministry of Health, Obst. 52
-ward and child welfare clinics, liaison officer between, Obst. 46, 47
-, preventive aspect of students’ work in, Obst. 44
Matrix, preservation of, in radical mastoid operation for cholesteatoma, two cases (J. Duudas
Grant), Otol. 12
Maxilla, alveolar border, loss of, treatment by epithelial inlay operation, Odont. 77, 78, 80
-, fractures of, ratio to fractures of mandible at Jaw Injuries Centre, Odont. 7
-, osteomyelitis of, causing infection of orbital tissues in children, Ophth. and Laryng. lii
-, chronic, case of (G. W. Dawson), Laryng. 212
-, palatal portion, loss of, Odont. 78
-, construction of special dentures for, Odont. 78-82
-, principally affected in multiple epulides, Child. 68
-, regional ansesthesia in, method, Odont. 3
Index
lxxxvii
Maxilla, sarcoma, commencement in, invading orbit, Ophth. and Laryng. lv
Maxillae, asymmetrical growth in Lagothrix infumatus , Odont. 44, 45
-, displacement backwards of, without loss of tissue, Odont. 76
-, appliance used to correct, Odont. 76
--, deformity resulting from, Odont. 77
-, due to flying accidents, OdoDt. 76
-, old injuries of, intra-oral appliances for, classification according to injury received,
Odont. 76
-, treatment, prosthetic (W. Kelsey Fry), Odont. 73-94
-, difficulties in taking impressions for construction of intra-oral
appliances, Odont. 73, 74
-, means of overcoming, Odont. 74, 75
Maxted, George.—C ase of malignant disease of the pituitary body, with comments, Ophth. 42
Mayou, M. S.- Discussion on migraine, Ophth. 54
Meader, Fred. M.—Discussion on influenza, R.S.M. Disc. (Infl.) 71
-, epidemiology of the outbreak of typhoid fever among the Fourth Casual Company
J.A.R.D., Epid. 5
Meal, pharyngeal lipoma causing death during, Laryng. 192
Measles and whooping-cough, relationship to influenza, R.S.M. Disc. (Infl.) 25
-, deaths from, average weekly prevalence in eight large towns of British Isles for forty
years, Epid. 98
-in Liverpool (1870-1912), Epid. 93, 95
-in London (1840-1912), diagram showing, Epid. 78
-, distribution in London (1890-1915), Epid. 82
-, epidemic periods intermixing, Epid. 96
-, epidemics, appearance to be expected when two intermix, Epid. 85-87
-in large towns of Great Britain and Ireland (1856-1917), Epid. 98-91
---, periodicities of (J. Brownlee), Epid. 77-120
---(1870-1910), amplitudes in periodogram analysis, Epid. 95
-in London, periodicities of, permanence, Epid. 79
-(1840-1912), amplitudes for groups of years and for whole epoch for certain
different periods in, Epid. 82
--, chief periods between, Epid. 78, 79, 110, 111
__, general study of figures relating to, Epid. 77
__, special investigations, Epid. 80
__, statistics, method of analysis employed, Epid. 80, 100
-, periodicities, seasonal, Epid. 97, 98
_, seasonal maxima, oscillation in, Epid. 119
_, spread of, method discussed, Epid. 96, 97
-, fatality among armies, R.S.M. Disc. (Infl.) 15
-in Aberdeen (1856-85), deaths from, periodicity, Epid. 107, 108
-in Fiji, first outbreak, R.S.M. Disc. (Infl.) 15
-in large towns of British Isles, Epid. 88
-in London, 1890-1915, distribution of, Epid. 82
-in Paisley, deaths from, in each quarter-year (1856-1917), Epid. 89
-, organisms of, variations in, as determining form of epidemic waves, Epid. 89, 96, 119
-, periods of, method of testing probability of, Epid. 112
-, seasonal distribution of, Epid. 97
-, similarity of pneumonia complicating influenza, to that complicating, R.S.M. Disc.
(Infl.) 65
Meatus, auditory, bony, removal of floor or of convexity on anterior wall of, in radical mastoid
operation, Otol. 35
-, condition as noted on operated and non-operated sides at modified radical mastoid
operations, Otol. 45
-, condition on operated:and non-operated sides compared, in cases of radical mastoid
operation, Otol. 32
lxxxviii
Index
Meatus, auditory, external and mastoid, microscopic examination in case of fracture of base
of skull with fracture dislocation of incus and rupture of roof of right mastoid antrum,
Otol. 110 -
-, microscopic examination in case of fracture of base of skull involving middle
and inner ear, Otol. 105
-, fibroma of auricle at entrance of (W. Stuart-Low), Otol. 79
-, internal, microscopic examination in case of fracture of base of skull involving
middle and inner ear, Otol. 109
-, with fracture dislocation of incus and rupture
of roof of right mastoid antrum, Otol. 115
Meatuses, auditory, internal, microscopical examinations in case of otosclerosis associated with
otitis media, Otol. 122, 126
Mediastinal glands, anterior, of same side, microscopic foci of breast cancer in, Electr, 48
-new growths, X-ray treatment, Clin. 5, 6
Medical profession, supervision of maternity centres by, Obst. 52
-students and pupil midwives, joint instruction to, Obst. 45
-, teaching of obstetrics and gynaecology to, report on, Obst. 108-134
-, qualifications for, Obst. 50, 51
-, value of work in maternity district to, Obst. 45
-work in lying-in ward should precede that in extern-district, Obst. 66
Medicine, clinical, application of electro-cardiograph to, Electr. 65
-, preventive, psychological aspect, Obst. 47, 48
-, teaching of obstetrics and gynaecology from standpoint of (J. S. Fairbairn), Obst. 40
-to students, Obst. 41
Mega-colon (Hirschsprung’s disease), case (J. P. Lockhart-Mummery), Proct. 44
-, with secondary carcinoma, case (J. P. Lockhart-Mummery), Proct. 44
Mehnert, enteromere theory of congenital dilatation of oesophagus, Laryng. 70
Meigs, G,, death-rate from child-bearing in United States, Obst. 78
Melanodermia and leucodermia associated with leuconychia (H. C. Samuel), Derm. 58
Melanoma of choroid (R. Foster Moore), Ophth. 60
-, with pigmented cells of ciliary muscle, Ophth. 60
Melanotic growths (carcinomatous), case (George Pernet), Derm. 11
Membrana secundaria, function of, Otol. 89, 90
Memories, painful, repression of, Psych. 6
-, repressed, in war neurosis, Psych. 56
Men and women, frequency of accidents to, in different factories compared, Epid. 51, 52
-, effects of detonation of mixed explosives on, experimentally tested, Neur. 45
Meningitis following fracture of the base of skull (J. S. Fraser), Otol. 103
-in American army in France (1918), R.S.M. Disc. (Infl.) 29
-, cerebro-spinal and influenza, association between, in military camps, Epid. 72
-, identity of origin, Med., Path, and Epid. vi
-, relationship between, R.S.M. Disc. (Infl.) 25
-and pneumonia, incidence in British Army in United Kingdom compared (1915-18),
R.S.M. Disc. (Infl.) 6, 7
-, annual death-rate in England and Wales, 1881-1917, R.S.M. Disc. (Infl.) 6
-, cause of onset, Med., Path, and Epid. x, xi
- f influenza and encephalitis lothargica, association between, discussed, Epid. 72,
73, 75
-, outbreak of (1916), relation of case-rate to carrier-rate, R.S.M. Disc. (Infl.) 26
-, sphenoidal sinus empyema in (D. Embleton and E. A. Peters), Laryng. 250
-, tuberculous, of spinal cord simulating anterior poliomyelitis, section from case (H. C.
Cameron), Child. 23
Meningococcal infection of sphenoidal sinuses, Laryng. 251, 252
Meningococcus, carriers of, R.S.M. Disc. (Infl.) 26
Miixnell, Z.—Discussion on closure of cavities in bone, Surg. 3
Index
lxxxix
Menstruation, enucleation of enlarged or diseased tonsils during, contra-indicated, Laryng. 247
Mental analysis, see Autognosis
-affections in pregnant women, best place for study of, Obst. 38
-breakdown in war, factors combining to bring about, Psych. 36, 37
-causes of pelvic symptoms, Obst. 48
-changes associated with disease of heart and lungs, Neur. 4
-conflict, as factor in production of war psychoses, Psych. 40, 41
-, disorders of conduct following, Psych. 6
-conflicts, opportunities for, in warfare, Psych 40, 41
-defects, recruiting of, excuse for, Psych. 48
-disease in war cannot be compared with that in civil life, Psych. 51.
-, factors contributing to onset of, Psych. 39
-, recovery-rate, Psych. 51
-, psychological factors in, undervaluation of, Psych. 64
-, care of, in Russo-Japanese campaign, Psych. 36
-, exhaustion psychoses wrongly included under, Psych. 38
-, psychogenesis in problem of (C. G. Jung), Psych. 63
-hygiene movement advanced in United States, Psych. 51
-processes, unconscious, Psych. 8, 9
-reactions, unhealthy, favoured by unaccustomed iron discipline of war, Psych. 36, 37
-stimulus inhibiting function of liver, R.S.M. Disc. (Shock) 27
Menthol and eucalyptus, inhalation of, in pneumonic influenza, Med. 70
Mercier, C., science of conduct suggested by, Psych. 4
Mercury, acid nitrate of, application to oriental sore, Derm. 34
- and salvarsan, intra-muscular injections in anti-syphilitic treatment of infants,
Obst. 10, 13
-, inunction, in anti-syphilitic treatment of infants, Obst. 10
-perchloride, intravenous injections in influenza, R.S.M. Disc. (Infl.) 85
-solution, washing with, as prophylactic against venereal disease, R.S.M. Lect. 9
-tube, passage of, in treatment of dilatation of oesophagus without anatomical stenosis,
Laryng. 60, 61
Mesenchymatous structures, defects of, association of otosclerosis with, Otol. 129, 130
Mesenchyme, diseases and deformities due to hereditary inferiority of, Otol. 129, 130
Mesenteric glands, calcified, radiogram showing, Electr. 82
Mesoblastic structure, defective development, case of, Otol. 22
Metallic plate, Syme’s, Surg. 23
Metals of high atomic weight in contact with skin, danger to X-ray workers, Electr. 16
Metastasis, secondary, in skull, chloroma or adrenal growth with (E. Cautley), Child. 90
Metcalfe, James. —Discussion on treatment by diathermy, Electr. 39
-, personal experiences of burning caused by secondary radiation, Electr. 13
-, stereoscopic radiography in the treatment of fractures of the femur, Electr. 72
Miasma and contagion, struggle between, in history of epidemics, Epid. 71
Mice, effects of explosives on, Neur. 43
Micrococcus catarrhalis associated with influenza, R.S.M. Disc. (Infl.) 93
-, cultures from influenzal material, R.S.M. Disc. (Infl.) 94
Micro-organisms, pathogenic, beneficial effects of injections of colloidal silver on animals
infected with, Bain. 11
—-, tolerance for injected cultures of, proved experimentally after injections of mineral
waters, Bain. 7
-present in intestines, Obst. 102
-, symbiotic relationship in human body, R.S.M., Disc. (Infl.) 93
-, producing complications in influenza, R.S.M. Disc. (Infl.) 92
Microphone, action of, in connection with transformation of sound waves into electric waves,
Otol. 86
-, detection of heart-sounds by, improvements needed in, Electr. 68, 71
xc
Index
Microphone, string-galvanometer connected with, record of heart sounds obtained from,
Electr. 67
Microscopical demonstration in Museum Room, Summer Congress, Section of Laryngology
(Wyatt Wingrave), Laryng. 266
Midas (Long-tusked marmosets or tamarins), variations in positions of teeth in, Odont. 53
Midwifery, extern district cases, practice in, by students, Obst. 66
-fees of general practitioners underpaid, Obst. 96, 103, 104
-, a surgical art, Obst. 83, 104 ; see also Obstetrics
Midwives, pupil, and medical students, joint instruction to, Obst. 45
Midwives Act (1902), decline in puerperal mortality following passing of, Obst. 98, 101
Migraine (J. Herbert Fisher), Ophth. 49
-, age and sex-incidence, Ophth. 50
-, attacks of, testing of blood-pressure during, Ophth. 53
-, classical symptoms of, Ophth. 49, 50, 51
-, exciting agent, Ophth. 51
-, familial tendency to. Ophth. 50
-, personal experiences of, recorded, Ophth. 49-55
-, prodromata of, Ophth. 53
-, sequelae of, Ophth. 54
-, spectrum of, Ophth. 50, 53
Military camps, association between influenza and cerebro-spinal meningitis in, Epid. 72
-life, mental mal-adaptation to, Psych. 36
-surgery, bone-grafting in, Surg. 23
Milk fever of cows, treatment by pneumatosis, Path. 58
-of syphilitic mothers, Obst. 11
Miller, E., Lieutenant R.A.M.C.—Case of cervical concussion (shown by Dr. J. Godwiu
Greenfield), Neur. 54
-, ca'se of pachymeningitis cervicalis of syphilitic origin (shown by Dr. J. Godwin
Greenfield), Neur. 55
Milligan, Sir William—D iscussion on alternatives to operations for adenoids in young
children, Laryng. 219
-, discussion on glycophylic method of treating atrophic rhinitis with ozacna,
Laryng. 233
-on spasm at entrance to oesophagus and clinical type of dysphagia, Laryng. 236
Milroy’s disease and trophcedema of leg, connection between, Child. 106
Mind and brain, diseases of, identity from materialistic standpoint, Psych. 63
-, individual and racial connexion between, Psych. 10
-, synthetic energy of, Psych. 4
Mineral water baths, leucocytosis reaction following, Bain. 4
-, injections, experimental, followed by injections of toxins, result, Bain. 6
-, treatment, immunity in relation to, Bain. 1-12
-waters, drinking of, leucocytosis reaction following, Bain. 4
-, injection, dosage, Bain. 9
-, effect on leucocytosis reaction, Bain. 4
-following experimental injection of toxins, Bain. 6
---, immunity conferred by, Bain. 9
-, natural and artificial, compared, Bain. 10
--, oxydizing properties, Bain. 11
-, regions for activity of, in body, Bain. 10, 11
Mirror, laryngeal, first demonstration of, Laryng. 2
-, post-nasal, inspection of adenoids by, Child. 50, 52
-, training in use of, Child. 50
Mitral valve, disease of, fatal case, embolus complicating, Child. 89
Mobilization treatment of acute suppurative arthritis of right knee, case (J. Everidge),
Clin. 16
Index
xci
Mobilization treatment of suppurating knee-joints, apparatus for, described, Glin. 12, 13, 14
-, model to demonstrate methods carried out in (J. Everidge), Clin. 10
Molars, irregularity in Cebus (unclassified), Odont. 42
-, mandibular, third, tilted and rotated inwards in Cebus xanthocephalus, Odont. 43
-, maxillary, right “ Echelon ” arrangement in Cebus (unclassified), Odont. 42, 43
-, second and third, irregularity in Cebus hypoleucus , Odont. 42
-, submucous anaesthesia of, Odont. 2
Mole, hairy, pigmented, benefited by impetigo contagiosa (A. Eddowes), Derm. 47
Mollison, W. M. — Case of acute mastoiditis followed by thrombosis of the internal jugular
vein as far as the clavicle, recovery, Otol. 10
-, case of double facial paralysis due to bilateral tuberculous mastoiditis, Otol. 6
-of necrosis of the internal ear, causing sequestration of the labyrinth, recovery
(sequestrum shown), Otol. 8
--of (?) sarcoma of the tonsil, Laryng. 211
-, discussion on acute osteomyelitis of right temporal bone, Otol. 3
-on bilateral ankylosis of vocal cords, Laryng. 161
-on case of chronic unilateral laryngitis, Laryng. 165
-of sarcoma of nose, Laryng. 164
-on cyst of larynx, Laryng. 195
-on deafness associated with stigmata of degeneration, Otol. 27
-on dilatation of the oesophagus without anatomical stenosis, Laryng. 60
-on foreign body removed from nose, Laryng. 160
-on functional aphonia, Laryng. 31
-on incipient singers’ nodules in vocalist, Laryng. 25
-on injuries and inflammatory diseases affecting the orbit and accessory sinuses,
Ophth. and Laryng. lii
-on sarcoma of maxillary antrum, Laryng. 24
-on septic infection of lateral sinus injured during mastoidectomy, Otol, 74
-on treatment of a case of epithelioma of epiglottis by diathermy, Laryng. 158, 159
-, specimens of dilatation of oesophagus, Laryng. 72, 73
Mongol, sclerodermia with calcification in (F. S. Langmead), Child. 94
Monkey (Macacus rhesus ), human acute infective polio-encephalo-myelitis in, manifestations,
Path. 35
-:-, mode of transmission, Path. 34, 35
Monkeys (New World), teeth in, variations in position of (J. F. Colyer), Odont. 39
Monoplegia, hysterical, case of, treatment, result, Psych. 60
Moore, Irwin. —Adhesions and contracture of faucial pillars following complete enucleation
of the tonsils, Laryng. 180
-, carcinoma of the maxillary antrum, lateral rhinotomy, recurrence, Laryng. 24
-, case of long fraenum lingu®, Laryng. 108
-, demonstration of some new instruments recently designed for the removal of foreign
bodies from the lungs by peroral endoscopy, Laryng. 20
-, displacement of the lateral cartilages of the nose, Laryng. 108
-, discussion on adenoids, Child. 47
-on case of tongue for diagnosis, Laryng. 199
-on cases of pharyngeal diverticulum, Laryng. 250
-on foreign bodies impacted in food and respiratory passages, Laryng. 18
-on naso-pharyngeai angeio-fibroma, Laryng. 176
-growth, Laryng. 209
-on removal of bone impacted in oesophagus, Laryng. 172
-on submucous lipoma of palate and larynx, Laryng. 192
-, epidiascopic demonstration of the normal histology of the vocal cord and ventricle of
larynx, considered in connexion with the development of adenomata, Laryng. 199
-, foreign bodies impacted in the food and respiratory passages recorded at the Section of
Laryngology of the Royal Society of Medicine since 1908, Laryng. 14
XC11
Index
Moore, Irwin.- x-Malignant growth of deep pharynx, Laryng. 210
-, nasopharyngeal growth, Laryng. 208
-, pathology of cesophagectasia (dilation of the oesophagus without anatomic stenosis at
the cardiac orifice), Laryng. 67
-, recurring spheno-choanal polypus in a child, Laryng. 104
-, remarks on Dr. Macleod’s specimen of adenoma of vocal cord, Laryng. 149
-, sarcoma of maxillary antrum, lateral rhinotomy, recurrence in glands, radium
treatment, Laryng. 21
-, the treatment of enlarged or diseased tonsils where surgical procedures are contra¬
indicated, Laryng. 243
Moore, R. Foster.—M elanoma of the choroid, Ophth. 60
-, sympathetic ophthalmitis with fundus changes, Ophth. 25
Moralists, attitude towards prophylaxis of venereal diseases, R.S.M. Lect. 10
Morel ear, associated with criminality, Otol. 26
Morison. Alexander.—D iscussion on the electrocardiograph, Electr. 68, 70
Morphia, administration, in avoidance of surgical shock, R.S.M. Disc. (Shock) 29
-in influenza, Med. 71
-, pneumonic, Med. 71
-, habit, spasm at entrance to oesophagus following relinquishment of, Laryng. 236
Morphine and atropine, preliminary injection before operation for tonsillectomy, Anaesth. 19, 20
-and hyoscine, injection into recipients of transfused blood before transfusion, Med. lO
Morphoea guttata, white spot disease, associated with linear sclerodermia, Derm. 24
-, cases of (S. E. Dore), Derm. 3
-(J. L. Bunch), Derm. 24
-, mother-of-pearl lesions accompanying, Derm. 5
Morphceo-sclerodermia and unilateral band sclerodermia of left leg, case (George Pernet),
Derm. 43
Morris, C. S.- Discussion on local anaesthesia in dental operations, Odont. 5
Mother, mortality in extra-uterine pregnancy, percentage according to time of operation,
Obst. 156
-, safety of, first aim in conduct of labour, Obst. 91, 92
-, results of operation to, in one hundred cases of extra-uterine pregnancy, Obst. 154, 155
Mothers, anti-syphilitic treatment of, in prevention and treatment of syphilis in unborn
infants, Obst. 9, 11
-, expectant and nursing, separation allowances and pension benefits for, Obst. 56
-, syphilitic, breast-feeding by, unreliable, Obst. 10, 11
-, children of, remaining permanently free from syphilis after treatment, Obst. 14, 16
-, early treatment, Obst. 14, 15
-, milk of, Obst. 11
Mother-of-pearl lesions accompanying morphcea guttata, Derm. 5
Motor and parallel saw, separation of tibial graft by, Odont. 97
Mott, Sir F. W., F.R.S.—Discussion on epidemic encephalitis, Med., Path, and Epid. i
-, discussion on shock, R.S.M. Disc. (Shock) 19
-, groups of neurons with inherited low power of storage energy, quoted, Otol. 21
-, importance of disturbances of the endocrine glands in the symptomatology of war
neuroses, quoted, Psych. 59
-, multiple punctate hemorrhages in substance of brain, quoted, Neur. 36
-, part played by the physical manifestations of the emotions in determining form taken
by war neurosis, quoted, Psych. 59
Moulds, relationship of bacteria to, R.S.M. Disc. (Infl.) 93
Mouth, driving of compressed air into, danger of, Path. 55
-, epithelioma of, treatment by diathermy, Electr. 27
-by figuration, Electr. 27
-, floor of, and right submaxillary region, tumour of, ? actinomycosis (W. H. Jewell),
Laryng. 215
Index
xciii
Mouth, opening to, frequent constriction, preventing insertion of impression tray, Odont. 74
-, ulcerations in, causing obliteration of buccal sulci, Odont. 18
-, use of toothbrush and antiseptics in, Odont. 29
-breathing, discouragement of, in prevention of adenoids, Child. 55
-, ill-effects of, Child. 33, 34, 53
-washes, antiseptic, Odont. 30, 31
Mucicarmine, use of, in demonstration of spread of cancer of mucous glands, Electr. 42, 43
Mucin, elixoid, in dilatation of oesophagus without anatomical stenosis, Laryng. GO
Mucocele of frontal sinus (G. W. Dawson), Laryng. 158
Mucosa, hyperesthesia of, in stenosis of pylorus, Laryng. 58
-of human intestine and stomach, non-sensitive, Path. 78
Mucous glands, cancer of, mode of dissemination, how demonstrated, Electr. 42
-membrane, pigmentation of. case (H. C. Samuel), Derm. 27
-secretion, deficiency, in dilatation of oesophagus without anatomical stenosis, Laryng. 60
Mummery, J. Howard.— On the nerve end-cells of the dental pulp (abstract), Odont. 1L
Munich, influenza epidemic at, 1889-90, R.S.M. Disc. (Infl.) 22
Murray, J. A.—Discussion on epidemic encephalitis, Med., Path, and Epid. v
-, sudden death in Chilian sea-eagle from over-distension of abdominal air-sac, quoted,
Path. 63
Muscle-grafting, continuous, in filling up bone oavities, Surg. 2, 3
-, advantages, Surg. 2, 3
-, points to be observed in, Surg. 5, 6
--, results, Surg. 5
--, selection of cases for, Surg. 3
-, muscle used for, must be muscle tissue only, Surg. 5
-grafts used for filling up bone cavities, fate of, Surg. 3, 4
-pains in influenza, R.S.M. Disc. (Infl.) 65
Muscles, abdominal, effect of visceral pain on, Neur. 6
-, sclerodermia with calcification affecting, Child. 96, 98
Muscular relaxation, absolute, during operations, produced by stovaine, Amesth. 9
Musical anus, Path. 54
Mustard, oil of, inhalation of, inducing cough and expectoration (J. Dundas Grant), Laryng. 26
—-inducing cough and expectoration in malingerers, Laryng. 26
Mutism, deafness and amnesia in walking case of war neurosis, Psych. 54
-of ten months’ duration, case (J. Dundas Grant), Laryng. 29
Mycetes (Howling monkeys), typical dental arch in, Odont. 47, 48
-, variation in position of teeth in, Odont. 47
- niger , irregularity of position of maxillary left first premolar in, Odont. 49, 50
-of premolars in, Odont. 49
-(unclassified), irregularity in position of premolars in, Odont. 48, 49
Mycosis fungoides, case (E. G. Graham Little), Derm. 24
Myoclonus multiplex, case of (F. J. Poynton), Child. 17
Myringotomy and partial ossiculectomy in case of chronic adhesive otitis (P. Watson-Williams),
Otol. 95
-in treatment of atresia of Eustachian tube, Otol. 96
Nabarro, David.— Discussion on case of multiple epulides, Child. 70
-, report on sections of case of multiple epulides shown by Mr. W. Warwick James, Child. 69
Ntevi, pigmented, extensive, case (E. G. Graham Little), Derm. 13
Noevo-carcinoma, case, treatment by radium, Derm. 42, 43
-, melanotic, case (George Pernet), Derm. 42
-, treatment by carbon-dioxide, Derm. 42
-, types of, Derm. 42
XC1V
Index
Nasal and septal supports, and bridge of nose, wounds causing loss of, method of repair,
Laryng. 126
-cavities, openings of palate into, causing difficulty in taking impression for construction
of dentures, Odont. 74, 76
-, wounds of, cases, casts, &c., illustrating methods of repair of (G. 8eccombe Hett),
Laryng. 115
-cavity, normal, sterility of, called in question, Laryng. 226
-obstruction and adenoids, Child. 32
-and depressed bridge of nose caused by wounds, treatment, Laryng. 130
-, causes of, Child. 32
-, left sided, due to hypertrophied left middle turbinal, with left-sided optic neuritis,
treatment, Ophth. and Laryng. xxvii
-, types of mal-development of jaws associated with, Child. 33
- passages, completely obstructed, restoration after injury, Ophth. and Laryng. lvii
-, narrowness in new-born infants, Child. 32
Naso-pharyngeal growth (Irwin Moore), Laryng. 208
Naso-pharyngitis, cause of adenoids, Child. 36
Nasopharynx, adenoid tissue of, hyperplasia of, hereditary tendency to, Child. 38
-, cultures from, in influenza, R.S.M. Disc. (Inf!.) 53
-, close relation of pterygoid muscles to, Child. 27
--, lymphatic tissue of, work of, how encumbered, Child. 42
-, narrowness in new-born infants, Child. 32
-, septum and middle ear, malformations in, associated with deafness, Otol. 28
-, small size in children with rickets, Child. 51
National Munition Factories, workers in, incidence of influenza epidemic (1918) on, R.S.M.
Disc. (Infl.) 22, 23
Natural science, only training of neurologists and alienists, Psych. 63, 64
Nebulae, clear lines in formation of (W. T. Holmes Spicer), Ophth. 1
-, following interstitial keratitis, Ophth. 2
-, geometrical, Ophth. 2
-, mushroom-head shaped, Ophth. 2
Neck, dislocation and fixation in upper part of, in treatment of pharyngeal diverticulum
(J. Dundas Grant), Laryng. 156, 166
-, emphysema of, Path. 56
-, complicating “ gassing,” Path. 57
-influenzal pneumonia, R.S.M. Disc. (Infl.) 60, 64, 100, Path. 57
-subcutaneous, in birds, Path. 60
-, enlarged glands in, in case of epithelioma of palate and anterior faucial pillar (Norman
Patterson), Laryng. 183
-, malignant glands in, treatment by diathermy, Electr. 27
-, root of, trilobed upper limit of air-sacs at, in birds, Path. 61
Necrosis of internal ear, causing sequestration of labyrinth, recovery (W. M. Mollison), Otol. 8
Negroes, pigmented cells in ciliary muscles in, Ophth. 61
Neo-Lamarckism, definition of, Psych. 11
Neo-pallium, development, results of, Neur. 5
Neoplasms, true, separation from blastomastoid conditions, Path. 1
Nephritis complicating influenza, R.S.M. Disc. (Infl.) 100
-followed by combined hysterical and organic hemiplegia of two years' duration ; almost
complete recovery with psychotherapy, case, Neur. 26
-of pregnancy, as cause of maternal mortality in childbirth, Obst. 83
Nerve, auditory, terminations of, transmission of sound waves to, Otol. 84
-cells in preparations from cases of encephalitis lethargica, Path. 44, 45
-——-, material in granular pigment resembling,
Path. 44, 45
- deafness and retro-bulbar neuritis, Ophth. and Laryng. xliii
Index
xcv
Nervo deafness associated with fragility of bones and blue sclerotics, Otol. 130
-end-cells of dental pulp (J. Howard Mummery), Odont. 11
-, processes of, Odont. 12
--endings, destruction of, cause of giddiness following labyrinthectomy, Otol. 102
--impulses, transmission of, in hearing, Otol. 88
-influence, loss of, and otosclerosis, Otol. 130, 131
-, optic, atrophy of, conclusive of structural change in central nervous system, Neur. 25
-haemorrhage, intravaginal, without fracture of orbit or optic foramen in head
injuries, Ophth. and Laryng. lxiii
-, incision of sheath of, in intravaginal haemorrhage preventing blindness, Ophth. and
Laryng. lxiii
-, pressure on, due to distension of maxillary antrum followed by blindness, Ophth. and
Laryng. lvi
Nerves, cranial, paralysis of, in encephalitis lethargica, Med., Path., and Epid. xv, xviii,
xix, xx
-, facial, microscopic examination in case of otosclerosis associated with otitis media,
Otol. 119, 123
-of tooth, mode of distribution anomalous, Odont. 12
-, peripheral, lesions of, condition of sensibility during protopathic stage of recovery from,
Neur. 7
-, sensory, stimulation of, producing contraction of blood-vessels throughout body, R.S.M.
Disc. (Shock) 10, 33
Nervous system, central, biphasic reaction, Neur. 11
-, factors in morbid manifestations produced by, Neur. 3
-, functions of, adaptation to fresh purposes, Neur. 5
-, higher, assisted by lower, Neur. 6
-, integration on evolutionary principles, Neur. 7
-, mode of evolution, Neur. 9
-, physiological, main features of, Neur. 11
-, teaching of Hughlings Jackson regarding, Neur. 6, 7
-, general resistance to impulses, variability in, Neur. 11
-, injury of, hysterical element in (A. F. Hurst and J. L. Symns), Neur. 21
-, lesion of, negative manifestations, how presented, Neur. 9
-, producing positive effects, Neur. 9
-, lesions found post-mortem in cases of encephalitis lethargica, Path. 43-45
-, localizing signs in, accompanying encephalitis lethargica, Med., Path,, and
Epid. xviii, xx, xxii
-, organic disease, hysterical element in (Arthur F. Hurst and J. L. M. Symns),
Neur. 21
-, hemiplegia with signs of, following concussion by shell
explosion, cured by psychotherapy, Neur. 27
-, physical signs qualitative, not quantitative, Neur. 22
-, reason for existence, Neur. 5
-, effect of reinstatement of intense emotion on, in war neurological cases with
amnesia, Psych. 57
-, functions of, general disturbance in encephalitis lethargiea, Med., Path., and
Epid. xviii, xix
- f integration of function within, on what based, Neur. 10
-, organic disease of, signs and symptoms of third group becoming part of hysterical
condition in hysterical paralysis, Neur. 25, 26
Neurasthenia and hysteria, no fundamental difference between, Neur. 14
-, case of, symptoms aroused by particular locality or position, Neur. 18
-, hysteria developing into, Neur. 14, 15
-, manifestations of, following spontaneous cure of hysterical manifestations, case
illustrating, Neur. 15
XCV1
Index
Neurasthenia, real shell-shock as distinguished from, case illustrating, Neur. 49, 50
-, shame as factor in onset of, Neur. 19
Neuritis, optic, connected with inflammatory condition of accessory sinuses, nature of,
Ophth. and Laryng. xxxvii
-, left sided, with left-sided nasal obstruction due to hypertrophied left middle
turbinal, treatment, Ophth. and Laryng. xxvii
-, retrobulbar, and disease of sphenoidal sinus and posterior ethmoidal cells, Ophth. and
Laryng. lxiv
-, and sinusitis, relations between, diversity of opinion as to, Ophth. and Laryng. lxvi
-, investigation by Joint Committee proposed, Ophth. and Laryng. lxvii
-, complicating inflammation of accessory sinuses, Ophth. and Laryng. xxvii, lxiii
-, due to hypertrophy of ethmoid without suppuration, Ophth. and Laryng. xxvii
-, pus not present in accessory sinuses in, Ophth. and Laryng. liii
-, with central scotoma, Ophth. and Laryng. xliii
-, with contraction of visual fields, Ophth. and Laryng. xlix
-, with loss of vision, Ophth. and Laryng. xlii
-due to nasal sinus suppuration or disease, Ophth. and Laryng. xlii
-, with nerve deafness, Ophth. and Laryng. xliii
-, without nasal lesion, Ophth. and Laryng. Ixv
-, unilateral, nasal lesions rare in cases of, Ophth. and Laryng. lx
- f without nasal disease, Ophth. and Laryng. xliii
Neurofibrils arising from axis cyclinders of medullated nerves of pulp, course of, Odont. 11, 12
Neurofibromatosis, multiple (von Recklinghausen’s disease) (E. Bronson), Child. 21
Neurogenic as opposed to commotional origin of shell shock, Neur. 42, 43
Neurological cases during push in war, causation, dissociation of psycho-physical functions,
Psvch. 55
-interest, cases with signs of (Henry Head, F.R.S.), Neur. 53
Neurologists, knowledge of psychology indispensable to, Psych. 65
-, natural science only training of, Psych. 63, 64
Neurology, some principles of (Presidential Address) (H. Head), Neur. 1
-, text-books of, unsatisfactory explanations given in, Neur. 2
Neuromata, multiple, of skin, case (E. G. Graham Little), Derm. 35
Neuropathies, inherited low power of storage energy in groups of neurons in, Otol. 21
Neuroses, always preceded by anxiety, Neur. 14
- following exposure to detonation of high explosives, differentiation from those of
psychogenic origin, Neur. 48, 50
-, peace and war, inter-relations between (T. A. Ross), Neur. 13
-, relapses in, treatment, Neur. 13
-, treatment of, element of relief in, Neur. 13, 14
-, value of anamnesis in, Neur. 16, 17
-, underlying anxiety in, treatment necessary, Neur. 14
-(war), symptomatology relation of disturbances of endocrine glands to, Psych. 59
Neurosis following detonation of high explosives, combined operation of emotion and
commotion in, Neur. 49
-war, [etiology, Psych. 55
-, amnesia in, treatment, Psych. 57
-, cases of, in late stage, treatment by mental analysis (autognosis). Psych. 60, 61
-, chronic, treatment, Psych. 55
-, incubation process, Psych. 55
-, vaso-motor and secretory symptoms in, Psych. 55
-, comparison of early cases seen in the field with those seen at base (William
Brown), Psych. 52
--, complex underlying, method of bringing to light, Neur. 15
-, dissociation of psycho-physical functions in, Psych. 55
-, early cases seen in the field, percentage of returns to duty iu the field, Psvch. 53
Index
XCVll
Neurosis, war, early cases treated in the field, after-histories, Psych. 59, 60
-, treatment by persuasion, Psych. 53
---, principal methods, Psych. 51
-form assumed by, part played by physical manifestations of emotion in determining,
F’sych. 59
-, in the field, cases of, blood-pressure in, Psych. 58
--, motor symptoms in, Psych. 55
---, resistant cases, symptoms arising after period of meditation, Psych. 55
-, stretcher cases, Psych. 54
-, types of, seen in cases during a push in the War, Psych. 53
-, walking case, with deafness, mutism and amnesia, Psych. 54
Newcastle-on-Tyne, measles epidemics in, amplitudes, Epid. 90, 92, 95
Newman, Sir George, advocacy of teaching of obstetrics and gynaecology simultaneously,
Obst. 42
-, criticism on the teaching of obstetrics ond gynaecology, quoted, Obst. 41
-, memorandum on medical education in England, quoted, Obst. 40, 41, 45, 47, 48
-, psychological aspect of preventive medicine, quoted, Obst. 47, 48
--, teaching of preventive medicine, quoted, Obst. 41
New 8 H 0 Lme, Sir Arthur, K.C.B.—Discussion on epidemic encephalitis, Med., Path, and
Epid. xiii
-, discussion on influenza, R.S.M. Disc. (Infl.), 1
-, excessive maternal mortality from child-bearing in United Kingdom, quoted, Obst. 77
Newt, collection of air in abdominal cavity of, Path. 52
New York and district, encephalitis lethargica epidemics in (1916), Med., Path, and Epid.
xxi, xxii
Night-terrors, cause of, Child. 34
Nile-blue sulphate, use in staining sections from cases of pyorrhoea, Odont. 105, 106
Nitch, C. A. R. and Shattock, S. G., F.R.S.—Diffuse emphysema of the intestinal wall
(two cases) with remarks on pneumatosis, Path. 46-86
Nitric acid and phloroglucin as decalcificant of teeth, Odont 36
Nitrogen, oxygen and carbon dioxide, relative diffusibility through intestinal wall, Path. 70
Nitrous oxide gas and oxygen, administration in cases of shook, R.S.M. Disc. (Shock), 23
-during operations on subjects of traumatic shock, R.S.M. Disc. (Shock) 32
-, laryngofissure with removal of intralaryngeal growth performed under
(H. E. G. Boyle), Anaesth. 20
Nocardiasis, primary, of lachrymal gland caused by species of Nocardia hitherto undescribed,
case (J. B. Christopherson and R. G. Archibald), Ophth. 4
-- clinical history and description of case, Ophth. 4
-, pathological histology, Ophth. 7
Noguchi, granulation of spirochaetes, quoted, Obst. 13
Non-naturals, explanation of, Epid. 59 (footnote)
Non-touch technique in preparation of operative field for mandibular bone-grafting, Surg. 15
Northcroft, George.—A short review of another year’s work at a Jaw Injuries Centre,
Odont. 7 ‘
Nose and "both orbits, through-and-through wounds of, Ophth. and Laryng. xxxix
-- and eye, gunshot wound of, use of reversed pedicle forehead flap in, Laryng. 142
-and nasal accessory sinuses, gunshot wounds of, epidiascopic demonstration of methods
of treatment (G. Seccombe Hett), Laryng. 135
-and orbit, gunshot injuries of, dangerous nature, Ophth. and Laryng. xxxviii
--, bony growth in (G. W. Dawson), Laryng. 213
-, bridge of, and nasal and septal supports, wounds causing loss of (pug-nosed type),
method of repair, Laryng. 126
-, wounds of, causing chronic dacryocystitis, treatment, Ophth. and Laryng. xiii
-, condition found at modified radical mastoid operations, Otol. 45
-, dermoid fistula of (W. Stuart-Low), Laryng. 102
7
XCV111
Index
Nose, epithelioma of, treatment by diathermy, Electr. 28
-, foreign body removed from, after thirteen years, case (R A. Worthington), Laryng. 159
-, lateral cartilages of, displacement of (Irwin Moore), Laryng. 108
-, loss of portion of one side of, treatment by lateral septal swing, Laryng. 125
-, method of repair of right side of, case showing (S. Hastings), Laryng. 110
-, sarcoma of, removal by external modified operation (Moure's lateral rhinotomy) (Andrew
Wylie), Laryng. 162
-, septic dermatitis of, followed by sphenoidal sinus thrombosis, ending fatally, Ophth.
and Laryng. xxxvii
--processes in, iritis and cyclitis associated with, Ophth. and Laryng. xxxvi, xxxvii
-, sunken bridge, due to gunshot wound, profile before and after insertion of costal
cartilage graft, Laryng. 144,146
——, syphilis of, tertiary, absorption of pre-maxilla in (Dan McKenzie), Laryng. 28 .
-, tip of, alee and columnella, restoration of, Laryng. 120
-, total loss of, treatment by rhinoplasty, Laryng. 186, 140
-, wounds of, causing depressed bridge and nasal obstruction, treatment, Laryng. 130
-, causing lachrymal sac suppuration, Ophth. and Laryng. xii
--, methods of repair (G. Seccombe Hett), Laryng. 117,136
-, use of forehead flap containing anterior division of superficial femoral artery,
Laryng. 142, 143
Novarsenobillon, intravenous injections in treatment of syphilis in mothers, Obst. 9
Novocain, in dental operations, Odont. 1, 5
-, dosage, Odont. 1, 6
-, method of application, Odont. 1
Nurses, value of clinical teaching of obstetrics to, Obst. 89
Nyctipithecus (Nocturnal owl-faced monkeys), variations in position of teeth in, Odont. 52
-, (unclassified), irregularity in position of maxillary and mandibular incisors in, Odont. 52
Nystagmus, caloric, in chronic suppurative otitis media, Otol. 33
-, rotatory, due to sudden alteration of tension in middle ear, Otol. 100
-, types of, in labyrinthitis complicating chronic middle-ear suppuration, Otol. 48
Oatmeal and potato diet, decline of, among Highlanders, Odont. 29 *
Obstetrical complications, pathology, teaching of, Obst. 35
- Department, and Department for Disease of Children at St. Thomas’s Hospital,
connexion between, Obst. 46
-operations, reduction of infantile death-rate by, Obst. 56
-outfit, source of funds for, Obst. 105
-*work, cardinal decisions in, Obst. 91
Obstetrician, sterilized outfit of, Obst. 90
Obstetrics and gynecology, examination regulations, reform in, Obst. 68
-, examination system, defects in, Obst. 66
-, knowledge of general medicine attained by students when entering on course of,
Obst. 41
-, research in, paucity of, Obst. 66
-should not be separated for purposes of teaching and research, Obst. 59
- 1 subjects to be taught in, and methods of teaching them to medical students
(W. S. A. Griffiths), Obst. 33
-, teachers of, qualifications, Obst. 66
-, qualifications needed, Obst. 58
--, teaching of, at Johns Hopkins Hospital, Baltimore, Obst. 70
-, clinical, Obst. 69, 70
-, reform of, Obst. 65
-, from point of view of general practitioner (Lovell Drage), Obst. 49
-, from standpoint of preventive medicine (John S. Fairbairn), Obst. 40
Index
XC1X
Obstetrics and gynaecology, teaching of, in Scotland, Obst. 68, 69
-, reforms in, Obst. 62, 63.
-, to medical students, reconstruction in, discussion on, Obst. 33-74 (H.
Andrews, 72 ; Lady Barrett, 68 ; G. F. Blacker, 56; Victor Bonney, 64 ; E. L. Collis,
T. W. Eden, 58 ; Sir Walter Fletcher, 60; Eardley Holland, 59; R. W. Johnstone,
F. J. McCann, 62 : J. D. Malcolm (President), 53 ; Amand Routh, 53; Lapthorn
Smith, 67 ; T. G. Wilson, 70 ; H. Williamson, 65)
-simultaneously, Obst. 72
-, importance of, Obst. 42
-, sketch of satisfactory scheme, Obst. 122
-, training in, damaging effect of examination system on, Obst. 47
-and pediatrics, dividing line between, where to be drawn, Obst. 46
-, study of, distinction between, Obst. 60, 65
-, combination of teaching of hygiene and diseases of infants with that of, Obst. 45, 46
-gynaecology, maternity and child welfare, teaching in one lyiug-in hospital, Obst. 57
-, isolated position of, Obst. 84
-, out-patient work in, departments of, Obst. 37
-, subjects relating to, capable of being taught by demonstration-lectures, Obst. 36
-to be taught in, Obst. 34
-, a surgical art, Obst. 64
-, teaching of, as means of preventing loss among the fit, Obst. 73
-, clinical, in, improvements suggested, Obst. 56, 57
-of post-graduates (F. J. McCann), Obst. 134
-means for, great importance of, Obst. 38
-, opportunities for teaching ill provided in most hospitals, Obst. 38
-, provision at Queen Charlotte’s Hospital, Obst. 39
-, value to nurses and students, Obst. 39
-, from standpoint of preventive medicine (J. S. Fairbairn), Obst. 40
-, methods, Obst. 35
-, defects in, of, Obst. 113
-, order in which subjects should be taken, Obst. 35
-, present system of, Obst. 109
-, scheme for, Obst. 122-129
-, to medical students and graduates in London, report on, Obst. 108-134
-, training in, efficient, basis of, Obst. 120-122
-, defective, consequences, Obst. 118-120
Occipital region, wound in, causing organic blindness, and associated with hysterical deafness
followed by partial hysterical blindness, psychotherapy curing, Neur. 29
CEdema of infra-orbital region, treatment by lymphangioplasty, Ophth. and Laryng. lxii
-, pulmonary, with subcutaneous emphysema following phosgene poisoning, Path. 58
-, symmetrical generalized, facial aspect of, simulating that of kidney disease, Derm. 27
-, transient, complicating malaria, Med. 29-30
-, erythromelalgia, and Raynaud’s disease combined, complicating malaria, Med. 29
CEsophagectasia, aetiology, various opinions as to, Laryng. 37
-, pathogenesis of, Laryng. 38
-, pathology of (dilatation of oesophagus without anatomic stenosis at cardiac orifice) (Irwin
Moore), Laryng. 67
-, without intrinsic anatomic stenosis, primary cause, Laryng. 38
CEsophagoscope, examination by, aspect of hiatal oesophagus under, Laryng. 50
-in differential diagnosis of various forms of dilatation of oesophagus, Laryng. 34, 42
CEsophagoscopy for removal of tooth-plate in oesophagus (Hunter Tod), Laryng. 11
(Esophagus and stomach, dividing line between, Laryng. 92, 97
-, aspiration of air into, during cesophagoscopy, Path. 54
-at rest, embraced by crura of diaphragm, Laryng. 36
-, cardiac orifice or cardiac end of, effect of cocainization on, Laryng. 59
8 2 td
c
Index
(Esophagus, collapsed at rest, at hiatal level, Laryng. 36
-, condition in extreme pyrosis, Laryng. 62
-, dental plates removed from, two cases (J. Gay French), Laryng. 12
-•, dilated, effect of hyperacidity on, Laryng. 62
-, flask-shaped, Laryng. 62
-, dilatation, congenital, enteromere theory of, Laryng. 70
-, estimation, Laryng. 238
-, share of superior constrictor in producing, Laryng. 66
-, simple, Laryng. 70
-, thickening of muscular coat in, Laryng. 96
--, treatment (A. Brown Kelly), Epid. 48
- 9 vocal paralysis in relation to, Laryng. 38
_ } with anatomic stenosis, aetiology of, explanation attempted, Laryng. 96
_, diagnosis from functional by endoscopy, Laryng. 34, 42
_, by X-ray, Laryng. 34, 42
_ t with overgrowth of cardiac sphincter, Laryng. 96, 97
_, without anatomic stenosis, aetiology, Laryng. 41
_, discussed, Laryng. 59
_, age and sex-incidence, Laryng. 59, 60
_, case of (Robert Worthington), Laryng. 95
_, cases described, Laryng. 60-64
__, complete, Laryng. 34
_, death from shock, following gastrostomy, Laryng. 62
__ deficiency of mucous secretion in, Laryng. 60
_, diagnosis by blind bougieing, Laryng. 34, 42
_I- 1 discussion on, Laryng. 33-100 (J. Dundas Grant, 62; Douglas
Harmer, 63 ; William Hill, 33, 66 ; W. Howarth, 64 ; A. Brown Kelly, 48, 67, 65, 67 ;
Dan McKenzie, 61; W. M. Mollison, 60 ; A. D. Sharp, 65 ; Professor S. G. Shattock,
57, 67, 95; W. Stuart-Low, 59 ; Sir StClair Thomson, 63 ; H. L. Whale, 65)
_, feeding through tube in, Laryng. 40, 46
_, forms of, Laryng. 33
_, inco-ordination theory, question of priority, Laryng. 70
_, nature of, discarded theory as to, Laryng. 37
_, pathology (Irwin Moore), Laryng. 67
_, site of obstruction, Laryng. 66
__, specimen from Victoria Infirmary, Glasgow (A. Brown Kelly),
Laryng. 78, 91
__ specimens, exhibited from London Museum, Laryng. 68-93, 96-100
_(H. S. Barwell), LaryDg. 68-71
_(W. Howarth), Laryng. 71-72
_(W. M. Mollison), Laryng. 72, 73
_(F. A. Rose), Laryng. 74
_(Herbert Tilley), Laryng. 75, 76
_, case-histories, Laryng. 68-78
__, sudden disappearance and relief of symptoms, Laryng. 68, 64
_•, treatment by bougieing, Laryng. 40
_by drugs, Laryng. 63
__by electricity, value limited, Laryng. 39
_by lavage, Laryng. 40
_by lubrication, Laryng. 60
__local, by passage of mercury tube, Laryng. 60, 61
_operative, Laryng. 41
_ ? examination of, by bougieing, in cases of dysphagia, Laryng. 236, 237, 238
---by endoscope, Laryng. 236, 238
_ t expulsion of air through, after aspiration into stomach, from displacement of viscera.
Path. 55
Index
ci
(Esophagus, foreign bodies impacted in, methods of removal discussed, Laryng. 17
-body in, case occurring at Royal Naval Base Hospital (J. Gay French), Laryng. 13
—, hiatal, appearances in cardiospasm, Laryng. 50, 51
- —, distance from upper incisors, Laryng. 48, 49
-, lumen of, size and shape, Laryng. 49
— . impediment to free passage of food through, suggested cause, Laryng. 36
-—, jagged piece of bone impacted in ; removal by indirect method (W. Jobson Horne),
Laryng. 171
-. lower end of, close apposition of crura to, Laryng. 92, 97
-, malignant disease of, probably present in case of bilateral ankylosis of vocal cords,
Laryng. 162
— , muscular hypertrophy without dilatation, accompanied by dilatation of heart,
Laryng. 99, 100
-, conditions represented by, Laryng. 100
--- normal, length of, sex, height and age in relation to, Laryng. 49
-, obstruction in, in relation to action of diaphragm, Laryng. 98, 99
- —, types connoted by term cardiospasm, Laryng. 35
-, with local dilatation above, due to aortic aneurysm, Laryng. 100
-, orifice of, dilatation, Laryng. 66
-, upper, dilatation, mechanism of, Laryng. 66
-, phreno-cardiac, dilatation, mechanism of, Laryng. 66
-, neuro muscular paresis and absence of co-ordinate active opening up of, during
swallowing, Laryng. 36
-, reflex achalasia of, due to irrtation of gastric ulcer, skiagram showing (S. G. Shattock),
Laryng. 94
---, in stomach preventing entry of ingesta from, Laryng. 99
--, spasm at entrance to (A. Brown Kelly), Laryng. 235
-- ? associated with dysphagia, Laryng. 235
---following relinquishment of morphia habit, Laryng. 236
-, diagnosis, Laryng. 236-239
-, functional, Laryng. 236, 237, 238
-, primary, Laryng. 237
-, secondary. Laryng. 237
--, stenosis of, site, Laryng. 34
-, tooth-plate impacted in, death following, Laryng. 18
--divided by Irwin Moore’s cutting shears (Somerville Hastings), Laryng. 7
-for eight weeks; three unsuccessful atttempts at removal, death from perfora¬
tion into pleural cavity (C. E. Woakes), Laryng. 8
-, oesophagoscopy, removal (Hunter Tod), Laryng. 11
-, tooth-plates (three) impacted in, removal (A. Brown Kelly), Laryng. 27
O’Flynh, Miss Eliz.—C ase of lymphadenoma, arsenical pigmentation, Clin. 17
Oil-ether anaesthesia, value of, in case of abdominal section in man with thoracic aneurysm,
Ansesth. 22
-, rectal administration in operation for mandibular bone-grafting, Surg. 14
Oleum sinapis, see Mustard , oil of
Oligsemia in shock, R.S.M. Disc. (Shook) 7
O’Malley, J. F.—Case of circumscribed labyrinthitis, Otol. 99
-, case of labyrinthectomy, Otol. 101
-, chronic middle-ear suppuration, Otol. 13
-, discussion on adherent palate, Laryng. 151
-on angeioma of left arytaenoid, Laryng. 150
-on bilateral ankylosis of vocal cords, Laryng. 161
-on case of adhesions and contracture of faucial pillars following complete enuclea¬
tion of tonsils, Laryng. 180
-of necrosis of internal ear causing sequestration of labyrinth, Otol. 9
Cll
Index
O’Malley, J. F.—Discussion on case of sarcoma of nose, Laryng. 163
-, discussion on extensive symmetrical lupus erythematosus, Otol. 6
-on functional aphonia, Laryng. 30, 31.
-on injuries and inflammatory diseases affecting the orbit and accessory sinuses,
Ophth. and Laryng. Ill
-on latent sinusitis in relation to systemic infections, Laryng. 225
-on non-surgical treatment of enlarged or diseased tonsils, Laryng. 246
--on sarcoma (?) of left tonsil, Laryng. 27
-on sellar decompression for pituitary tumours, Laryng. 254
-on treatment of wounds of nose and nasal accessory sinuses, Laryng. 133
-on two cases of radical mastoid operation for cholesteatoma, Otol. 12
-, gunshot wounds of the nasal accessory sinuses, Laryng. 241
-, vertigo ; (?) labyrinthine or cerebellar, Otol 79
Omentum, lesser, structures between, radiogram showing, Electr, 78
-, lipoma of, as distinguished from prevertebral lipoma, Obst. 198, 199
Onodi, on sphenoidal and posterior ethmoidal sinuses, quoted, Ophth. and Laryng. ii
Opaque meal, gall-stones in gall-bladder, patient after taking, Electr. 81
Operations, minimum loss of vital energy under, Anaesth. 11
Ophidium , gas-gland of, Path. 67
Ophthalmic complications of sinusitis, Ophth. and Laryng. iii
Ophthalmitis, sympathetic, investigation by committee of Ophthalmologieal Society, Ophth. 28
-, onset after enucleation of exciting eye, Ophth. 28
-, course of, Ophth. 28
-, with fundus changes (R. Foster Moore), Ophth. 25
-, complicated by keratitis punctata, Ophth. 27, 28
Ophthalmoplegia externa (bilateral), ptosis with, unusual case (M. L. Hine), Ophth. 61
-in encephalitis lethargica, Med., Path, and Epid. xvi.
Opinions, holding of, emotional basis for, Psych. 17
Opium, question of giving or withholding after abdominal operation (1884), Obst. 3, 4
Optic chiasmaand sella turcica, drawing of transverse section through, to show relations of
pituitary body (J. Herbert Fisher), Ophth. 56
-disk, pigmented connective tissue immediately in front of, and covering (L. V. Cargill
and W. J. Lindsay), Ophth. 57
-, causation discussed, Ophth. 58
-foramen, fracture of, intravaginal haemorrhage of optic nerve in head injuries without,
Ophth. and Laryng. lxiii
-thalamus, loss of control of cortex over, Neur. 7
Optics, physiological, of stereoscopic vision, Electr. 5
Orbit and accessory sinuses, gunshot wounds of, danger and fatality according to area
involved, Ophth. and Laryng. xxix
-, early suture, Ophth. and Laryng. xliv, lxiv, lxv
-, symptoms in early stage, Ophth. and Laryng. xxviii, xxix
-in later stages, Ophth. and Laryng. xxix
- ? injuries of, treatment in early stage, Ophth. and Laryng. ?i
-in later stages, Ophth. and Laryng. xi
-operative, conclusions as to, Ophth. and Laryng. xxvi
-, inflammatory disease of, Ophth. and Laryng. xxvi, ilii
-, frontal headache in, Ophth. and Laryng. xxvi, xxvii
- 1 injuries and inflammatory diseases affecting, discussion on, Ophth. and
Laryng. i-lxvii (L. V. Cargill, ii; E. D. D. Davis, xxxviii; D. Leighton Davies, xlvi ;
James Donelan, lxii; H. D. Gillies, xliv ; G. Seccombe Hett, xi; W. M. Mollison, lii ;
J. F. O’Malley, liii; A. W. Ormond, xxviii; G. H. Pooley, lv; W. T. Holmes Spicer,
i; E. H. E. Stack, lvii; W. Stuart-Low, lviii; Herbert Tilley, lx: H. I awson
Whale, lxi)
--, war injuries of, Ophth. and Laryng. v, vi
Index
ciii
Orbit and accessory sinuses, war injuries of, final results of, Ophth. and Laryng. vi
--and antrum, gunshot wounds involving, case histories and treatment, Ophth. and
Laryng. xiv, xviii
-, injury to, Ophth. and Laryng. ix, x
-and face, shell-explosions driving fragments into, results, Ophth. and Laryng. vii
-and frontal sinus, gunshot wounds involving, case histories and treatment, Ophth. and
Laryng. xiii, xiv, xvi, xvii
--of, resulting in chronic suppuration of frontal sinuses, Ophth. and
Laryng. xi
— -, case histories and treatment, Ophth. and Laryng. xiv, xv,
xviii, xix
-and maxillary antrum, thrust wound of, Ophth. and Laryng. vi
- and nose, gunshot injuries of dangerous nature, Ophth. and Laryng. xxxviii
- } early suture in, Ophth. and Laryng. xli
-, followed by penetration of dura, Ophth. and Laryng. xxxviii
-by septic meningitis, Ophth. and Laryng. xxxviii
-, position of patients in bed after operation, Ophth. and Laryng. xli
-, treatment, operative, at casualty clearing station, Ophth. and Laryng. xi,
xli
-and right antrum, carcinoma of, treatment by excision, radium and X-rays (Norn.au
Patterson), Laryng. 194
-and sphenoid, injury to, with foreign body retained in sphenoidal region, Ophth. x
-, close connexion with accessory sinuses, Ophth. and Laryng. ii
-, diseases of, due to sinus suppuration in young children, Ophth. and Laryng. xxxvii
-, ethmoid and antrum, injury to, Ophth. and Laryng. ix
-, foreign bodies in, Ophth. v
-. fracture of, intravaginal haemorrhage of optic nerve in head injuries without, Ophth. and
Laryng. lxiii
-of skull without injury to, Ophth. aud Laryng. lxiii
-floor of, left eyeball dropping through, Ophth. and Laryng. xii
-, frontal sinus, ethmoid and antrum, injury to, Ophth. and Laryng. viii
--and ethmoid communicating with, in severe injuries to frontal sinus, treat¬
ment, Ophth. and Laryng. xii
---, injury to, Ophth. and Laryng. viii
-. gunshot wounds of, Ophth. and Laryng. lvi
--, with chronic dacryocystitis, case histories and treatment, Ophth. and Laryng.
xv, xix, xx
-, inflammation and abscess, principal cause of, Ophth. and Laryng. iii
--of, due to acute sinusitis in childhood, Ophth. and Laryng. iii, lxiv
-of nasal origin, hospital records, Ophth. and Laryng. iv
--of possible sinus origin, opinion of rhinologistjto be sought in, Ophth. and Laryng. iv
-, inflammatory disease of, resulting from sinusitis, rare, Ophth. and Laryng. xlvi
-, injuries of, with chronic dacryocystitis, Ophth. and Laryng. xv
-, invaded by sarcoma commencing in orbit or maxilla, Ophth. and Laryng, lv
-, lodgment of foreign body at back of, causing sympathetic paralysis, Ophth. and Laryng.
vii
-, method of drainage for orbital cellulitis, Ophth. and Laryng. xxxix
-, pulsating tumour of, of uncertain nature (H. Grimsdale), Ophth. 35
-, roof of, deficiency, in severe injury to frontal sinus, removal of eyeball for, Ophth. nnd
Laryng. xii
— -, fissure fractures, Ophth. and Laryng. xxxviii, lxiii
-, tumour of, case (J. F. Cunninghhm), Ophth. 20
-, sphenoid and antrum, injury to, with foreign body retained in sphenoidal region,
Ophth. and Laryng. x
--, suppurations in, treatment, operative, Ophth. and Laryng. iv
civ
Index
Orbit, wall of, fractures, complicating wounds of accessory sinuses, Ophth. and Laryng. lii
-, war injuries of, treatment, Ophth. v
-*-, use of antitetanic serum in, Ophth. and Laryng. v
-, wound of region of, blindness following, Ophth. and Laryng. xl
Orbits and ethmoid, injury to, fatal cases, Ophth. and Laryng. vii
-, both, and nose, through-and-through war wounds of, Ophth. and Laryng. xxxix
Orbital and cranial cavities, ivory exostoses, growing from roof of frontal sinus into, removed
through osteoplastic opening in cranium (William Lang and Douglas Armour), Ophth. 16
Oriental sore, case for diagnosis, possibly, Derm. 33, 34
-, prevalence at Biskra, Derm. 34
-, treatment, methods of, Derm. 34
Ormond, A. W.—Case of (?) pituitary tumour, Ophth. 37
-, discussion on case of angioma of retina, Ophth. 22
-on fold in internal limiting membrane retina, Ophth. 16
-on injuries and inflammatory diseases affecting the orbit and accessory sinuses,
Ophth. and Laryng. xxviii, lxiv
Os calcis, apophysitis of (Paul Bernard Roth), Child. 99
Osseous cyst, lower limb of mature foetus contained in, and remaining in abdomen of mother
for fifty-two years, specimen (Herbert Williamson), Obst. 171
Ossicles and muscles, microscopic examination in case of fracture of base of skull involving
middle and inner ear, Otol. 108
-, with fracture dislocation of
incus and rupture of roof of right mastoid antrum, Otol. 112
-, in case of otosclerosis associated with otitis media, Otol. 119, 123
-, mal-development, embryological tissue concerned in, Otol. 22
-, (malleus and incus), findings in, at radical mastoid operations, Otol. 36
-, massage of, Otol. 96
Ossicular chain, function of, Otol. 91
Ossiculectomy, effect upon hearing, Otol. 97
-in treatment of chronic suppuration of middle-ear, Otol. 97
-, partial, in case of chronic adhesive otitis (P. Watson-Williams), Otol. 95
Osteoblast-bearing surface, greatest possible, principal aim in bone-grafting, Surg. 22, 23
Osteoblasts, function of, Surg. 22
-in Haversian canals, Surg. 13, 16
-on open mouths of Harversian canals, Surg. 22
-, proliferation of, Surg. 22
-, source of osteo-genetic properties of transplanted bone, Surg. 13
Osteogenesis imperfecta, cases of (E. Bronson), Child. 15
-, subjects of, temperament, Child. 16
-unilateralis ? shortening of limbs on one side of body, case (Joseph E. Adams),
Child. 5
--—, see also Fragilitas ossium
Osteogenetic activity, relative, of transplanted bone and bone-fragments, Surg. 13
-properties of transplanted bone, Surg. 13
-, what due to, Surg. 13
Osteomyelitis, acute, of right temporal bone, case in boy, clinical history, Otol. 1, 4
-, operations, recovery (H. Tilley), Otol. 1
-, chronic, of maxilla, case of (G. W. Dawson), Laryng. 212
-of frontal sinus, after operation, Otol. 3
-of maxilla or frontal bone causing infection of orbital tissues in children, Ophth. and
Laryng. liii, lv
-of right temporal bone, case, rarity, Otol. 1, 2, 3
-, cause of, and path of infection, Otol. 2, 3
_, complicated by hernia cerebri after operation, Otol. 1, 2
-, operations for, spinal anaesthesia indicated in, Anaesth. 8
Index
cv
Osteomyelitis, suppurative, chronic, of right humerus, with contraction of visual fields,
Ophth. and Laryng. 1
-, with contraction of visual fields, Ophth. and Laryng. 1
Otic vesicle in lower fishes, Otol. 81, 82
- -, transformation into organ of hearing, conditions necessary for, Otol. 82
Otitis, adhesive, chronic case of; treatment by myringotomy and partial ossiculectomy
(P. Watson-Williams), Otol. 95
-, treatment by injection of collosol argentum, Otol. 96
-interna, purulent, following fracture of base of skull involving right middle and inner
ear (J. S. Fraser), Otol. 104
-, media, acute, cases healing without operation, Otol. 58
-, following delay in operating for adenoids, Child. 39
-, treatment, preventive, Otol. 55
-and double acute purulent, following fracture of the base of skull (J. S. Fraser),
Otol. 110
-following fracture of the base of the skull (J. S. Fraser), Otol. 103
-, otosclerosis associated with (J. 8. Fraser), Otol. 115, 133
---, clinical history of case, Otol. 115-117
-, purulent, following fracture of base of skull involving right middle and inner ear
(J. S. Fraser), Otol. 104
-suppurative, acute, treatment, promptness in, desirable, Otol. 31
-chronic, as indication for radical mastoid operation, Otol. 33
-, cause, Otol. 30
----—, duration, Otol. 31
--—--, nasal complications in, Otol. 31
-, pharyngeal complications in, Otol. 32
-, prevalence among poorer classes, Otol. 30, 31
-, state of vestibular apparatus in, Otol. 33
Otolith, Otol. 82
Otology and laryngology, experts in, attachment to special hospitals for epidemic diseases,
resolution passed respecting, Otol. 31, 51
-in relation to public health, requirements of, Otol. 52, 59
Otorrhoea, chronic, with contraction of visual fulox, Ophth. and Laryng 1
Otosclerosis, aetiology, discussed, Otol. 130
-and chronic adhesive process, impossibility of distinguishing between, Otol. 122
-and hammer-toe, inheritance in one familv, Otol. 131
-and loss of nerve influence, Otol. 130, 131
-and toxaemia, Otol. 130
-, associated with choice middle-ear suppuration, microscopical examination of left ear
(J. S. Fraser), Otol. 122-126
-with defects of mesenehymatous structures, Otol. 129, 130
-with fragilitas ossium and blue sclerotics, three cases, clinical report (J. S. Fraser),
Otol. 126-131
-, hearing tests employed in, Otol. 126-128
-, illustrated by pedigree chart of Currie family, Otol. 127
-with otitis media (J. S. Fraser), Otol. 115, 133
-, clinical history of case, Otol. 115-117
-, bone disease in, Otol. 132, 133
-, diminished secretion of cerumen in, Otol. 26
-, effect of pregnancy and puerperium on, Otol. 131
-, factors in causation of, Otol. 130
-, hereditary tendency to, Otol. 126, 127, 130, 131, 132, 133
-, percentage of sufferers from, Otol. 130
Oval window, microscopic examination in case of otosclerosis associated with otitis media,
Otol. 119 ; see also Fenestra ovaiis
CV1
Index
Ovariotomy, death-rate from, at Samaritan Free Hospital (1884), Obst. 7
Ovary, tumour of, mistaking hydro-nephrosis for, Obst. 7
Over-crowding as factor in causation of adenoids, Child. 45
Over-feeding as factor in causation of adenoids, Child. 26, 45
Oxycephaly with symmetrical polysyndactylia, case (H. C. Cameron), Child. 8
Oxydizing properties of mineral waters, Bain. 11
Oxygen, administration, in cases of shock, R S.M. Disc. (Shock) 23
-and carbon-dioxide, direction of passage in cutaneous respiration contrasted, Path. 70
-and warm ether, administration with Shipway’s inhaler in cases of abdominal surgery,
Ansesth. 16
-, chloroform and ether administration, after induction by ether, incase of tonsillectomy,
Antesth. 19
-, nitrogen and carbon-dioxide, relative diffusibility through intestinal wall, Path. 70
-treatment of virulent influenza hopeless, R.S.M. Disc. (Infl.) 101
-want, test for, Epid. 37
-, see also Nitrous oxide gas and oxygen
Ozjena, atrophic rhinitis with, treatment by application of ichthyol with vaseline, Laryng. 186
-by douching nasal cavities contra-indicated, Laryng. 231
-, undergoing treatment by glycophylic method; four cases (C.^H. Hay ton).
Laryng. 184
-, foetor of, how produced, Laryng. 228
-, see also Rhinitis , atrophic
Pachymeningitis cervicalis of syphilitic origin (E. Miller), Neur. 55
Pain, heat and cold excited by same temperature, Neur. 10
-in dilatation of oesophagus without anatomical stenosis, Laryng. 42, 43
-in extra-uterine pregnancy, 100 cases, Obst. 153
-in side in malaria, Med. 23
-, oldest defensive reaction, Neur. 6
-, relief of, by diathermy in inoperable cancer of cervix uteri, Electr. 17, 18
-, visceral, effect on abdominal muscles, Neur. 6
Paisley, measles in, deaths from, in each quarter-year (1856-1917), Epid. 89
Palate, adherent (G. W. Dawson), Laryng. 150
-, treatment, operative, discussed, Laryng. 151, 152
-, alveolus and premaxilla, total loss of, Odont. 90
-and anterior faucial pillar, epithelioma of, enlarged glands in neck (Norman Patterson),
Laryng. 183
-and pharynx, submucous lipoma of, large (Herbert Tilley), Laryng. 189
-, malignant disease of, recurrence in lip due to implantation-epithelioma, Laryng. 170, 171
-, openiugs into nasal cavities, causing difficulty in taking impression for construction of
dentures, Odont. 74, 75
- 1 prosthetic, constructed and fitted in case of total loss of premaxilla, alveolus and palate,
Odont. 90, 91
-, soft, complete removal, see Staphylectomy
-, tonsil, tongue and floor of mouth, epithelioma of, treatment by diathermy (successful)
(N. Patterson), Laryng. 182
Pallor and anaemia, difference between, Med. 34
Pancreas, weight of salivary glands compared with that of, Child. 28
Pansinusitis, suppurative, with irido-cyclitis, Ophth. and Laryng. xlvi
Panton, P. N.—Discussion on epidemic encephalitis, Med., Path, and Epid. iii, xiii
Papaverin, in treatment of cardiospasm, Laryng. 51
Paracentesis tympani, in treatment of chronic ear discharge in children, Otol. 55
Paraffin, liquid, in dilatation of oesophagus without anatomic stenosis, Laryng. 60
-injection in treatment of dropped eye, Ophth. and Laryng. lvii
-, contra-indicated, Ophth. and Laryng. lxvi, lxvii
Index
evil
Paralysis, facial double, due to bilateral tuberculous mastoiditis (W. M. Mollison), Otol. 6
—— following indirect concussion from high explosives, Neur. 48
-stovaine’anesthesia, rarity, Anaesth. 7, 8
-, general, of insane, what is expressed by term, Neur. 3
-, hysterical, development with disappearance of organic, Neur. 25
-, supervening on organic, Neur. 26
-in encephalitis lethargica, Med., Path, and Epid. xxii
- in poliomyelitis and encephalitis lethargica, distinction between, Med., Path, and
Epid. xvii
-, infantile, early stage of, resemblance to influenza, Med., Path, and Epid. xii.
-, points of difference from infantile paralysis, Med., Path, and Epid. ix.
-, muscular pseudohypertrophic, in girl aged 10 years (F. J. Poynton, shown by Miss K.
Cass), Child. 18
■-of arm, functional, destruction of conviction of, by suggestion, Psych. 22
-, development, Psych. 20
-in soldier, therapeutic superiority of analysis over suggestion and persuasion
in dealing with, indicated, Psych. 29, 30
--of left vocal cord in woman aged 49 (James Donelan), Laryng. 181
-, organic and hysterical, symptoms and physical signs aiding in diagnosis between three
groups of, Neur. 25
-- three groups of, comparative value, Neur. 25
-, physical signs of organic lesions of pyramidal tract persisting after recovery from,
and associated with hysterical paralysis, Neur. 24
-, perpetuation of, in suggestible subjects by development of hysterical element, Neur.
24, 25
-, sympathetic, from lodgment of foreign body at back of orbit, Ophth and Laryng. vii
-, vagal, in relation to dilatation of oesophagus, Laryng. 38
Paramnesia preceding migraine, Ophth. 53
Paranoid reactions as war psychoses, Psych. 45
- : -, with alcoholic history, Psych. 46
-, pronounced feature of war mental reactions, Psych. 45
-, see also Persecutory ideas
Paranosmia preceding migraine, Ophth. 53
Paraplegia, case of labour in woman suffering from (G. Drummond Robinson), Obst. 22
-, hysterical, and hysterical incontinence of urine following concussion of spinal cord with
organic physical signs, Neur. 28
-, as war neurosis, Psych. 55
-ataxic, associated with Friedreich’s ataacy, case, Neur. 23
-, method of cure in, Neur. 24
-, with physical signs of organic paraplegia, Neur. 22
-, treatment with good results acting as form of psychotherapy,
Neur. 22
-. labour in women suffering from, Obst. 25
Parasites, examination of blood-film for, before treatment in cases of obscure fever in tropics,
Med. 39, 40
-, malarial, antibodies found against, Med. 40
-, concentrated, solution of, Med. 41
-, dilution with normal saline, Med. 41
-, experiments carried out to determine if separate strains of, react differently to
various antigens, Med. 44
Parasyphilis, explanation of term, Neur. 3
Paratyphoid and typhoid fevers, fatality rate among civilian population of Flanders in area
occupied by Allies, compared, Epid. 27
-, proportion in outbreak of enteric among French soldiers in Flanders, Epid. 25
- —-, proportion of occurrence among Allied armies, Epid. 26
cviii Index
Paratyphoid fever among French soldiers in Flanders, Epid. 24, 25
-A and B, proportion among Allied armies, Epid. 26, 27
-in Germany before war, Epid. 26
- —cases of, exceeding typhoid in British Army, Epid. 33
-, infection by, antityphoid inoculation not protective against, Epid. 33
Paresis, facial, following radical mastoid operation, Otol. 38
Parietal region, injury to, with loss of sensation in left hand, case of (Henry Head, F. R.S.) %
Neur. 53
Parkinson, J. Porter.— Aplastic anaemia. Child. 72
-, case of aplastic anaemia (previously shown), Child. 2
-, discussion on adenoids, Child. 40, 42
-on case for diagnosis, Child. 22
--* of achondroplasia with hydrocephalus, Child. 10
-— of adrenal growth and case of multiple glandular swellings, Child. 93
--of chronic priapism, Child. 11
-of myoclonus multiplex, Child. 19
--of severe rickets, Child. 104 '
- —--of tuberculous meningitis of spiual cord, Child. 24
--on chorea complicated by gangrene of fingers, Child. 89
-- on sclerodermia with calcification in mongol, Child. 98
--on shortening of limbs on one side of body. Child. 7
-on undoscended and imperfectly descended testes, Child. 63
-specimens, from case of aplastic anaemia, Child. 110
Paroleine, in dilatation of oesophagus without anatomic stenosis, Laryng. 60
Parosmia following through-and-through bullet wounds of accessory sinuses, Ophth. and
Laryng. lii
Parotid tumour, mixed, malignant (so-called) (W. S. Syme), Laryng. 108
Parrott, Arthur H., Billington, William, and Round, Harold.— Bone-grafting in gun¬
shot fractures of the jaw, Odont. 55
Parsons, J. Herbert, F.R.S.—Discussion on fundus changes, resulting from war injuries,
Ophth. 25
-, discussion on migraine, Ophth. 54
Parturition, action of, views as to, Obst. 25
-, physiology of, further knowledge required as to, Obst. 25
Pascal’s law, applications of, Otol. 84, 86
Paterson, D. R.—A clinical type of dysphagia, Laryng. 235
-, discussion on case of acute mastoiditis followed by thrombosis of internal jugular vein,
recovery, Otol. 11
--of acute osteomyelitis of right temporal bone, Otol. 3
-of necrosis of internal ear, causing sequestration of labyrinth, Otol. 9
-- on foreign bodies impacted in food and respiratory passages, Laryng. 17
-on gunshot wounds of nasal accessory sinuses, Laryng. 242
-on two cases of radical mastoid operation for cholesteatoma, Otol. 13
Pathological Sub-Committee of Section of Dermatology : Report on Dr. Pringle’s two cases of
Kaposi’s disease (?), Derm. 52
Paton, Leslie. —Discussion on migraine, Ophth. 53
Patterson, Norman. —Carcinoma of right antrum and orbit (microscopic report), treatment
by excision, radium and X-rays, Laryng. 194
-, case of diathermy for epithelioma of palate, tonsil, tongue and floor of mouth, patient
well nearly four years after first appearance of disease, Laryng. 182
-, cyst of larynx, Laryng. 194
-, discussion on case of epithelioma of tonsil after diathermy, Laryng. 170
-of naso-pharyngeal angeio-fibroma, Laryng. 175
-on epithelioma of left tonsil, Laryng. 102
-on removal of bone impacted in oesophagus, Laryng. 172
Index
cix
Patterson, Norman. —Discussion on submucous lipoma of palate and larynx, Laryng. 192
-, epithelioma of palate and anterior faucial pillar; enlarged glands in the neck,
Laryng. 183
Peachey, G. C.—Discussion on Sydenham as epidemiologist, Epid. 74
Pechey, John, “Collections of Acute Diseases,” consisting of extracts from Sydenham’s
writings, Epid. 74
- 9 extreme rarity of, Epid. 74
Pectoralis major muscle (left), and left mammary gland, congenital absence of left portion
of (E. A. Cockayne), Child. 59
Pediatrics and obstetrics, dividing line between, where to be drawn, Obst. 46
-, study of, distinction between, Obst. 60, 65
Pedicle graft, application in ununited fractures of mandible, Odont. 13
--, operation, in ununited fractures of mandible, Odont. 13
-, conditions necessary for performance of, Odont. 13, 14
— - grafts in ununited fractures of mandible (Percival Cole), Odont. 13
Pegler, L. H.—Case of laryngeal whistling, Laryng. 173
Pellagra, case for diagnosis, probably. Derm. 39, 40
Pelvic femur splint, application in treatment of compound fractures of femur in upper third,
Surg. 8
-, advantages, Surg. 8, 9
-splint, new, demonstration of (J. R. Lee), Surg. 6, 8
-operations with patient’s hips raised, routine performance expected, Obst. 6
-organs, anatomy, teaching of, Obst. 34
-symptoms, mental causes, Obst. 48
Pelvis, contraction of, discovery before labour important, Obst. 73
-, measurement of, learnt in out-patient departments by students, Obst. 37
-, obstetric anatomy of, teaching of, Obst. 34
-, removal of intestines from, under influence of gravity (1884), Obst. 6
Penetration scale, value of, in radiography of gall-stones, Electr. 79
Penetrometer scale, dried femur radiographed with, Electr. 80
Pension award, question as to, in case of chronic suppuration of middle ear, Otol. 13-16
-, benefits for expectant and nursing mothers, Obst. 56
-, increase of, application for, on account of suffering from chronic malaria, Med. 15
Percussion of ununited fractures, Surg. 30
Perez’s bacillus, factor in production of foBtor of ozsena, Laryng. 227
-, method of destroying, Laryng. 228, 229
Perichondritis following radical mastoid operation, Otol. 38
-of larynx, case (G. W. Dawson), Laryng. 176
Perinceum, deep bullet wound across, explosive effect, Proct. 48
-, lacerations of, must be sterile before suture, Obst. 93
-, septic, Obst. 93
-, ruptured, healing of, Obst. 99
---, plastic operation for, success of, Obst. 101, 102
Period, range of amplitudes due to, Epid. 115
Periods, probability of, method of testing, Epid. 112
Periodicity in disease, method of investigations with, examples, Epid. 100
Periodogram analysis, Epid. 100
-, fallacy possibly arising in, Epid. 112, 118
Periodontal membrane, micro-organisms in, demonstrated in sections from cases of pyorrhoea.
Odont. 110
Peri-sinus abscess complicating acute mastoiditis, Otol. 10
Perisplenitis in malaria, Med. 20
-, diagnosis from pleurisy, Med. 20, 21
Perithelioma of right maxillary antrum, radium treatment (J. Gay French), Laryng. 114
-, unilateral, of maxillary antrum, upper jaw, and ethmoid, removed at one operation,
after ligature of external carotid, Laryng. 179
cx
Index
Peritoneal cavity, gas in, without perforation of stomach or intestine, Path. 71, 72
-, see also Pneumoperitoneum
Peritoneum investing caecum, rupture of, in cases of extreme intestinal distension. Path. 75
-, in reduction of ileo-csecal intussusceptions, Path. 75
Peritonitis, deaths from, attributed to shock, R.S.M. Disc. (Shock), 17 (
-, general, treatment by continuous saline infusions, R.S.M. Disc. (Shook), 30
-, risk of, after abdominal operations, methods of avoidance attempted (1884), Obst. 4
-, suppurative, diffuse, death from, following abdominal operations conducted without use
of antiseptics, Obst. .5
Pernet, George.—C ase of lymphangiectodes, Derm. 64
-, case of melanotic growths (carcinomatous), Derm. 11
-nsevo-carcinoma previously shown, Derm. 42
-of multiple leuconychia streata, associated with leuconychia totalis of one thumb¬
nail, Derm. 28
-of unilateral band sclerodermia and morphceo-sclerodermia of the left leg, Derm. 43
-, discussion on case for diagnosis, Derm. 30, 34, 39
_of arsenical pigmentation and hyperkeratosis, Derm. 32
-,— of Dercum’s disease, Derm. 36
_of erythrodermia with lymphatic leukaemia, Derm. 55
__of pigmentation of mucous membrane, Derm. 28
_on white-spot disease (morphcea guttata), Derm. 26
_ t two cases of epidermolysis bullosa hereditaria, Derm. 64
Persecutory ideas among mental defects in warfare, Psych. 45
-, see also Paranoid reactions
Personal factor, errors in new method for enumerating Entomceba coli cysts in stools, due to,
M.B.L. 9
Perspective, sense of, on what dependent, Ophth. 63, 64
Persuasion, aim of, Psych. 23
_and re-education in treatment of case of ataxic paraplegia associated with Friedreich’s
ataxy, Neur 24
_and suggestion, difference between, Psych. 22, 23
_, therapeutic superiority of analysis over, indicated, Psych. 28, 29, 30
-, definition vague, Psych. 22
_ t D4jerine’s conception of, complexity of, Psych. 24
_ # distinction of analysis from, Psych. 27
_ t Dubois* and D^jerine’s conceptions of, contrasted, Psych. 23, 24, 25
_ t part played by logical reasoning in, Psych. 22, 23
_ t rational, in treatment of chronic cases of war neurosis, Psych. 55
_ f suggestion and analysis, relation between, as therapeutic methods, Psych. 27
_ f therapeutic employment of, upon what dependent, Psych. 23
_indications apart from analysis. Psych. 31
_ i treatment by, of early cases of war neurosis, Psych. 53
_, two separate schools of thought regarding, Psych. 22-25
Peters, E. A.—Attempt at cutting through tooth-plate impacted in oesophagus, Laryng. 19
_ 9 discussion on sellar decompression for pituitary tumours, Laryng. 254
_and Embleton, D.—Sphenoidal sinus empyema in cerebro-spinal meningitis, Laryng. 250
Petrosal sinus, septic infection of, almost always fatal, Otol. 66
__, superior, septic infection of, case-history, with fatal issue, Otol. 65
_, rare, Otol. 66
Peyer’s patches, condition seen post mortem in well-nourished and ill-nourished children,
contrasted, Child. 52
Pharyngitis complicating malaria, Med. 26, 27
Pharynx and palate, submucous lipoma of, large (Herbert Tilley), Laryng. 189
_ f condition as noted in cases of modified radical mastoid operations, Otol. 45
-, deep, malignant growth of (Irwin Moore), Laryng. 210
Index
cxi
Pharynx, diseases of, complicating chronic suppurative otitis media, Otol. 32
-, diverticulum of, two cases (W. H. Kelson), Laryng. 248
-, see also Diverticulum , pharyngeal
-, lipoma of, causing death during meal, Laryng. 192
-, lower, spasm in, Laryng. 237
-, wall of, closure in gap of, after staphylectomy, Laryng. 240
Phloroglucin and nitric acid, as deoalcificant of teeth, Odont. 36
Phosgene poisoning followed by pulmonary oedema and subcutaneous emphysema, Path. 58
Photographs, stereoscopic, effect obtainable from, to what due, Ophth. 64
- f point of importance in, Electr. 5
Phreno-cardiac segment of oesophagus, Laryng. 99
Phrenospasm, synonym for cardiospasm, Laryng. 35
Physical efficiency, simple tests for (Martin Flack), Epid. 35
-, practised on Royal Air Force Officers, Epid. 35
-tests, examination of candidates for Royal Air Force by, Epid. 33-45
-, factors in response to, Epid. 44
-for air pilots, results, Epid. 40
-, use in combination, Epid. 41, 42
-, generic factor in, Epid. 45
-uses for which suitable, Epid. 43
Physiology and gymecology, connexion between, Obst. 61, 74
-and surgery, relationship between, R.S.M. Disc. (Shock), 28
Pickerill, H. P.—Discussion on bone grafting in ununited fractures of mandible, Odont. 15
-, discussion on influence of food deficiencies on teeth, Odont. 37
-, intra-oral skin-grafting; the establishment of the buccal sulcus, Odont. 17
-, malar-coronoid screw fixation in treatment of posterior fragment in fracture of
mandible, quoted, Surg. 12
Pigeon, trilobed upper limit of air-sacs at root of neck in, Path. 61-
Pigmentation, arsenical, hyperkeratoses occurring in course of dermatitis herpetiformis
(E. G. Graham Little), Derm. 31
--, in case of lymphadenoma (Miss Eliz. O’Flynn), Clin. 17
-, congenital, of cornea (Miss Rosa Ford), Ophth. 34
-, not due to Addison’s disease, Derm. 28
-of lips complicating malaria, Med. 28
-of mucous membrane, case (H. C. Samuel), Derm. 27
-resembling Addison’s disease in malaria, Med. 38
Pigmented cells in ciliary muscle in case of melanoma of choroid, Ophth. 61
-in negroes, Ophth. 61
Pin accidentally inhaled into lungs, some statistics and results of (Irwin Moore), Laryng. 15
-in bronchiole of posterior lobe of right lung; failure to remove by bronchoscope, coughed
up eighteen months later (Hunter Tod), Laryng. 10
Pinna, embryological derivation, Otol. 22
-, value in lower animals and man contrasted, Otol. 23
Pipette, errors in use of new method for enumerating Entamoeba coli cysts in stools, due to,
M.B.L. 9
Pistol bullets, removal from base of brain, successful, case showing (Henry Head, F.R.S.),
Neur. 53
Pithecia (Saki monkeys), variations in position of teeth in, Odont. 53
Pitt, G. Newton.—D iscussion on influenza, R.S.M. Disc. (Infl.) 84
-, muscular hypertrophy of oesophagus without dilatation, quoted, Laryng. 99, 100
Pituitary body: drawings of transverse section through optic chiasma and sella turcica to
show relations of (J. Herbert Fisher), Ophth. 56
-, hormones of, action, Ophth. 51
-, malignant disease of, case (G. Maxted), Ophth. 42 ; clinical history, Ophth. 42 45
--, post-mortem appearances and pathological report, Ophth. 45, 46
cxu
Index
Pituitary body: malignant disease of, epistaxis accompanying, Ophth. 48
-, perimeter charts, Ophth. 43
-, skiagrams of, Ophth. 45, 47
-, treatment by transphenoidal decompression, Ophth. 44, 48
---, visual disturbances accompanying, Opth. 46, 47, 48, 49
-, swelling of, connexion with onset of migraine, Ophth. 51
-tumour (?) case (A. W. Ormond), Ophth. 37
--,'clinical history, Ophth. 37, 38
- 9 perimeter charts, Ophth. 39
—-, skiagram of, Ophth. 40
-case, trans-sphenoidal operations; great improvement in pressure symptoms
(H. Lawson Whale), Laryng. 169
--, hypopituitarism (L. V. Cargill), Ophth. 41
-, operation on, method of approach for, Laryng. 179
-, sellar decompression and removal of endotheliomatous tissue, great improvement
(H. Lawson Whale), Laryng. 178
-tumours, operations on, sellar decompression in (W. G. Howarth), Laryng. 253
-:-, sellar decompression in, results, Laryng. 263
-extract, administration, in avoidance of surgical shock, R.S.M. Disc. (Shock) 29
-fossa, operations on, objects for which undertaken, Laryng. 253
-, shrapnel in, Ophth. and Laryng. lxi
Placenta and sac, method of dealing with in one hundred cases of extra-uterine pregnancy,
Obst. 154, 155
-, rapid separation during treatment of intra-uterine pregnancy, Obst. 185
_ f removal, risk of, in operating for extra-uterine pregnancy, Obst. 186
—retention of, Obst. 103, 106
-, syphilitic (Eardley Holland), Obst. 204-215
-and non-syphilitic, histology compared, Obst. 210, 211
-, weight-ratios compared, Obst. 206-209
-, avascularity of villi in, Obst. 209, 210
-, changes in, locality of, Obst. 215
-diagnosis, Obst. 205, 211-215
--, histology, Obst. 209
-, naked-eye appearances, Obst. 205
-, weight ratio, Obst. 205
-, with maternal Wassermann reaction, Obst. 213
Plague, prevented entering Tuscany by Grand Duke Ferdinand II, Epid. 69, 70
Plasmodium falciparum and Plasmodium vivax , experiments on complement fixation in
malaria with antigens prepared from cultures of (J. Gordon Thomson), Med. 39
- vivax , antigen prepared from, in preliminary experiments carried out on known cases of
benign tertian malaria with Plasmodium vivax present in blood, Med. 43
-, cultures of, and spleen from malignant tertian case, antigens respectively prepared
from, experiments with, Med. 45
-in blood of malarial patients, Med. 18, 19
Plastic operation for ruptured perinseum, success of, Obst. 101, 102
Platysma muscle, paralysis of, when only a sequel of hysterical paralysis, Neur. 25
Pleasure, desire of, in action, Psych. 3 ; see also Hedonism
Pleural cavity, death from perforation into, of tooth-plate impacted in oesophagus (C. E.
Woakes), Laryng. 8
-effusion in influenza epidemic in Macedonia, Med. 57
Pleurisy complicating influenza, treatment by mixed vaccines, R.S.M. Disc. (Infl.) 79
-, diagnosis from perisplenitis in malaria, Med. 20, 21
Pleuro pneumonia, acute, complicating influenza in Royal Navy stationed at Plymouth,
R.S.M. Disc. 30
Plummer, treatment of cardiospasm by distensible bags, Laryng. 52, 53
Index
cxiii
Plymouth, Royal Navy stationed at, influenza in, R.S.M. Disc. (Infl.) 30
Pneumatoses, bacterial, Path. 49
-due to entrance of air into serous cavities, connective tissue, or alimentary or genito¬
urinary tracts, Path. 50
-, remarks upon (C. A. R. Nitch and S. G. Shattock, F.R.S.), Path. 46
Pneumatosis, curious examples of, Path. 54
-, therapeutic employment in milk fever of cows, Path. 58
-, uterine, Path. 53
-, how produced, Path. 53
Pneumococcus in influenza, R.S.M. Disc. (Infl.) 31, 33, 44, 55, 66, 93
Pneumo-hfemothorax, Path. 49
Pneumonia, acute, occurrence in connexion with presence of lymphadenomatouti glands at
roots of lungs, Clin. 18
-and cerebro-spinal fever, incidence in British Army (1915-18) compared, R.S.M. Disc.
(Infl.) 6, 7
-, bronchitis and influenza, relationship between, R.S.M. Disc. (Infl.) 24, 69
-complicating influenza, blood changes in, Med. 67
-, hrematuria in, R.S.M. Disc. (Infl.) 69
- 1 treatment of every kind sometimes valueless, R.S.M. Disc. (Infl.) 100, 101
-outbreak of respiratory disease among American troops aboard a transport, incidence
and mortality, R.S.M. Disc. (Infl.) 74
-following epidemic of influenza in Macedonia (J. Burnford), Med. 49
-stovaine anaesthesia, Ansesth. 7
-, grave type of, clinical convergence towards, in influenza epidemics, Epid. 64
-, influenzal, complicated by emphysema of neck, R.S.M. Disc. (Infl.)60, 64,100 ; Path. 57
-, lobar, complicating influenza, intracardiac ante-mortem thrombosis associated with,
R.S.M. Disc. (Infl.) 81
-, occurrence in those taking arsenic, Clin. 18
Pneumopericardium, Path. 52
Pneumoperitoneum from gas formation following perforation of the vermiform appendix,
intestine or stomach, Path. 50
-of non-bacterial origin, Path. 51
Pneumothorax, Path. 50
-, specimen from case of, Path. 50, 51
Point-’o-lite lamp, use in connexion with electrocardiograph, Eleotr. 70
Polio-encephalo-myelitis, human, acute, infective, experimental inoculations, lesions at site of,
Path. 40 •
-experimental inoculations of virus, lesions of brain and spinal
cord due to, Path. 41
-occurring in Australia, clinical manifestations, Path. 33, 34, 41
. —-, conveyance of virus to monkeys, sheep, a calf and a foal, Path. 33
-, seasonal and geographical distribution, Path. 33
-, transmission to calf, Path. 38, 39
-, manifestations, Path. 38, 39
-to horse, Path. 39
-, manifestations, Path. 99
-to monkey, Path. 34, 35
-, manifestations, Path. 35
-to sheep, Path. 36
- 9 manifestations, Path. 36
Poliomyelitis, acute, and resulting encephalitis, encephalitis lethargica distinct from, Med.,
Path, and Epid. x, xv
-- and encephalitis lethargica, association with prevalence of influenza, Med., Path, and
Epid. xii, xiii
- f paralyses in, distinction between, Med., Path, and Epid. xviii
8
CX1V
Index
Poliomyelitis, anterior, tuberculous meningitis of spinal cord simulating, section from case
(H. C. Cameron), Child. 23
-, haemorrhagic, diagnosis of encephalitis lethargica from, Med., Path, and Epid. ii
-, influenzal, nature of, Med., Path, and Epid. vi
Pollitt, G. Paton.—D iscussion on local anaesthesia in dental operations, Odont. 6
Polymorphism of the malignant epiethelial cell (E. H. Kettle), Path. 1-32
Polypi, aural, found at radical mastoid operation, Otol. 43
-, question of removal before radical mastoid operation, Otol. 33
-, choanal, in children, two cases (Douglas Guthrie), Laryng. 153
-, recurrence, question of, Laryng. 154
-, removal of, Laryng. 153, 154, 155
Polypus, antral, large (James Donelan), Laryng. 167
-, antro-choanal, recurrence of, Laryng. 107
-, nasal, deafness rare in, Otol. 29
-of larynx removed with snare, case (J. Dundas Grant), Laryng. 165
-showing areas of squamous-celled carcinoma associated with a sarcomatous stomach in
case of adeno-carcinoma of the uterus, Path. 13-17
-, spheno-choanal, cases recorded, Laryng. 105
-, evolution of, Laryng. 107
-(recurring) in child (Irwin Moore), Laryng. 105
-, report on specimens (Irwin Moore), Laryng. 105
Polysyndactylia, symmetrical oxycephaly with, case (H. C. Cameron), Child. 8
Pooley, G. H.—Discussion on injuries and inflammatory diseases affecting the orbit and
accessory sinuses, Ophth. and Laryng. lv.
Poperinghe, cases of enteric fever at, Epid. 24, 25
Porcelain sheath attached to electrodes used in fulguration, Electr. 23
Port Said, prophylactic measures against venereal diseases among Australian troops at, R.S.M.
Lect. 8, 9
Port Sunlight, reduction of industrial accidents at, Epid. 51
Porter, A. W. — Discussion on electrical methods of measuring body temperature,
Electr. 60
-, discussion on the electro-cardiograph, Electr. 70
Position, perception of, in three dimensions, Ophth. 63
-, relative, perception in three dimensions, Ophth. 63
Post-graduates, clinical teaching of, in midwifery (F. J. MoCann), Obst. 134
-, teaching of obstetrics and gynaecology to, report on, Obst. 108-134
Potassium, iodide of, in treatment of thoracic actinomycosis, Clin. 1, 3 •
-, permanganate, dilute, gargling of, as prophylactic against influenza, R.S.M. Disc.
(Influ.), 102
-, solution of, irrigation of anterior urethra with, as prophylactic against venereal
diseases, R.S.M. Lect. 9
Powell, Llewellyn.—C ase of Caesarean section under spinal anaesthesia, Anaesth. 21
-, case of successful heart massage, Anaesth. 17
Powell, Sir R. Douglas, Bt.—Discussion on some simple tests for physical efficiency, Epid. 43
Poynton, F. J.—Case of pseudohypertrophic muscular paralysis in a girl, aged 10 years
(shown by Miss K. Cass), Child, 18
-, myoclonus multiplex in a girl aged 2 years 11 months (shown by Miss K. Cass), Child. 17
Praxiology, definition of, Psych. 4
Pregnancy, abdominal, primary, Obst. 182
-, secondary, Obst. 182
-and labour, chief causes of death directly due to, Obst. 79
-, dangers of, underrated by public, Obst. 65, 85
-, deaths directly due to, now classified, separated from deaths associated with, Obst. 77
-, maternal death-rate due to, in England and Wales and Scotland, Obst. 64
-, capacity of women for industrial work during, Obst. 64
Index
cxv
Pregnancy, clinical instruction in, Obst. 110
-considered as abdominal neoplasm, Obst. 87
-, diagnosis of, in out-patient departments, Obst. 37
-, effect on otosclerosis, Otol. 131
-, extra-uterine, advanced, Bacillus coli infection of urine in, Obst. 184
-, cases of (J. S. Fairbairn), Obst. 183
---(H. R. Andrews), Obst. 173
-(Bellingham Smith), Obst. 176
-(J. D. Malcolm), Obst. 179
-(H. R. Andrews), Obst. 173
-, children surviving, future health of, Obst. 182
-, diagnosis, Obst. 182
-, false capsule of foetal sac in, Obst. 185
-, full-time (Gordon Ley), Obst. 140
-, modes of occurrence, Obst. 181, 182
-, treatment, operative, risk of hemorrhage, Obst. 183
--, two cases (W. Gilliatt), 177
--(Gordon Ley), Obst. 140
--, clinical history, Obst. 140, 144
--, specimens from, pathological description, Obst. 143, 149
---, treatment, operative, Obst. 141, 146, 152
-, 100 cases, complications following on labour or death of foetus, Obst. 154
-, method of dealing with sac and placenta, Obst. 154, 155
-—-, nature of pregnancy, Obst. 152
--- —, percentage of death of foetus in, Obst. 154
-, percentage of maternal mortality, according to time of operation, Obst. 156
--of occurrence of labour in, Obst. 153
-, site of pregnancy in, Obst. 152
-, symptoms atypical of normal pregnancy in, Obst. 153
-, tabulated abstracts of, from literature (Gordon Ley), Obst. 157
-, time at which operation was performed, with results to mother and, if
living, the child, Obst. 154, 155
-, treatment, ideal, Obst. 154, 156
-, question of leaving dead full-term ectopic foetus in abdomen, Obst. 152
-of saving life of child, Obst. 156
-, specimen from case (Cecil Marriott), Obst. 180
- -, treatment, Obst. 182
—-, operative, preliminary ligature of vessels supplying placenta and foetal sac in,
Obst. 185
-, proper time for, Obst. 156, 182, 183
--, rapid separation of placenta in, Obst. 185
-, risk of removal of placenta, Obst. 186
-, with living foetus, diagnosis difficult, Obst. 176
-, full-term, in rudimentary uterine horn, case (Clifford White), Obst. 138
--, in tra-ligamentary or broad ligament, Obst. 185
-, mesometric, Obst. 182
--, pathology, teaching of, Obst. 35
-, special points with regard to teaching of, Obst. 34
-toxaemia as cause of maternal mortality in childbirth, Obst. 82, 83
-, work of health visitor in relation to, Obst. 44
Pregnant, ventrifixation contra-indicated in those capable of becoming, Obst. 218, 219
-women at home, attendance by students, Obst. 37
-, advantages of, Obst. 37, 38
-, attendance at out-patients’ departments of hospitals, Obst. 37
--, chorea in, demonstration to students, Obst. 38
CXV1
Index
Pregnant women, clinic for, training of students in, from social standpoint, Obst. 44
-, history and examination of, personal responsibility of students for, in out-patient
departments, Obst. 37
-, mental affections of, best place for study of, Obst. 38
-, supervision of, resulting in rearing of unfit adults. Obst. 53, 56, 60, 72
-, urine of, examination by students, Obst. 38
Pre-maxilla, absorption of, in tertiary syphilis of nose (Dan McKenzie), Laryng. 28
-, alveolus and palate, total loss of, in old injuries of maxilla, Odont. 90
-, prosthetic treatment, Odont. 90-94
-, loss of, prosthetic treatment after operation, Odont. 83
-, with part of alveolus and palatal portion of maxillae, loss of, Odont. 85, 86
-, treatment by epithelial inlay operation, followed by
prosthetic treatment, Odont. 86, 87, 88
Premolar, maxillary, left first, irregularity in position in Mycetes niger , Odont. 49, 50
-, misplaced in Cebus apella , Odont. 40, 41
-, third, misplacement in Lagothrix (unclassified), Odont. 45
-, third, misplacement in Lagothrix Humboldtii , Odont. 44
Premolars, irregularity in position in Callithrix , Odont. 52
-, in Cebus hypoleucus , Odont. 40, 41
_, position in Mycetes niger , Odont. 49
_in Mycetes (unclassified), Odont. 48, 49
_ y maxillary, filling, under submucous infiltration anaesthesia, Odont. 2
-, irregularity in position in Ateles vellerosus , Odont. 46, 47
Priapism, chronic case (Eric Pritchard), Child. 10
Prince, Morton, unconscious mental processes, quoted, Psych. 8, 9
Pringle, Hogarth, post-mortem examinations in case of fractured skull in civil life, quoted,
Ophth. and Laryng. lxiii
Pringle, J. J.—Another probable case of the miscalled multiple idiopathic haemorrhagic
sarcoma of Kaposi (with histological report by H. MacCormac, M.D., and report by
Pathological Sub-Committee), Derm. 48-54
_, case of the condition described as “ multiple, benign, tumour-like new growths ” (shown
by Henry MacCormac), Derm. 21
_, discussion on case of Delhi boil, Derm. 71
_of dermatitis herpetiformis, Derm. 73
_of folliculitis decalvans, Derm. 13
_of keratosis follicularis, Derm. 68
_of lichen obtusus comeus, Derm. 16
_of senile tuberculosis cutis, Derm. 18
Pritchard, Eric.—D iscussion on adenoids, Child. 41, 53
-discussion on case of achondroplasia with hydrocephalus, Child. 10
_of adrenal growth and case of multiple glandular swellings, Child. 92
___of apophysitis of os calcis, Child. 103
_of congenital absence of lower portion of left pectoralis major muscle and left
mammary gland, Child. 59
-of severe rickets, Child. 104
--on specimens from case of purpura, Child. 109
_ f notes on a case of chronic priapism, Child. 10
- 1 specimen of liver abscess. Child. 108
-, specimens from case of purpura, Child. 107
Procidentia, ohanges in uterus as result of (G. Drummond Robinson), Obst. 18
-, elongation of supravaginal cervix in cases of, Obst. 19
Production, speed of, factor in causation of industrial accidents, Epid. 48
Propositions, acceptation of, grounds for, Psych. 16
Proptosis, inflammatory, causation of, Ophth. and Laryng. lviii
-, fatal nature of, Ophth. and Laryng. lviii
Index
CXVll
Prostate, adenocarcinoma of, with metaplasia in squamous-celled carcinoma associated with
sarcomatous stroma, Path. 18-23
Prosthetic appliance constructed and fitted in case of total loss of premaxilla, alveolus and
palate, Odont. 90-94
-, in position, coronal section showing,
Odont. 92
-worn after loss of pre-maxilla, Odont. 83
-treatment of old injuries of maxillae (W. Kelsey Fry), Odont, 73-94
Protozoal cysts in stools, diagnosis by “concentration methods,” statistical evidence for,
M.B.L. 12
Protozoometer, uses of, M.B.L. 11
Protrusion, inferior, frequency in Brachyteles, Odont. 46
-, tendency to, in Lagothrix, Odont. 46
Pseudo-pelade, Brocq’s, and folliculitis decalvans (Quinquaud’s disease), distinction between,
Derm. 14
Psychiatry, materialistic dogma in, on what dependent, Psych. 63, 64
-, (war) (C. Stanford Bead), Psych. 35
-, a new study. Psych. 36
-, main source of literature dealing with previous to present war, Psych. 36
-, subjects connected with, differ from those in civil life, Psych. 35
Psychical causes of industrial accidents, Epid. 49
Psycho-analysis and analysis not identical, Psych. 26
Psychogenesis, problem of, in mental diseases (C. G. Jung), Psych. 63
Psychogenic origin, neurosis following exposure to high explosives, differentiation from those
of, Neur. 48, 50
Psychological aspect of preventive medicine, Obst. 47, 48
-conflicts in dementia prsecox, Psych. 70
-factors in mental disease, undervaluation of, Psych. 64
-- tests in examination of candidates for Royal Air Force, Epid. 44, 45
Psychology, clinical, contamination with fallacies of mechanistic psychology, Psych. 9
-, in relation to heredity, Psych. 11
-, present position in (W. McDougall), Psych. 1
-, knowledge of, indispensable to neurologists and alienists, Psych. 65
-, mechanistic and materialstic, Psych. 3
-, evolution of, Psych. 12
-, inadequacy illustrated, Psych. 4
-, undermining of, Psych. 8
-, teleological, Psych. 7, 8
Psychoneuroses, fear as source of all, Psych. 7
-, psychogenic origin of, Psych. 26
-, symptoms of, how to destroy patients’ conviction of. Psych. 23
-, how resulting, Psych. 23
-, utility of suggestion in, Psych. 22
-(war), fear and desire for death in, Psych. 50
Psychopathies, inherited, low power of storage energy in groups of neurons in, Otol. 21
Psycho-physical functions, dissociation in war neurosis, Psych. 55
Psychoses, aetiology and progress, psychological factor in, Psych. 71
-, not produced by intense physical exhaustion, Psych. 37
-, toxic alcoholic, in warfare, Psych. 49
-(war) associated with epilepsy, Psych. 49
-, cases at Royal Victoria hospital, Netley, analyses and classification, Psych. 42
--, study of, Psych. 41
Psychotherapy, almost complete recovery from combined hysterical and organic hemiplegia
following nephritis under, Neur. 26
-, combined hysterical and organic hemiplegia, following gunshot wound of skull, showing
great improvement after, case, Neur. 27
cxviir
Index
Psychotherapy, curing hysterical hemiplegia with organic'disease following concussion by shell
explosion, case, Neur. 27
-, incontinence of urine and hysterical paraplegia following concussion of spinal
cord, case, Neur. 28
-, partial hysterial blindness, following organic blindness caused by wound in occipital
region and associated with hysterical deafness, Neur. 29
-, disappearance of hysterical tabes dorsalis under, Neur. 22
-manifested in improvement of gait of tabetic patients under use of Frenkel’s methods,
Neur. 23
--, methods and procedures in, caution in accepting, Psych. 12
-of (Bernard Hart), Psych. 13
-of, analytical, Psych. 26
-of, conclusions as to, Psych. 32
—~, treatment with good results in hysterical paraplegia with organic symptoms acting as
form of, Neur. 22
Pterygoid muscles, external, close relation to nasopharynx, Child. 27
Ptosis with bilateral ophthalmoplegia externa, unusual case of (M. L. Hine), Ophth. 61
Puberty, occurrence of symmetrical disease of macula at, in both sexes, Ophth. 35
Puerperal eclampsia, premonitory signs of, Obst. 83
-fever, slight, becoming virulent from wrong treatment, Obst. 93
-, prevalence during dry years, Med., Path, and Epid. xiii
-, prevention of, Obst. 50
-infection, evil results of, Obst. 105
-, reception of cases of, into Department for Diseases of Women, Obst. 48
-—- sepsis, death-rate from, decline in, Obst. 98
-, percentage, Obst. 82
-, death-rates per 1,000 births from, in United Kingdom, Obst. 77
-, main cause of, Obst. 81
-, morbidity of, why injurious to nation, Obst. 82
-, mortality from, reduction in, Obst. 101
-", one chief cause of maternal mortality in child-birth, Obst. 79
-, prevention, sole weapon against, Obst. 95
-, septicaemia, early, localized, treatment, Obst. 102
-, epidemics of, disappearance from hospitals, Obst. 82
---, notification of, Obst. 101
-- toxffimia, tests for, recognition of, Obst. 55
Puerperium considered as period of post-operative convalescence, Obst. 92
-, effect on otosclerosis, Otol. 131
-, general management, conduct of, Obst. 92
-, pathology, teaching of, Obst. 35
-, special points with regard to, teaching of, Obst. 35
I'ug-nose, type of, loss of bridge of nose, Laryng. 126
Pulmonary complications, following stovaine anaesthesia, Anaesth. 6, 7
-type of influenza, Med. 52
-, treatment, Med. 70
-, see also Pneumonia
Pulp cavity, bacteria in, demonstrated in seotions from cases of pyorrhoea, Odont. 107, 108
-, dental, affected by scurvy, Odont. 36, 37, 38
-, fibrosis of, in guinea-pig kept on scorbutic diet, Odont. 32, 35
-, histology and histo-pathology in normal relationship to dentine, Odont. 31, 32, 33
-of rodents, degeneration normally occurring in, Odont. 37
-, living, bacteria in, demonstrated in sections from cases of pyorrhoea, Odont. 106, 107
Pulsating tumour of orbit, of uncertain nature (H. Grimsdale), Ophth. 35
Pulse, imperceptible in profound shock, R.S.M. Disc. (Shock), 11
-in pulmonary type of influenza, Med. 54
Index
cxix
Pulse rate, reduction in migraine, Ophth. 49
- -, measurement during performance of tests with U-tube manometer. Epid. 39
-, response to exercise, as test of physical efficiency, Epid. 36
Purpura, case of, specimens from (Eric Pritchard), Child. 107
Purse-string suture, minute escape of gas from puncture during applications to distended
colon, Path. 73
Pyloric canal, hypertrophic stenosis of, specimen (S. G. Shattock), Laryng. 78
-, normal, Laryng. 92
-, stenosis, hypertrophic, Laryng. 93, 98
Pylorus, fork accidentally swallowed and impacted in (William Hill and K. A. Lees),
Laryng. 110
-, stenosis of, case of, diffuse emphysema of intestinal wall in, Path. 46, 47, 48
-, examination of portion of small intestine excised during life, Path. 65, 66
-, hyperresthetic condition of mucosa in, Laryng. 58
Pyorrhoea alveolaris, bacteriology of, experimental inquiry into (J. G. Turner and A. Drew),
Odont. 104
---, technique employed, Odont. 104
-, sections from, cases of, method of staining, Odont. 105, 106
-method of treating, Odont. 105
Pyramidal tract, organic lesion of, physical signs persisting after recovery from organic
paralysis and associated with hysterical paralysis, Neur. 24
Pyrexia, as indicative of septic infection of lateral sinus, Otol. 64, 65, 68, 72, 73
-in fatal case of encephalitis lethargica, Neur. 57
-in recipients of transfused blood, Med. 10
-, intermittent septic, without rigors, commencing ten days after mastoid operation, type
of pyrexia from which to be distinguished, Otol. 73
-, what is indicated by, Otol. 73
-, malarial, due to malarial parasite, proof, Med. 18
-, irregular type in patients taking quinine, chart showing, Med. 18, 19
Pyrexial infection, disappearance of pyrexia during, Child. 53
Pyrosis, extreme, condition of oesophagus in, Laryng. 62
Queen Alexandra Hospital, Dunkirk, established by French Ambulance Unit, Epid. 28
---, fatality rate of typhoid and paratyphoid among cases admitted to,
compared, Epid. 27
-, proportion of cases of typhoid and paratyphoid fever admitted to, Epid. 25
-, treatment of civilian cases of enteric fever at, Epid. 28
-Charlotte’s Hospital, clinical teaching of obstetrics at, Obst. 39
Quinine, course of malaria in case of patient taking, Med. 20, 21
-, irregular type of malarial pyrexia in patients taking, chart showing, Med. 18, 19
- treatment, various courses of, cases of malaria under, experiments on complement
deviation in, Med. 46
Quinquaud’s disease, see Folliculitis decalvans
Rabbit, experimental infection with Aspergillus fumigatus, Laryng. 187
-, function of lactation in, Obst. 27
Rabbits, inoculation experiments with micro-organisms obtained from influenza patients,
results, R.S.M. Disc. (Infl.), 38, 39, 40
-, intravenous injection with Choussy-Perri&re water, leucocytosis reaction following,
Bain. 5
Radiant heat baths in treatment of keratosis follicularis (Darier’s disease), Derm. 67
Radiation, field of, undue restrictions, in treatment of cancer of breast, Electr. 46
-, mode of spread of cancer in relation to its treatment by (W. Sampson Handley), Electr. 41
cxx
Index
Radiation, treatment by, of breast cancer without operation, Electr. 45 ; see also X-rays
Radiographs, method of taking and viewing, Electr. 6, 7
Radiography, stereoscopic (the late Sir James Mackenzie Davidson), Electr. 1
-, condition of vision of observer in, Electr. 1.
-, distance of tube displacement in, Electr. 8
-, in treatment of fractures of femur (James Metcalfe), Electr. 7*2
-, advantages, Electr, 74
--, of lateral view in, Electr. 74, 75
--, frequency of examination important, Electr. 75
-, method described, Electr. 73
-, Screen localization of foreign bodies in, Electr. 7, 8
Radio-ulnar joint, inferior, ankylosis, treatment, Surg. 25
Radium and X-ray treatment of breast cancer compared, Electr. 50
-, application after diathermy in treatment of inoperable cancer of cervix uteri, Electr. 18
-emanation in Choussy-Perrifcre water, Bain. 3
- treatment in recurrenoe in glands of sarcoma of maxillary antrum (Irwin Moore),
Larynx. 21
-, nature of cells of tumours yielding best results from, Clin. 5, 6
-of epithelioma of face, Derm. 2, 3
-of keratoma senile, Derm. 65
-of melanotic naevo-carcinoma, Derm. 43
-of perithelioma of right maxillary antrum (J. Gay French), Laryng. 114
- -of sarcoma of jaw, Laryng. 164
-of scapula (T. H. Kellock), Clin. 3
-X-rays and excision in treatment of carcinoma of right antrum and orbit (Norman
Patterson), Laryng. 194
Radius, fracture of, ununited, treatment by bone-grafting, Surg. 24, 27
Random sampling, errors in new method for enumerating Entamceba coli cysts in stools due
to, M.B.L. 10
Rankine (Dr.).—Discussion on electrical methods of measuring body temperatures, Electr. 60
Raphael, F. C.—Discussion on electrical methods of measuring body temperatures, Electr. 63
Rashes in encephalitis lethargica, characters of, Med., Path, and Epid. xxii
Rational thinking and oomplex thinking, distinction between, Psych. 23
Rats, effects of explosives on, Neur. 43
Raynaud’s disease, erythromelalgia, transient oedema, combined, complicating malaria,
• Med. 29
-, treatment by diathermy, Electr. 36
-, symptoms, complicating malaria, Med. 28, 29
Rayneb, E. H.—Discussion on electrical methods of measuring body temperatures, Electr. 61
Read, C. Stanford.—W ar psychiatry, Psych. 36
von Recklinghausen’s disease ; see Neurofibromatosis , multiple
Recruiting of mental defects, excuse for, Psych. 48
Recruits at medical examination, previous attacks of insanity concealed by, Psych. 37
Rectum and great bowel, gunshot wound of (Arthur Keith), Proct. 47
-, carcinoma of, abdomino-perineal incision for, followed three years later by recurrence
in posterior vaginal wall (W. S. Handley), Proct. 46
-, entrance of air into, Path. 53 ; see also Pvieumatosis , rectal
-, gunshot wounds of, extraperitoneal, treatment, Proct. 48
-, treatment by delayed primary suture, Proct. 48
-, high mortality, cause of, Proct. 47
- 1 intraperitoneal and extraperitoneal combined, Proct. 47
-, large, lacerated, Proct. 47
-, mortality high, Proct. 48
-, treatment in all cases by colostomy, Proct. 47
-, prolapse of, complete, resection in, two cases illustrating, result (Percival P. Cole),
Proct. 46
Index
CXXl
Rectum, resection of, for carcinoma, case showing result (Percival P. Cole), Proct. 45
Rectus abdominis muscle, spontaneous rupture in influenza, R.S.M. Disc. (Infl.) 100
Re-education and persuasion in treatment of case of ataxic paraplegia associated with
Friedreich’s ataxy, Neur. 24
Reflex level, morbid conditions at, how manifested, Neur. 9
Reflexes, primitive, basis of, Neur. 6
Reis and Nussbaum, gas-gland of Ophidinm , quoted, Path. 67
Relatives as donors of transfused blood, Med. 9
Repression of painful memories, Psych. 6
Reproduction, normal and abnormal processes of, simultaneous study with that of diseases of
reproduction, Obst. 42
-, physiology, teaching of, Obst. 61, 74
Resonance curve in diathermy apparatus, Elect. 21 *
Respiration, cutaneous, direction of passage of oxygen and carbon dioxide in, contrasted.
Path. 70
-, secretion of carbon dioxide from human skin during, Path. 68
-, impeded, causing deformity of chest, Child. 33
-, interference with, under stovaine anaesthesia, Amesth. 5
-, case illustrating, Amesth. 5
-, nasal, training of children in, Child. 50
-and oral interfered with by adenoids, Child. 33
-, stridulous, cause of, Child. 34
Respiratory disease, acute, outbreak among American troops aboard a transport, R.S.M.
Disc. (Infl.) 71
--, epidemiological data, R.S.M. Disc. (Infl.) 72
-, general features, R.S.M. Disc. (Infl.) 71
-, hospitalization after disembarkation, R.S.M.
Disc. (Infl.) 72
, incidence and mortality of pneumonia following,
R.S.M. Disc. (Infl.) 74
----, predisposing causes, R.S.M. Disc. (Infl.) 73
--, sanitary officer’s report, R.S.M. Disc. (Infl.) 71
-, methods of checking, R.S.M. Disc. (Infl.) 74, 75
-distress in pulmonary type of influenza, Med. 54
-exercises in treatment of adenoids, Child. 43, 49, 53
-, contra-indicated, Child. 35, 49, 58
-passages, foreign bodies impacted in, recorded at Section of Laryngology since 1908
(Irwin Moore), Laryng. 15
Rest in avoidance of surgical shock, R.S.M. Disc. (Shock) 29, 30
-and warmth in treatment of shock, R.S.M. Disc. (Shock) 18, 19
Retina, angeioid streaks in (E. W. Brewerton), Ophth. 33
-, in brother and sister, Ophth. 34
—-, angioma of (H. Goldsmith), Ophth. 3
-, case (E. W. Brewerton), Ophth. 20
-, cases reported, Ophth. 21
-, cells of, toxic influence on, causing defective vision, Ophth. and Laryng. lvi
-, folds in internal limiting membrane of (A. C. Hudson), Ophth. 15
-; see also Haemorrhage , retinal, slight
Reynolds, E. S., arsenical poisoning among beer-drinkers, quoted, Clin. 18
Rhabdomyoma ; see Teratoblastoma , congenital, of vulva
Rhinitis, atrophic, with ozaena, question of infection of accessory sinuses in, Laryng. 232
_, treatment by application of ichthyol with vaseline, Laryng. 186
-by douching nasal cavities, Laryng. 231
-by glycophylic method (T. H. C. Benians and C. H. Hayton), Laryng.
227-234
CXXU
Index
Rhinitis, atrophic, with ozaena, treatment by glycophylic method, results in ten cases,
Laryng. 231
-undergoing treatment by glycophylic method, four cases (C. H. Hay ton),
Laryng. 184
-, with disease of ethmoidal labyrinth, Laryng. 233
Rhinolith in nose causing discharge and foetor, Laryng. 160
Rhinologists, aid to be sought in treatment of diseases affecting orbit and accessory sinuses,
Ophth. and Laryng. iv
Rhinoplasty, chest flap, in gunshot wound of face, Laryng. 142, 144, 145
-, for total loss of nose, Laryng. 136, 140
Rhinotomy, lateral, in carcinoma of maxillary antrum, recurrence (Irwin Moore), Laryng. 24
-, in sarcoma of mamillary antrum ; recurrence in glands ; radium treatment (Irwin
Moore), Laryng. 21
-, Moure’s, in sarcoma of nose (Andrew Wylie), Laryng. 162
-, with removal of nasal process of superior maxillary bone, as method of approach
in operating on pituitary tumour, Laryng. 178
Rib as bone-graft, Surg. 23
-as mandibular bone-graft, Surg. 16, 18
-as transplant graft in ununited fractures of mandible, Odont. 96, 97
Richards, removal of floor of bony meatus in radical mastoid operation, quoted, Otol. 35
-, results of hearing after radical mastoid operation, quoted, Otol. 42
Richardson, Capt.—Discussion on radiography of gall-stones, Electr. 85
Rickets, affection of bones in, Odont. 26
-, early stage of, difficult to diagnose, Odont. 26
-, enamel organ of infant suffering from, microscopical appearances, Odont. 34
-, foBtal, conditions included under, Otol. 129
-, ill-effects of, permanent throughout life, Odont. 26
-, infantile, delayed dentition in, Odont. 26
-, painful teething in, Odont. 26
-, infants with, fatness of, Odont. 26
-, percentage in London clinics, Odont. 25
-, prevalent among infants of Scottish Lowlandcrs, Odont. 29
-, prevention of, Odont. 26
-, rarity, increasing, Odont. 34
-, severe in child of 3 years (G. Graham), Child. 103
-, small size of nasopharynx in children with, Child. 51
-, spread of, development of adenoids coincident with, Child. 31, 45, 48
-, symptoms of, Odont. 25, 26
-, types of maldevelopment of jaws associated with, Child. 33
-, unknown in Australia, Child, 39, 57
-in county of Sutherland, Odont. 28
Riddoch, George.—C ase of acromegaly, Neur. 35
Rigby, Sir Hugh.—S pecimen of dilatation of oesophagus showing overgrowth of cardiac
sphincter, Laryng. 76, 96
-, and Turnbull, H.—Specimen of dilatation of oesophagus without anatomical stenosis,
from Pathological Institute of London Hospital, Laryng. 77, 90
Rigors, apyrexial, in malaria, Med. 17, 38
-, charts from five cases showing, Med. 22
- in recipients of transfused blood, Med. 10
Ring forceps, for removal of twenty teeth inhaled with fang downwards, Laryng. 20
Risdon, E. F., Captain, C.A.M.C.—Discussion on atrophic rhinitis with ozaena undergoing
treatment by glycophylic method, Laryng. 186
-, discussion on cases of pharyngeal diverticulum, Laryng. 250
-on gunshot wounds of nasal accessory sinuses, Laryng. 242
-and Waldron, C. W., C.A.M.C.—Mandibular bone-grafts, Surg. 11
Index
CXXlll
Rishworth, Major, apparatus to correct displacement of maxillae, Odont. 76, 77
Robertson, drop in blood volume in shock, quoted, R.S.M. Disc. (Shock), 18
Robertson, John. —Discussion on epidemic encephalitis, Med., Path, and Epid. xiv
Robinson, G. Drummond —Short communication on a case of labour in a paraplegic woman,
Obst. 22
-, skiagram of foreign body in the gravid uterus, Obst. 17
-, Uterus in which changes had taken place as the result of procidentia. Obst. 18
Rodent ulcer, treatment by diathermy, Electr. 25, 26, 28
-by fulguration, Electr. 28
Rodents, teeth of, pulp degeneration normally occurring in, Odont. 37
Rolleston, Sir Humphry, K.C.B.—Cause of cesophagectasia, quoted, Laryng. 37
-, discussion on carcinoma of appendix, Surg. 41
-on case of lymphadenoma : arsenical pigmentation, Clin. 18
-on influenza, R.S.M. Disc. (Infl.) 84
-on spirochsetosis icterohaemorrhagica, Med. 4
-, inco-ordination theory of dilatation of oesophagus without anatomical stenosis, quoted,
Laryng. 70
-, post-mortem findings in cases of puerperal anuria, quoted, Obst. 29, 31
-, simple dilatation of oesophagus, quoted, Laryng. 70
-, vagal paralysis in relation to dilatation of oesophagus, quoted, Laryng. 38
-, and Jones, Lawrence, cases of primary malignant disease of vermiform appendix,
quoted, Surg. 41
Rolleston, J. D.—Discussion on case of trophoedema of leg, Child. 106
-, discussion on chorea complicated by gangrene of fingers, Child. 89
Romanis, W. H. C., local subcutaneous emphysema at site of punctured wounds, quoted,
Path. 59
Romberg and Passler, cause of circulatory depression in bacterial infections, R.S.M.
Disc. (Shock), 6
Romberg’s sign, hysterical, in tabes dorsalis, Neur. 22
Rood, Felix. — Discussion on the present position of spinal amesthesia, Anaesth. 1, 14
Rose, Frank. —Case of epithelioma of tonsil two years and nine months after diathermy,
Laryng. 170 •
-, discussion on case of adhesions and contracture of faucial pillars following complete
enucleation of tonsils, Laryng. 180
-on choanal polypi in two children, Laryng. 155
-on dermoid fistula of nose, Laryng. 103
-on non-surgical treatment of enlarged or diseased tonsils, Laryng. 247
-, specimen of dilatation of oesophagus, Laryng. 74
Rosenmuller, fossae of, masses of adenoid tissue in, Child. 34
Rose spots in typhoid in inoculated soldiers, Epid. 2
Ross, T. A.—Certain inter-relations between peace and war neuroses, Neur. 13
Roth, Paul Bernard.— Apophysitis of os calcis, Child. 99
-, discussion on case of severe rickets, Child. 104
Round, Harold, Billinqton, William, and Parrott, Arthur H. -Bone-grafting in gun¬
shot fractures of the jaw, Odont. 55
Round window, microscopic examination in case of otosclerosis associated with otitis media,
Otol. 120; see also Fenestra rotunda
Routh, Amand. —Discussion on case of labour in paraplegic woman, Obst. 26
-on changes in uterus as result of procidentia, Obst. 21
-on foreign body in gravid uterus, Obst. 18
-on high maternal mortality of child-bearing, Obst. 101
-on retro-peritoneal bleeding after dilatation of cervix, Obst. 204
-on syphilitic placenta, Obst. 215
-on teaching of obstetrics and gynaecology, Obst. 53
-on treatment of ante-natal and post-natal syphilis, Obst. 12
CXX1V
Index
Koval Air Force, candidates for commissions in, rejection on account of chronic middle-ear
suppuration, Otol. 52
—--, examination of, by clinical methods, Epid. 44
-, by physical efficiency tests, Epid. 33-45
-, by psychological- tests, Epid. 44, 45
-, incidence of influenza epidemic (1918) on, R.S.M. Disc. (Infi.) 22
-, minimum standard of breath-holding test for admission to, Epid. 38
-, tests with U-tube manometer for admission to, Epid. 39
Royal Navy, British, influenza in, treatment by vaccines, R.S.M. Disc. (Infl.) 83
-, stationed at Plymouth, influenza epidemic in (1918), R.S.M. Disc. 30
Royal Society of Medicine, suggestions for future usefulness of, Laryng. 7
Royal Victoria Hospital, Netley, study of cases of war psychoses at, Psych. 41
Rubber gloves, not a sufficient protection against infection in conduct of labour, Obst. 88, 90
-tubing attached to syringes used in transfusion of blood, Med. 7
Rumen, tympanites of, in cattle. Path, 55
Russ, Sidney.— Discussion on the electrocardiograph, Elect. 68
Russel, J. C., treatment of cardiospasm by distensible bags, quoted, Laryng. 52
Russians, literature of war psychiatry previous to present war mainly derived from, Psych. 36
Russo-Japanese campaign, care of mental diseases during, Psych. 36
Rrr.AND, Archeb, and Wylie, Andrew.— Chronic unilateral laryngitis for diagnosis,
Laryng. 164
Ryley, C. Meadows and Iredell, C. E.—Diathermy in diseases of the eye, Electr. 31
Sac, fcetal, false capsule of, in extra-uterine pregnancy. Obst. 185
-and placenta, method of dealing with, in one hundred cases of extra-uterine pregnancy,
Obst. 154, 155
St. Bartholomew’s Hospital, Museum of, specimen of dilatation of oesophagus without
anatomical stenosis, exhibited from (F. A. Rose). Laryng. 74, 86
St. George’s Hospital, Museum of, specimens of dilatation of oesophagus without anatomical
stenosis, exhibited from (H. S. Barwell), Laryng. 68-71, 79-81
St. Thomas’s Hospital. Museum of, specimen of hypertrophic stenosis of pyloric canal from
(S. G. Shattock, F.R.S.), Laryng. 78, 93
-, specimens of dilatation of oesophagus without anatomical stenosis, exhibited
from (W. G. Howarth), Laryng. 71, 72, 82, 83
-, Obstetric Department and Department for Diseases of Children, connexion between,
at, Obst. 46
Salads, consumption of, benefit from, Child. 30
Salford, measles epidemics in, amplitudes, Epid. 90, 92, 95
-, deaths from, average weekly prevalence for forty years, Epid. 98
Salicin in treatment of influenza, R.S.M. Disc. (Infl.), 87-90, 92
Saline infusion, continuous, in treatment of cholera, R.S.M. Disc. (Shock), 30
-of general peritonitis, R.S.M. Disc. (Shock), 30
-of toxic shock, R.S.M. Disc. (Shock), 30
-injection, followed by blood-transfusion in shock, results, R.S.M. Disc. (Shock), 21, 22, 33
-, normal, dilution of concentrated solution of malarial parasites with, Med. 41
-, rectal administration, before and after operation in cases of shock, R.S.M. Disc. (Shock),
23, 33
-solution, injection into axillae, to obviate shock following operations for acute intestiual
obstruction, R.S.M. Disc. (Shock), 27
-solutions, simple, injection ineffectual in treatment of shock, R.S.M. Disc. (Shock), 3
-stovaine, specific gravity, Annesth. 13
-, superiority over glucose solution, Ansesth. 13
Saliva, diastasic ferment in, animals without. Child. 27
Salivary depressants, oral toxaemia due to feeding on, scurvy in relation to, Odont. 37
Index
cxxv
Salivary excitants, Odont. 38
-glands, function of, in man, Child. 27
-, weight of, compared with that of pancreas, Child. 28
Salmond, R. W. A.—Discussion on radiography of gall-stones, Electr. 83
Salt solution, normal, as medium for conducting current to eye, in diathermy treatment of
glaucoma, Electr. 39
Salvarsan and mercury, intramuscular injections in antisyphilitic treatment of infants. Obst.
10,13
——, in treatment of thoracic actinomycosis, Clin. 3
-, syphilis not cured by, Obst. 13
Samaritan Free Hospital, abdominal operations at, conducted upon Lister’s methods, Obst. 2
-r-, mortality from abdominal operations, 1884 and 1916 compared, Obst. 7
-, vaginal operations forbidden to surgeons at, Obst. 2
Samuel, H. C.—Case for diagnosis, sent from University College Hospital (shown for J. H.
Stowers), Derm. 30
-, case of atrophy of face with telangiectases, quoted, Derm. 64
-of leucodermia and melanodermia associated with leuconychia, Derm. 58
-of leuconychia, Derm. 57
-of pigmentation of the mucous membrane. Derm. 27
-, discussion on case for diagnosis, Child. 22; Derm. 46
--of Dercum’s disease, Derm. 36
--of multiple idiopathic haemorrhagic sarcoma, Derm. 7
--on circinate persistent erythema multiforme, Derm. 8
-on hypertrichosis in mentally defective child. Child. 23
Sapnemia, Obst. 94, 100, 106
Sarcoma, beneficial effect of Coley’s fluid on, Clin. 18
-, commencing in ethmoid or maxilla, invading orbit, Ophth. and Laryng. lv
-, development at periphery of carcinoma, Path. 3
-, during propagation of carcinoma, Path. 3
-in ethmoidal region, Laryng. 163
-, melanotic, associated with squamous-celled carcinoma of the skin, Path. 27-31
-, microscopic appearances, Path. 28, 29, 30
- 1 dissemination, mode of, Electr. 42
-, multiple idiopathic hfflmorrhagic, of Kaposi, case (E. G. Graham Little), Derm. 5
-(miscalled) (J. J. Pringle), Derm. 48
-of jaw, treatment by diathermy, Electr. 29
—-, treatment by radium, Laryng. 164
- of maxillary antrum, lateral rhinotomy, recurrence in glands, radium treatment
(Irwin Moore), Laryng. 211
-- of nose, removal, modified external operation (Moure’s lateral rhinotomy) (Andrew
Wylie), Laryng. 162
-of scapula, treatment by radium (T. H. Kellock), Clin. 3
-of tonsil, case (G. W. Dawson), Laryng. 177
-/pathologist’s report on, Laryng. 177
-(?) of tonsil, case of (W. M. Mollison), Laryng. 211
---(left) (A. Wylie), Laryng. 26
-, polymorphic-celled, adeno-carcinoma of the thyroid gland, disseminating as. Path. 4-8
-, spindle-celled, in combination with squamous-celled carcinoma of the epiglottis,
Path. 23-27
Sarcomatous stroma, adenocarcinoma of the prostate with metaplasia in squamous-celled
carcinoma associated with, Path. 18
-associated with polyp showing areas of squamous-celled carcinoma, Path. 13-17
-, giant-celled, in case of adenocarcinoma of the breast, Path. 8-13
Saboent, Percy.—C ase of endothelioma of appendix, quoted, Surg. 39
-, closure of cavities in bone, Surg. 1
CXXV1
Index
Saunders, Arthur, references to musical anus, Path. 54
Savill, Mrs.—Discussion on case for diagnosis, Derm. 46
-, on case of senile tuberculosis cutis, Derm. 19
Saw, circular, motor-driven, use in bone-grafting, Surg. 32, 34
-, prevention of heating of bone, Surg. 34
Scalp and eyebrows, alopecia of, associated with Graves’s disease (H. W. Barbor), Derm. 41
Scapula, sarcoma of, treatment by radium (T. H. Kellock), Clin. 3
Scarf-pin in stomach, gastroscopy, expelled by vomiting (C. E. \Voakes), Laryng. 10
Scarlet fever, change in clinical type, Epid. 63
-fpllowing in cases of radical mastoid operation, Otol. 37
-, prevalence during dry years, Med., Path, and Epid. xiii
Soar tissue of wounds, excision before bone-grafting, 8urg. 25 •
Schofield, Miss Mary. —Report on case of trichorrhexis nodosa, Derm. 59
Schofield, S. R., results of vaccine treatment of influenza, quoted, R.S.M. Disc. (Infl.) 82
School children, chronic suppuration of middle-ear in, recovery from, without operation,
Otol. 53, 55
-, poor, prevalence of chronic suppuration of middle-ear among, OtoL 52, 53
Schuster, A., method of testing probabilities of periods, Epid. 112
-, periodogram analysis designed by, Epid. 100
Schwartze’s mastoid operation, Otol. 52, 54, 57, 58
de Schweinitz and Randall, acute catarrhal pharyngitis, Child, 36
Sclerodermia, linoar, association of morphcea guttata with, Derm. 25
-——, unilateral band, and morphoeo-sclerodermia of left leg (George Pernet), Derm. 43
-with calcification affecting muscles, Child. 96, 98
-in mongol (P. S. Langmead), Child. 94
Sclerotics, blue, and fragilitas ossium, nerve-deafness associated with, Otol. 130
-, association with hereditary tendency to fractures, Otol. 129
-with otosclerosis, three cases (J. S. Fraser), clinical report, Otol. 126-131
Scopolamine-morphine, administration by special method for increasing effect, Anoesth. 4
-, preliminary administration before spinal anaesthesia, Ansesth. 12
-for less severe operations, Anaesth. 3, 4
Scorbutic diet, effect on pregnant guinea-pigs, Odont. 34
-, fibrosis of dental pulp in guinea-pig kept on, Odont. 32, 35
Scotch, Highland, diet of, Odont. 27, 28
-, Lowland, infants of, scurvy prevalent among, Odont. 29
Scotland, maternal death rate due to pregnancy and labour in, Obst. 64, 69
-, teaching of obstetrics and gynaecology in, Obst. 68, 69
-, vital statistics in connexion with maternal mortality of child-bearing, Obst. 76
Scotoma, central, in retrobulbar neuritis, Ophth. and Laryng. xliii
-preceding migraine, Ophth. 53, 54
-, scintillating, in migraine, Ophth. 49, 50
Scotomata, in inflammatory diseases of nasal accessory sinuses, Ophth. and Laryng. xlviii
Scott, Sydney.— Discussion on case of circumscribed labyrinthitis, Otol. 100
-, discussion on case of iabyrinthectomy, Otol. 102
-on new theory of hearing, Otol. 89
-on otosclerosis associated with fragilitas ossium and blue sclerotics, Otol. 132
-, three instruments to simplify the control of haemorrhage in difficult cases of enucleation
of the tonsils, Laryng. 215
Scratch-reflex, how evoked, Neur. 5
Screen localization of foreign bodies in stereoscopic radiography, Electr. 7, 8
Screw fixation, malar coronoid, in treatment of posterior fragment in fracture of mandible,
Surg. 12
Scrotum, left testicle transplanted to right side of, and right testicle to left side of, in operation
for double imperfectly descended testicle, case (Philip Turner), Child. 61
Scurvy, [etiology of, Odont. 23
Index
CXXVll
Scurvy, among adults, course of, Odont. 24
-, antiquity of, Odont. 24
-, dental pulp affected by, Odont. 36, 37, 38
-, guinea-pigs suffering from, resulting from scorbutic diet, histological appearances of
teeth, Odont. 31, 32, 35
-in relation to oral toxaemia due to feeding on salivary depressants, Odont. 37
-, infantile, age of appearance, Odont. 25
-, clinical picture of, Odont. 25
-, course of, Odont. 24
-, early stages of, difficult to diagnose, Odont. 2G
-, prevalent among infants of Scottish Lowlanders, Odont. 29
Sea air in treatment of adenoids, Child. 52
Sea eagle, Chilian, sudden death of, from over distension of abdominal air-sac, Path. 63
Secretory symptoms in war neuroses, Psych. 56
Self abasement, recognition by clinical psychology, Psych. 6
-, suggestion in relation to, Psych. 19, 20
-assertion, recognition by clinical psychology, Psych. 6
-, suggestion in relation to, Psych. 19, 20
-preservation, instinct of, Psych. 7
Sella turcica and optic chiasma, drawing of transverse section through, to show relations of
pituitary body (J. Herbert Fisher), Ophth. 56
-, changes in, associated with Leber’s atrophy (James Taylor), Ophth. 22
-, t^ansphenoidal approach to, methods of, Laryng. 253
Sellar decompression and removal of endotheliomatous tissue in pituitary tumour, great
improvement (H. Lawson Whale), Laryng. 178
-in operations on pituitary tumour (W. G. Howarth), Laryng. 253
Semaphoric apparatus in fishes, Otol. 81, 82
Semicircular canal, lateral, findings in, at radical mastoid operations, Otol. 36
-canals, and part of cochlea, obliteration of, by bone in case of vertigo (R. Lake), Otol. 77
-and vestibule, microscopic examination in case of fracture of base of skull with
fracture dislocation of incus and rupture of roof of right mastoid antrum, Otol. 114
-, microscopic examination in case of fracture of base of skull involving middle[Jand
inner ear, Otol. 109
-.-, in case of otosclerosis associated with otitis media, Otol. 121, 125
Semmelweis, discoverer of antiseptics, Obst. 99
Semon, H. C.—Case of keratoma senile, Derm. 65
-, discussion on case for diagnosis, Derm. 31, 40
-of arsenical pigmentation and hyperkeratoses, Derm. 32
-of dermatitis herpetiformis, Derm. 20
-of lichen obtusus corneus, Derm. 16
-of multiple benign tumour-like new growths, Derm. 23
-on unilateral band sclerodermia and morphoea sclerodermia, Derm. 45
Sensationism and associationism, combination of, Psych. 2J
-, definition of, Psych. 2
Sense cells, auditory, Otol. 82
- f hairlets of, phases in completed movement of, Otol. 83
-organs, peripheral, behaviour in response to physical efficiency tests, Epid. 44
Separation allowances for expectant and nursing mothers, Obst. 56
Sepsis, cause of death of mother in extra-uterine pregnancy, Obst. 155 ; see also Puerperal
sepsis
-complicating wounds of war, difficult to control by aseptic principles, R.S.M. Disc.
(Shock) 29
-following operations, control in civil practice, R.S.M. Disc. (Shock) 28
Septal swing, lateral, in treatment of loss of portion of one side of nose, Laryng. 125
Septicaemia, influenzal pneumococcal or influenzal streptococcal, R.S.M. Disc. (Infl.) 99
-. see also Puerperal septicaemia
cxxviii Index
Septicsemic factor in influenza, R.S.M. Disc. (Infl.) 59, 60
Septum, nasal, nasopharynx, and middle ear, malformation in, associated with deafness,
Otol. 28
-, recto-vaginal, purpose of, Obst. 102
Sequeira, J. H.—Alopecia areata following partial thyroidectomy, quoted, Derm. 42
-, case of erythrodermia with lymphatic leukaemia, Derm. 54
-, of lichen planus annularis, Derm. 57
-, discussion on case of idiopathic multiple haemorrhagic sarcoma of Kaposi (miscalled),
Derm. 51
Serous cavities, entrance of air into, pneumatosis due to, Path. 50
Serum, administration in influenza, Med. 72
-, anti-pneumococcal and anti-streptococcal, in treatment of influenza, useless m
virulent cases, R.S.M. Disc. (Infl.), 101
-, anti-streptococcic, administration in influenza, R.S.M. Disc. (Infl.) 85, 86, 92
-, anti tetanic, use in cases of war injury of orbit, Ophth. and Laryng. v
-therapy in influenza, R.S.M. Disc. (Infl.) 85
Serums, malarial, method of testing, Med. 42
Sex in relation to length of normal oesophagus, Laryng. 49
Sexual desire, ungratified, depressive anxiety traced to, Psych. 43
-, impulse, effect on human conduct, Psych. 5, 6
Shame as factor in onset of neurasthenia, Neur. 19
Sharp, A. D.—Discussion on alternatives to operations for adenoids in young children,
Laryng. 219
-, discussion on chronic middle-ear suppuration, Otol. 15
-on dilatation of the oesophagus without anatomical stenosis, Laryng. 65
-on latent sinusitis in relation to systemic infections, Laryng. 225
Shattock, S. G., F.R.S.—Cause of oesophagectasia, quoted, Laryng. 37
-, discussion on dilatation of the oesophagus without anatomical stenosis, Laryng. 57,
67, 95
-, histological report on submucous lipoma of palate and larynx, Laryng. 191
-, normal histology of the vocal cord and ventricle of larynx, considered in connexion with
the development of adenomata, Laryng. 201
-, further report of specimen from case of vocal cord removed by thyro-fissure, Laryng. 149
-, report on specimens of recurring spheno-choanal polypus in child, Laryng. 105
-, skiagram showing reflex achalasia of the oesophagus due to the irritation of a gastric
ulcer, Laryng. 94
-, specimen of hypertrophic stenosis of the pyloric canal, Laryng. 78
-of normal cardiac orifice and canal, Laryng. 78
-, submucous lipomata, quoted, Laryng. 192
-and Nitch, C. A. R.—Diffuse emphysema of the intestinal wall (two cases) with remarks
upon pneumatosis, Path. 46-86
Shaw, H. Batty.—D iscussion on latent sinusitis in relation to systemic infections,
Laryng. 226
-and Woo, A. W., oesophagectasia, quoted, Laryng. 37
Sheep, experiments with, dealing with inability of heart to fill during diastole, R.S.M. Disc.
(Shock) 24, 25
-, human, acute infective polio-encephalo-myelitis in, manifestations, Path. 36, 37
-, manifestations, variability in, Path. 37, 38, 41
-- mode of transmission. Path. 36
Sheffield, encephalitis lethargies, epidemic at, Med., Path, and Epid. xv
-, measles epidemics in, amplitudes, Epid. 90, 91, 95
-in, deaths from, average weekly prevalence for forty years, Epid. 98
Shell explosion, concussion by, followed by hysterical hemiplegia with organic disease, cured
by psychotherapy, case, Neur. 27
-, explosions, demoralizing effects of, Neur. 46
Index
cxxix
Shell, explosions, driving fragments into region of orbit and face, results of, Ophth. and
Laryng. vii
-factory, burns and eye accidents more frequent in women than at fuse factory, Epid. 52
— shock, cause of, Neur. 36, 37
-, htemorrrhages into substance of brain in, R.S.M. Disc. (Shock), 20
-, neurogenic as opposed to commotional origin of, Nbur. 42, 43
-, old cases of. Psych. 53
-, real, as distinguished from neurasthenia, case illustrating, Neur. 49, 50
-wound of both frontal sinuses, case history, Ophth. and Laryng. xliv
-of knee-joint producing septic arthritis, Olin. 15
Shells, German, with mixed and layered fillings, demoralizing effects of, Neur. 46
Shiblds, Oswald.—D iscussion on closure of cavities in bone, Surg. 3
Shipway, F. E.—Case of abdominal section in a man with a thoracic aneurysm, Anaesth. 22
-, case of sudden collapse during laparotomy under ether; treatment by heart massage,
Anaesth. 17
-of tonsillectomy in a man weighing 23 stone, Anaesth. 18
-, discussion on the present position of spinal anaesthesia, Anaesth. 13
Shipway’s inhaler, administration of oxygen and warm ether with, in cases of abdominal
surgery, Anaesth. 16
Shock, clinical, constriction of arteries in, R.S.M. Disc. (Shock) 6, 9
-, death from, following gastrostomy for dilatation of oesophagus without anatomical
stenosis, Laryng. 62
-, definition of, uncertainty as to, R.S.M. Disc. (Shock) 29
-, discussion on, R.S.M. Disc. (Shock) 1-34 (W. M. Bayliss, 1, 33; H. C. Bazett, 31;
C. J. Bond, 24 ; H. H. Dale, 4; C. H. S. Frankau, 31; Sir W. Arbuthnot Lane, 26;
J. D. Malcolm, 9; Sir F. W. Mott, 19 ; J. P. Lockhart-Mummery, 27; Kenneth
Walker, 21; Cuthbert S. Wallace, 17)
-, experimental, toxaemia in, suggested test for, R.S.M. Disc. (Shock) 30, 34
-following burns, and surgical shock, similarity between, RJ3.M. Disc. (Shock) 29
-, heart failure due to, successful massage in case of (Ashley Daly), Anaesth. 15
-operations associated with spinal anaesthesia under, Anaesth. 8, 9
-, primary, R.S.M. Disc. (Shock) 1, 5
-and secondary, difference between, R.S.M. Disc. (Shock) 4
-, signs of, R.8.M. Disc. (Shock) 13, 14
-, post-operative and traumatic compared, R.S.M. Disc. (Shock) 31
-, blood concentration in septic cases, R.S.M. Disc. (Shock) 33
-, chief factors in, R.S.M. Disc. (Shock) 33
-, red blood cells in capillary and venous blood in, R.S.M. Disc. (Shock) 14, 15
-, resistance to all forms of, lowered by bombardments, Neur. 47
-, secondary, R.S.M. Disc. (Shock) 1, 5
-, acidosis in, explained, R.S.M. Disc. (Shock) 13
-, anaesthetics in, R.S.M. Disc. (Shock) 23
-and sequelae, amount of, relationship to degree of infection of gastro-intestinal
tract, R.S.M. Disc. (Shock) 26, 27
-, anuria in, R.S.M. Disc. (Shock) 12
-, brain-cell changes in, R.S.M. Disc. (Shock) 20
-, blood out of circulation in, R.S.M. Disc. (Shock) 18
-complicated by haemorrhage, treatment, R.S.M. Disc. (Shock) 16
-, condition of chemical poisoning set up by massive injuries of tissues in war
wounds, R.S.M. Disc. (Shock) 29
-, conditions to be distinguished from, R.S.M. Disc. (Shock) 10
-, contributory causes of, R.S.M. Disc. (Shock) 3, 7
-, cyanosis in, R.S.M. Disc. (Shock), 33
--, deaths from gas gangrene attributed to, R.S.M. Disc. (Shock) 17
-from peritonitis attributed to, R.S.M. Disc. (Shock) 17
o
cxxx
Index
Shock, secondary, deficiency of blood in circulation in, R.S.M. Disc. (Shock) 2, 24
-, definition, R.S.M. Disc. (Shock) 10
-, dilatation of capillaries in, R.S.M. Disc. (Shock) 2
-, diminution of blood in vessels in, R.S.M. (Shock) 12
-, disappearance in civilian surgical practice, R.S.M. Disc. (Shock) 28
--of blood from heart and great vessels under, R.S.M. Disc. (Shock) 8
-, due to intestinal auto-intoxication, R.S.M. Disc. (Shock) 26
-, experimental production, R.S.M. Disc. (Shock) 2
--, fall of blood-pressure in, R.S.M. Disc. (Shock) 21
— —, following operation for acute intestinal obstruction, how combated, R.S.M. Disc.
(Shock) 27
-for chronic intestinal stasis, how avoided, R.S.M. Disc. (Shock) 27
-, treatment, R.S.M. Disc. (Shock) 16
-, in wounds of war, not controlled by methods of civil practice, R.S.M. Disc.
(Shock) 29
-, lowering of arterial blood-pressure in, R.S.M. Disc. (Shock) 5
-, nature same in civil as in military cases, R.S.M. Disc. (Shock) 26
-, oligsemia in, R.S.M. Disc. (Shock) 7
-, prevention, R.S.M. Disc. (Shock) 2
-, profound, action of heart in, R.S.M. Disc. (Shock) 11, 33
-, state of pulse in, R.S.M. Disc. (Shock) 11
-, signs of, R.S.M. Disc. (Shock) 13, 14
-, sweating in, R.S.M. Disc. (Shock) 12
-, symptoms identical with those of acute auto-intoxication, R.S.M. Disc. (Shock) 27
-, toxaemia of, chemical element in, R.S.M. Disc. (Shock) 24
-, toxic, agent producing, R.S.M. Disc. (Shock) 2, 3
-products of not always recoverable from damaged structures, R.S.M. Disc.
(Shock) 27
-, treatment, R.S.M. Disc. (Shock) 30
-, treatment by blood transfusion, R.S.M. Disc. (Shock) 3, 4, 18, 24
-followed by saline injection, R.S.M. Disc. (Shock) 21,
22, 33
-, by injections of gum-saline solution, R.S.M. Disc. (Shock) 3, 26, 33, 34
--, by simple saline solutions ineffectual, R.S.M. Disc. (Shock) 3
---by intravenous injection of gum-saline solution, R.S.M. Disc. (Shock), 18
--by rest and warmth, R.S.M. Disc. (Shock), 18
-, drugs unsuitable for, R.S.M. Disc. (Shock), 3
-, posture during, R.S.M. Disc. (Shock), 25
- -—, uncomplicated, explanation, R.S.M. Disc. (Shock), 10
--, treatment, R.S.M. Disc. (Shock), 15, 16
-, vasomotor theory of, R.S.M. Disc. (Shock), 28, 29
-, vomiting in, R.S.M. Disc. (Shock), 12
-, spinal antesthesia dangerous for patients suffering from, Ansesth. 9
-, supposed, death from, due to fat embolism, R.S.M. Disc. (Sho'k), 30
-, surgical, and that following burns, similarity between, R.S.M. Disc. (Shock), 29
- --, different physiological conditions described as, R.S.M. Disc. (Shock). 29
-, method of avoidance, R.S.M. Disc. (Shock), 29, 30
-. traumatic, anaesthetics during operations on subjects o*, R.S.M. Disc. (Shock) 32
-, and post-operative compared, R.S.M. Disc. (Shock), 31
---, dilution of blood during head operations in subjects of, R.SA Disc. (Shock), 32
--, haemorrhage during, R.S.M. Disc. (Shock), 31,32
-, stasis in peripheral biood-vessels in subjects of, R.S.M. Disc. (Shock), 32
--, various kinds of, vascular changes in brain in, R.S.M. Disc. (Shock), 19
Shrapnel embedded in antrum, Ophth. and Laryng. lix.
-in pituitary fossa, removal, Ophth. and Laryng. lxi.
Index
CXXXl
Sibley, W. Knowsley.—C ase of lichen obtusus corneus, Derm. 14
-, case of senile tuberculosis cutis, Derm. 18
Sidis, Boris, fear as source of psychoneurosis, quoted. Psych. 7
Sigmoid sinus, findings in, at radical mastoid operations, Otol. 36
-, thrombosis complicating chronic middle-ear suppuration, Otol. 51
Silver wire, fixation of transplant grafts with, Odont. 98
Singer, Charles.—D iscussion on Sydenham as an epidemiologist, Epid. 71
Singer’s nodules (incipient), in vocalist, case (J. Dundas Grant), Laryng. 25
Singers, voice-training in, after enucleation of tonsils, Laryng. 180, 181
Singing, question of assistance of air-sacs to birds during, Path. 63
Sinuses developing after healing of bone wounds, Surg. 4
-, nasal, Aspergillus fumigatus from specimens (Douglas Harmer and T. Jockes), Laryng.
187.
Sinusitis and retrobulbar neuritis, relations between, diversity of opinion as to, Ophth.
and Laryng. lxvi
-, investigation by joint committee proposed, Ophth. and Laryng. lxvii
—- caseosa, traumatic, Ophth. and Laryng. lxii
-, inflammatory diseases of eye or orbit resulting from rare, Ophth. and Laryng. xlvi
-, latent, in relation to systemic infections (P. Watson-Williams), Laryng. 220.
-, nasal, principal cause of orbital inflammation and abscess, Ophth. and Laryng. iii
-, with ophthalmic complications, Ophth. and Laryng. ii, iii
Skin, carcinoma, squamous-celled, associated with melanotic sarcoma, Path. 27-31
-surfaces, temperature thermometer for testing, Electr. 55.
-flap used in radical mastoid operations, Otol. 37
-grafting in radical mastoid operations, Otol. 35
-, contra-indications for, Otol. 37
-, method employed, Otol. 37
-(intra-oral), establishment of buccal sulcus (H. P. Pickerill), Odont. 17
-, human, secretion of carbon dioxide from, in cutaneous respiration, Path. 68
-, malignant disease of, resulting from over-exposure to X-rays, Derm. 66
-, multiple neuromata of, case (E. G. Graham Little), Derm. 35
-, supposed visible secretion of gas from, during submersion of body, Path. 68
Skull, chloroma or adrenal growth with secondary metastasis in (E. Oautley), Child. 90
-, fracture of, in civil life, post-mortem results, Ophth. and Laryng. lxiii
-of the base of, followed by otitis media, meningitis and death (J. S. Fraser), Otol. 103
-, involving right middle and inner ear (J. S. Fraser), Otol. 104
-, with fracture dislocation of incus and rupture of roof of right mastoid antrum
(J. S. Fraser), Otol. 110
--, fractures of, without injury to orbit, Ophth. and Laryng. lxiii
-, gunshot wound of, followed by combined hysterical and organic hemiplegia, groat
improvement with psycho-therapy, Neur. 27
Skylark, subcutaneous emphysema of neck in, Path. 60
Sleeping sickness, diagnosis of encephalitis lethargica from, Med., Path, and Epid. ii
Slesinger, E. G.—Exhibition of pneumatic injector for local anaesthesia, Ansesth. 24
Small-pox, natural history of, Sydenham’s description, Epjd. 67
Smell, loss of, following through-and-through bullet wounds of accessory sinuses, Ophth. and
Laryng. Iii
Smith, Alwyn.—D iscussion on bone-grafting, Surg. 29
Smith, A. Lapthorn.—D iscussion on changes in uterus as result of procidentia, Obst. 21
-, discussion on extra-uterine pregnancy, Obst. 185
-on high maternal mortality of child-bearing, Obst. 103
-on obstructed labour due to ventrifixation, Obst. 219
-on teaching of obstetrics and gynaecology, Obst. 67
Smith, Sir Francis, supposed visible secretion of gas from skin during submersion of body,
quoted, Path. 68
CXXX11
Index
Smith, G. Bellingham.—C ase of extra-uterine pregnancy, Obst. 176
-; see also Iredell , C. E., diathermy in gynaecology
Smith, Morisette, results of hearing after radical mastoid operation, Otol. 42
Smith, Travers.—D iscussion on case of senile tuberculosis cutis, Derm. 19
Smurthwaite, Henry.—D iscussion on functional aphonia, Laryng. 31
Snare, polypus of larynx removed with (J. Dundas Grant), Laryng. 166
Sneezing exercises, in adenoids, Child. 35
Snuffing as supposed remedy for adenoids in young children, condemned, Laryng. 217, 219,
220
Soda, bicarbonate of, administration in dilatation of oesophagus, Laryng. 63
-, caustic, and slaked lime, application to enlarged or diseased tonsils, Laryng. 244-248
-, method demonstrated, Laryng, 248
Sodium, acetylaminophenyl, stibiate of, in treatment of Delhi boil, Derm. 72
-chloride, bath of, effect on white cells, Bain. 4
-, stovaine solution in spinal anaesthesia, Anaesth. 12
-, use in transfusion of blood, Med. 7
-hypochlorite, ionization with, in treatment of Delhi boil, Derm. 71
-, salicylate of, see Urotropin , benzoate of ammonium and salicylate of sodium
Soldier, hysterical paralysis of arm in, therapeutic superiority of analysis over suggestion
and persuasion in dealing with, indicated, Psych. 29, 30
Soldiers drawn from farm labouring classes, development of confusional symptoms among,
Psych. 48
-. inoculated, outbreak of typhoid fever in (Clinton B. Hawn), Epid. 1
-(J. G. Hopkins), Epid. 9
-, recuperative powers after intense physical exhaustion, Psych. 37, 38
Solid form, visual perception of (E. M. Eaton), Ophth. 63
-, requirements for, Ophth. 64
Soltau, A. B.—Discussion on influenza. K.S.M. Disc. (Infl.), 27
Sound analysis in brain, Otol. 93
-wave, transmission of, Otol. 90
-, in cochlea, Otol. 84
-to nerve terminations, Otol. 84
-, transformation into electric wave. Otol. 86
-waves, phases corresponding to phases of completed movement of hairlet of sense-cell,
Otol. 83
-, transmission to inner ear, factor in, Otol. 93
Spectrum of migraine, Ophth. 50, 53
-compared with epileptic aura, Ophth. 50
Speech, cortical lesion affecting, negative manifestations, mode of presentation, Neur. 9
-, disorders of, in encephalitis lethargica, Med., Path, and Epid. xvi, xix
Spectacles, with red and green light, use of, in apparatus for production of stereoscopic
picture, Electr. 3
Speculum, Kelly’s, for cystoscopy of female bladder, and ureteral catheterization, modus
operand i, upon what dependent, Path. 53
Spencer, Herbert R.—Discussion on high maternal mortality of child-bearing, Obst. 100
Spencer, W. G.—Discussion on treatment of ante-natal and post-natal syphilis, Obst. 13
Spheno-choanal polypus, see Polypus , spheno-choanal
Sphenoid and orbit, injury to, with foreign body retained in sphenoidal region, Ophth. and
Laryng. x
-, antrum and orbit, injury to, with foreign body retained in sphenoidal region, Ophth.
and Laryng. x
-, gunshot wounds of, cases, Ophth. and Laryng. xii
Sphenoidal sinus abscess, treatment by suction, Ophth. and Laryng. lix
-, cultures from, in influenza, H.S.M. Disc. (Infl.) 52
-, disease of, in relation to retro-bulbar neuritis, Ophth. and Laryng. lxiv
Index cxxxiii
Sphenoidal sinus, empyema of, in cerebro-spinal meningitis (D. Embleton and E. A. Peters),
Laryng. 260
--in cerebro-spinal meningitis, treatment in acute and relapsing stages of
meningitis, Laryng. 251, 252
-, examination in cases of empyenfa complicating cerebro-meningitis, Laryng. 261,252
-, exploration of, with transphenoidal decompression in case of malignant disease of
pituitary body, Ophth. 44, 48
--, gunshot injuries of, Ophth. and Laryng. xl
-, wounds of, injuries to eye in, Ophth. and Laryng. xxxi
-, suppuration of, blindness associated with, Ophth. and Laryng. xxxv, xxxvi
--, thrombosis of, ending fatally, following septic dermatitis of nose, Ophth. and
Laryng. xxxvii
-sinuses, development in young children, Ophth. and Laryng. lx
-, exploration of, before mastoid operation, Otol. 98
--, infected, micro-organisms found in cultures from, Laryng. 221, 223
-, meningococcal infection of, Laryng. 251, 252
-, suppuration in, no eye symptoms present, Ophth. and Laryng. liii
-sinusitis, acute, Ophth. and Laryng. lix
Sphincter, cardiac, comparison with pyloric sphincter, Laryng. 92, 97, 98
-, form and shape of, Laryng. 92, 97
- 1 exact position and dimensions of, Laryng. 92, 97
-, overgrowth in dilatation of oesophagus, Laryng. 96, 97
-, thickening of circular fibres forming, Laryng. 92, 97
-, pyloric, position of, Laryng. 98
-, rectal, troubles connected with, following direct concussion from high explosives, Neur.
47
Spicer, W. T. Holmes.—D iscussion on angeioid streaks in the retina, Ophth. 34
-, discussion on changes in sella turoica, in association with Leber’s atrophy, Ophth. 23
—-on congenital pigmentation of the cornea, Ophth. 34
-- on injuries and inflammatory diseases affecting the orbit and accessory sinuses,
Ophth. and Laryng. i
-- --on ivory exostosis, growing from roof of frontal sinus into orbital and cranial
cavities, removed through osteoplastic opening in cranium, Ophth. 19
-— on migraine, Ophth. 54
-on symmetrical disease of macula, Ophth. 36
-, the formation of clear lines in nebulee (President’s address), Ophth. 1
Spilsbdry, B. H.—Discussion on influenza, R.S.M. Disc. (Infl.), 55
Spinal cord and brain, injuries and diseases of, resulting in changes without loss of function,
but with permanent presence of organic physical signs, Neur. 24
-, concussion of, with organic physical signs followed by hysterical incontinence of
urine and hysterical paraplegia cured by psychotherapy, case, Neur. 28
-, disseminated sclerosis of, abnormal degree of suggestibility in subjects of, Neur. 2‘2
-, hysterical element in, Neur. 21
-, improvement of vision in, how explained, Neur. 22
-, periods of spontaneous improvement in, how explained, Neur. 22
-, membranes of, sarcoma of, wrongly diagnosed in case of pure hysteria, Psych.
64, 65
--, injury to, flexor spasms and excessive sweating following, cause of, Neur. 7
-, phenomena of mass-reflex after, Neur. 7, 9
-, lateral and posterior columns, physical signs of disease of, preceding onset of
symptoms in tabes dorsalis, Neur. 22
-, lesions of, following experimental inoculation of virus of human acute infective
polio-encephalo-myelitis, Path. 41
-, in epidemic encephalitis lethargica, Epid. i, ii
-, tuberculous meningitis of, simulating anterior poliomyelitis, section from case
(H. C. Cameron), Child. 23
CXXX1V
Index
Spine, caries of, fate of bone-graft after Albee’s operation for, Surg. 31
-, tuberculous disease of, treatment by bone-grafting, Surg. 23
Spirit lotions, use of, as factor in causation of trichorrhexis nodosa, Derm. 60
Spiritualism and materialism, controversy between, Psych. 11
Spirocha?tos, granulation of, Obst. 13 *
-, prevention of development in mother by chorionic ferments, Obst. 12, 13
Spirochfetosis icterohremorrhagica (Sir Bertrand Dawson), Med. 1
-, clinical course, Med. 1
-, diagnosis, Med. 4
-, jaundice in, Med. 3
-, morbid appearances in fatal cases, Med. 2
Spleen, cultures from, in influenza, R.S.M. Disc. (Infl.) 52
-, enlarged in malaria, diagnosis, Med. 20
-, in malaria, rarity of, Med. 34
-, in typhoid fever of inoculated soldiers, Epid. 2
-of malignant tertian case, and cultures of Plasmodium vivax , antigens respectively
prepared from, experiments made by using, Med. 45
-post-mortem appearances in, in influenza, R.S.M. Disc. (Infl.) 56
Splint for fractures of upper extremity (J. R. Lee), Surg. 6, 9
--, pelvic-femur, new (J. R. Lee), Surg. 6
Splints, lower or upper, posterior extensions from, in prevention of displacement and in
control of edentulous posterior fragments in fractures of mandible, Surg. 12
-, re-adaptation, in ununited fractures of the mandible, Odont. 58
-, small, insertion on one fragment in ununited fractures of mandible, Surg. 12
-, time of removal after bone-grafting iu fractures of mandible, Surg. 17
Spokes, Sidney.—D iscussion on influence of food deficiencies on teeth, Odont. 37
Sprains more frequent in women than in men at fuse factory, Epid. 51
Spriogs, E. I.—Examination of the vermiform appendix by X-ray, Electr. 9
Spurway, association of blue sclerotics with horeditarv tendency to fractures, quoted, Otol. 129
Sputum, examination, after injection of new antituberculous medicament by intratracheal
route in cases of pulmonary tuberculosis, Therap. 5
-in pulmonary type of influenza. Med. 56
Stack, E. H. E.—Discussion on injuries and inflammatory diseases affecting the orbit and
accessory sinuses, Ophth. and Laryng. lvi
Stacke’s mastoid operation, Otol. 54
Staining methods employed for demonstration of micro-organisms in teeth, bone and tissues
from cases of pyorrhoea, Odont. 105
-for preparations from cases of encephalitis lethargica, Path. 43, 44, 45
Stansfeld, A. E.—Discussion on treatment of ante-natal and post natal syphilis, Obst. 15
Stapes, fixation of, in relation to hearing, Otol. 90
Staphylectomy, by combination of use of diathermy and cold snare, in closure of gap in
pharyngeal wall, Laryng. 240
-, indications and contra-indications for, Laryng. 239
-- technique described, Laryng. 239, 240
Staphylococcus associated with influenza, R.S.M. Disc. (Infl.) 46, 50, 53, 80, 93
Staphylococcus albus in culture from infected sphenoidal sinus, Laryng. 221
-cultures from influenzal secretions, R.S.M. Disc. (Infl.) 94
- aureus, associated with influenza, R.S.M. Disc, (Infl.) 50, 53, 80
-, cultures from influenzal secretions, R.S.M. Disc. (Infl.) 94
-in cultures from infected sphenoidal sinus, Laryng. 223, 225
Starch, conversion of, into dextrin and maltose, Child. 27
-, digestion of, time taken by, Child. 28
-, salivation of, in pre-cookery times, Child. 28
Starchy food, ingestion of, without salivary digestion, Child. 28
-, limited, in pre-cookery times, Child. 28
Index
cxxxv
Starchy food, supply of, increased in early period of cookery, Child. 28
Status catarrhalis, Child. 27
-lymphaticus, Child. 41, 43
Steam, liberation from boiling water following addition of fragments of earthenware. Path. 69
Stench from body in influenza, R.S.M. Disc. (Infl.) 100
-in purulent bronchitis, R.S.M. Disc. (Infl.) 100
Stenosis, phreno-cardiac, functional, skiagrams of, Laryng. 44-47
-, swallowing easier after eructations in, Laryng. 38
-, hypertrophic, of pyloric canal, specimen (S. G. Shattock), Laryng. 78
Stepping-reflex, flexor aspect of, Neur. 5
Stereoscopic picture, apparatus for production of, Electr. 2
-pictures, erroneous, how to avoid production of, Electr. 5
-radiography, see Radiography , stereoscopic
-vision, see Vision , stereoscopic
Sterility, causes of, teaching of, Obst. 55
-following severe labour, Obst. 92
Stevens, T. G.—Specimen of subperitoneal lipoma weighing 16f lb., Obst. 189
Stevenson, T. H. C.—Discussion on influenza, R.S.M. Disc. (Infl.) 19
Stewart, Sir J. Purves, physical basis of neurosis, quoted, Neur. 37, 38
Stimulus, physical, response to, different methods of, Neur. 11
Stock, Colonel, S.A.M.S.—Discussion on influenza, R.S.M. Disc. (Infl.) 29
Stomach and oesophagus, dividing line between, Laryng. 92, 97
——, aspiration of air into, from displacement of viscera, expulsion through oesophagus,
Path. 55
-, discharge of gas from, in gout and hysteria, Path. 71
-, human, mucosa of, non-sensitive, Path. 78
-, perforation of, gas in peritoneal cavity without, Path. 71, 72
--, pneumo-peritoneum from gas formation following, Path. 50
—reflex in, preventing entry of ingesta from oesophagus, Laryng. 99
-, ulcer of, irritation of, causing reflex achalasia of oesophagus, skiagram showing (S. G.
Shattock), Laryng. 94
-, wall of, emphysema of, occurring about site of simple ulcer, Path. 75
Stoney, Miss Florence.—D iscussion on stereoscopic radiography in fractures of femur,
Electr. 74
Stool, uniform emulsion for preparation of, for enumeration of Entamaba coli cysts,
M.B.L. 3
Stools, Entamaba coli cyst-content in, effect of concentration on, table showing, M.B.L. 13
-, enumerative study (J. W. Cropper), M.B.L. 1-14
-, protozoal cysts in, diagnosis by “concentration methods,” statistical evidence for,
M.B.L. 12
Storage energy, inherited low power of, in groups of neurons in neuropathies and psycho¬
pathies, Otol. 21
Story, J. B.—Discussion #n migraine, Ophth. 54
Stovaine, absolute muscular relaxation produced by, under operation, Antesth. 9
-, administration in abdominal surgery, Anaesth. 10
-in intestinal obstruction, Anaesth. 10
-in spinal anaesthesia, Anaesth. 1, 2
-, advanced age not a contra-indication, Antesth. 5
-, administration, complications following, Anaesth. 5
-, deaths under, Anaesth. 4
-, mode of, Anaesth. 12
-, disadvantage of, Anaesth. 3
-, dosage, Anaesth. 5
--saline solution in spinal anaesthesia, Anaesth. 2
Stowers, J. H.—Case for diagnosis, sent from University College Hospital (shown by H. C.
Samuel), Derm. 30
CXXXV1
Index
Stowers, J. H.—Discussion on case of dermatitis herpetiformis, Derm. 74
-■, discussion on case of epithelioma of face, Derm. 2
-- --on guttate morphoea, Derm. 5
--, report on a case of tuberculosis cutis of six years' duration in the person of a male
patient, aged 53 (exhibited at the meeting held on July 18, 1918). confirming the
diagnosis (communicated), Derm. 9
Streptococcal infection in influenza, R.M.S. Disc. (Infl.) 31, 33, 44, 66, 94
-complicated by leucopenia, R.S.M. Disc. (Infl.) 81
Streptococcus, tolerance for injected cultures of, proved experimentally, after injection of
mineral waters, Bain. 7, 8
-, see also Empyema , streptococcal
Streptococcus brevis , cultures from influenzal secretions, R.M.S. Disc. (Infl.) 94
-, in culture from infected sphenoidal sinus, Laryng. 221
- longus , cultures from influenzal secretions, R.S.M. Disc. (Infl.) 94
- pyogenes longus t associated with influenza, R.S.M. Disc. (Infl.) 42
- viridans, associated with influenza, R.S.M. Disc. (Infl.) 46
Streptothrix infection of thoracic wall, Clin. 1, 2
Strophanthus, tincture of, in prevention of ante-mortjpm intracardiac thrombosis, R.S.M.
Diso. (Infl.) 81
Structure, anatomical, arrangements expressing functions in abeyance, Neur. 5
Stuart-Low, W.—Dermoid fistula of nose, Epid. 102
-, discussion on adenoids, Child. 37
-on case of acute osteomyelitis of right temporal bone, Otol. 2
-of double facial paralysis due to bilateral tuberculous mastoiditis, Otol. 7
-of tongue for diagnosis, Laryng. 199
-on choanal polypi in two children, Laryng. 155
-on chronic middle-ear suppuration, Otol. 15
-on cyst of larynx, Laryng. 195
-on deafness associated with stigmata of degeneration, Otol. 25
-on dilatation of oesophagus without anatomical stenosis, Laryng. 59
-on injuries and inflammatory diseases afiecting the orbit and accessory sinuses,
Ophth. and Laryng. lviii
-- on mastoid operations, Otol. 55
-on naso-laryngeal growth, Laryng. 209
- -on new theory of hearing, Otol. 93
-on radiograms showing absence of right frontal sinus, Laryng. 169
-on sarcoma of maxillary antrum, Laryng. 24
-on septic infection of lateral sinus injured during mastoidectomy, Otol. 74
-on suppurating dermoi^ cyst removed from forehead in child, Laryng. 193
-, epithelioma of the epiglottis, Laryng. 104
-of the left auricle after operation (specimen of ear removed shown), Otol. 78
-, extensive symmetrical lupus erythematosus, Otol. 5
-, female with fibroma of the auricle at the entrance of the mfatus, Otol. 79
Stucky, results of hearing after radical mastoid operation, quoted, Otol. 42
Stupor in encephalitis lethargica, Med., Path, and Epid. xviii, xx, xxii
Subcutaneous tissue, local inflation around puncture in paracentesis of chest, Path. 60
Subliminal self, conception of, Psych. 9, 10
Submaxillary region, right, and floor of mouth, tumour of ? actinomycosis (W. H. Jewell),
Laryng. 215
-, secondary growth in, treatment by diathermy, fatal case, Electr. 26
Submersion, supposed visible secretion of gas from skin during, Path. 68
Submission, recognition by clinical psychology, Psych. 6
Suckling, interference with, due to mouth-breathing, Child. 33
Sugar and glycerine, application in treatment of atrophic rhinitis with ozsena, Laryng. 230
Suggestibility, abnormal, degree of, Psych. 20
Index
CXXXVll
Suggestibility, abnormal, degree of, in subjects of disseminated sclerosis, Ncur. 22
Suggestion and persuasion, difference between, Psych. 22, 23
-, therapeutic superiority of analysis over, indicated, Psych. 28, 29, 30
-, conception of, narrowing down of, Psych. 18
--, definition of, Psych. 15
-, amended. Psych. 19
-, need for better. Psych. 30
-, distinction of analysis from, Psych. 27
-, destruction of conviction of functional paralysis of arm by, Psych. 22
-in causation of onset of war neuroses, Babinski’s theory of, Psych. 55
-in treatment of functional aphonia, Laryng. 31
-, omnipresence of, Psych. 34
-, perpetuation of paralysis in subjects amenable to, by development of hysterical element,
Neur. 24, 25
-, persuasion and analysis, relation between, as therapeutic methods, Psych. 27
-, process of, relation to herd instinct, Psych. 20
-, in relation to self-assertion and self-abasement, Psych. 19, 20
-to sex instinct, Psych. 20
-, processes ascribed to, examples of “ complex thinking,” Psych. 21
—. therapeutic aim of, Psych. 22
-value, limitation of, defined, Psych. 27, 28, 29, 30
—-indications.for use of, apart from analysis, Psych. 31
-, utility in psycho-neuroses, Psych. 22
Suicide among soldiers, principal mode of, Psych. 49
-, psychology of. Psych. 50
Sulci, buccal and labial, obliteration, cause of, Odont. 17, 18
-, establishment of (H. P. Pickerill), Odont. 17
-, obliteration, treatment, methods adopted, Odont. 18
-, preventive, Odont. 18
-, labial, obliteration of (H. P. Pickerill), Odont. 17
Sulcus, narrow, causing difficulty in taking impressions in construction of intra-oral
appliances, Odont. 74
Summer and winter, death-rate of wounded during, compared, R.S.M. Disc. (Shock), 31
Sunstroke as factor in production of mental disease in war, Psych. 39
Supraclavicular glands of same side, microscopic foci of breast cancer in, Electr. 48
Suprarenal gland, defective action in malaria, Med. 38
Surgeon and X-ray worker, correctness of binocular vision in, important, in stereoscopic
radiography, Electr. 2
Surgeons, general, performance of gynaecological operations by, Obst. 50, 54
Surgery and physiology, relationship between, R.S.M. Disc. (Shock), 28
-, antiseptic, application abolishes sepsis in civil practice, Surg. 28
--, art of, obstetrics a division of, Obst. 64
-, gynaecology should be taught as part of course in, Obst. 50
-, preventive, evolution of, effect on war surgery, Obst. 6
Sutherland, County of, breast feeding of infants universal in, Odont. 28
-, rickets unknown in, Odont. 28
Sutherland, Halliday.—D iscussion on new anti-tuberculous medicament, Therap, 8
Swallowing easier after eructations in phreno-cardiac stenosis, Laryng. 38
-, enlargement of hiatus cesophageus during, Laryng. 36
-, neuro-muscular paresis and absence of co-ordinate active opening up of phreno-cardiac
oesophagus during, Laryng. 36
-, pharyngeal and laryngeal, Laryng. 237
Sweating, excessive, following injury to spinal cord, cause of, Neur. 7
Swim-bladder of fish, secretion of gas in, Path. 67
Swine, intestinal emphysema in, Path. 84
CXXXVU1
Index
Sydenham, Thomas, as epidemiologist (M: Greenwood), Epid. 55
-, doctrine of epidemic constitutions, Med., Path, and Epid. viii; Epid. 58, 59, 60
-, epidemio diseases observed by, Epid. 67
-, observations upon epidemics appearing during 1661 and 1676, Epid. 67
-, Pechey’s “Collections of Acute Diseases ” consist of extracts from writings of, Epid. 74
-, works of, Latin text, Epid. 56
-, views on causation of epidemics, Epid. 70, 71
Syme, W. S.—A series of cases of maxillary antral disease: some points of interest (read
by Dr. Irwin Moore), Laryng. 255
-, discussion on case of infiltration and ulceration of vocal cords, Laryng. 113
-on glycophilic method of treating atrophic rhinitis with oz®na, Laryng. 233
-on recurring spheno-choanal polypus in child, Laryng. 107
-, removal of larynx for malignant disease, Laryng. 109
-, so-called malignant mixed-parotid tumour, Laryng. 108
Symns, J. L. M., and Hurst, Arthur F.—Hysterical element in organic disease and injury
of the central nervous system, Neur. 21
Syncope, attacks of, under stovaine anaesthesia, Anaesth. 5, 6
Synovitis, syphilitic, Wassermann reaction in, Child. 84, 85
Synthetic energy of mind, Psych. 4
Syphilis, ante-natal and post-natal, treatment of (John Adams), Obst. 9
-, prevention and treatment in unborn children by means of anti syphilitic treatment
of mothers, Obst. 9
-, children of syphilitic mothers remaining permanently free from, after treatment,
Obst. 14
-, maternal, prevention, Obst. 73
-not cured by salvarsan treatment, Obst. 13
-of central nervous system, factors in morbid manifestations produced by, Neur. 3
-.pre-existing, as factor in production of mental disease in war, question difficult io
decide, Psych. 39
-, post natal, treatment in infants immediately after birth, Obst. 9
-, tertiary, of nose, absorption of pre-maxilla in (Dan McKenzie), Laryng. 2£
-, Wassermann reaction for, not affected by attack of malaria, Med. 47
Syphilitic origin, case of pachymeningitis cervicalis of (E. Miller), Neur. 55
-placenta ; see Placenta , syphilitic
Syringes used in transfusion of blood, Med. 7
--, rubber-tubing attached to, Med. 7
Syringing, intratympanic, before radical mastoid operation, Otol. 33
Syringomyelia (alleged plumbism), case (F. Eve), Neurol. 31
Tabes dorsalis, hysterical, auto-suggestion and hetero-suggestion in, Neur. 22
-hysterical, disappearance under psychotherapy, Neur. 22
-element in, Neur. 22
-, Romberg's sign in, Neur. 23
-, physical signB of disease of lateral and posterior columns preceding onset of
symptoms in, Neur. 22
-, what is expressed by term, Neur. 3
Tabetic patients, improvement in gait of, under use of Frenkel’s methods, a phase of psycho¬
therapy, Neur. 23
Table-top for resting patient, in radiographic examination for gall-stones, Electr. 78
Tabo-paresis, Neur. 3
Tachycardia in malaria, Med. 33, 34
-, clinical forms of, Med. 38
Tainter, Frank J.—Discussion on bone-grafting in ununited fractures of mandible,
Odont. 15
Index
exxxix
Taylor, James.—C hanges in the sella turcica in association with Leber’s atrophy, Ophth. 22
-discussion on case of pituitary tumour (hypo-pituitarism), Ophth. 42
-on migraine, Ophth. 53
Tea-drinking, excessive, among Highland Crofters, Odont. 28
Teale, F. H.—Bacteriological report on case of tuberculosis cutis of six years’ duration,
Derm. 10
Teat of feeding-bottle, use of, factor in malformation of jaws, Child. 33
Tectorial membrane, Otol. 82
Teeth, abnormal spacing in Mycetes , Odont. 49
-, calcification and fixation of, food deficiencies as factor influencing (F. M. Wells),
Odont. 23
-, in infants, effect of artificial light upon, Odont. 36
-, decalcification, experimental method employed, Odont. 35, 36
-, examination, in fractures of mandible. Surg. 12
-, extraction, in fractures of mandible, Surg. 12
-, under alveolar anaesthesia, Odont. 4
-, filling of, under submucous infiltration anaesthesia, Odont. 2
-inhaled with fang downwards, forceps for removal of, Laryng. 20
-, loss of, in old injuries of maxillae, prosthetic treatment, Odont. 77
-, only, in injuries of maxillae, Odont. 77
-,- f denture used for, Odont. 77, 79
-, micro-organisms in, staining-methods employed for demonstration, from cases of
pyorrhoea, Odont. 105
-of guinea-pigs suffering from scurvy, microscopical investigation, Odont. 31
-resulting from scorbutic diet, histological appearances, Odont. 31, 32, 35
-, preservation, where necessary, in fractures of mandible, Surg. 12
-, state of, among Highland recruits over and under 20 years of age, compared, Odont. 29
-, variations in position of, in New World monkeys (J. F. Colyer), Odont. 39
Teething, painful, in rickets, Odont. 26
Telangiectases, atrophy of face with, Derm. 64
Temperature, minute fractions of, measurement by thermo-couple and resistance thermo¬
meters, Electr. 61, 62
-, unsuitable, as factor in production of industrial accidents, Epid. 50; see also Body
temperature
Temporal bone, osteomyelitis of, before and after operation, Otol. 2, 3
-, cause of, and path of infection, Otol. 2, 3
-, rarity, Otol. 1, 2, 3
-, right; acute osteomyelitis of, case in boy; operation, recovery (H. Tilley),
Otol. 1
-, clinical history, Otol. 1, 4
Teratoblastoma, congenital, of vulva (rhabdomyoma), in infant (Gordon Ley), Obst. 190
-, microscopical description, Obst. 193
-, pathological report, Obst. 191
Testicle, double (imperfectly descended), operated on (1914), case (Philip Turner), Child. 61
-, left (imperfectly descended) four and a half years after operation, case (Philip Turner),
Child. 60
-, undescended, Bevan’s operation for, Child. 63
-, diagnosis, difficulty in, Child. 62, 63
-made too readily, Child. 62
Testicles, undescended, operation for, cases (Philip Turner), Child. 61
Thalamic over-reaction, Neur. 7, 9
Thavies Inn Venereal Centre, treatment of ante-natal and post-natal syphilis at, Obst. 9
-, results as regards negative Wassermann reaction in
infants, Obst. 11
Thermal waters, treatment by anaphylaxis and, Bain. 8
cxl
Index
Thermometer for testing temperature of body cavities, Electr. 55, 56
-of surfaces of skin, Electr. 55, 56
-, rectal, construction of, Electr. 55
-resistance, use of, in taking temperature in pulmonary tuberculosis, Electr. 59, 60
-, resistance, measurement of minute fractions of temperature by, Electr. 61, 62
-, use of in taking temperature of cattle, Epid. 59
-(skin), difficulties in use of, Electr. 60, 63
-•, thermo-electric couple, as means of determining quickly changing temperature,
Electr. 60
-, cold junction, immersion in melting ice, Electr. 61, 63
-, determination of body temperature in, Electr. 55
-, experiments with, Electr. 62
-, india-rubber container, Electr. 60
-, measurement of minute fractures of temperature by, Electr. 61, 62
-, reduction of surface pad, Electr. 60
-, second junction, kept at constant temperature by thermostat, Electr. 61
—--, use of, Electr. 55, 59
---, difficulties in, Electr. 59, 60
--, in determining path of current through body, Electr. 62
Thermostat, use of, in keeping second junction of thermo-couple thermometer at constant
temperature, Electr. 61
Thomson, J. A., pulmonary spirochetosis, quoted, Med. 27
Thomson, J. Gordon. —Experiments on the complement fixation in malaria with antigens,
prepared from cultures of malarial parasites ( Plasmodium falciparum and Plasmodium
vivax), Med. 39
Thomson, Sir J. J., F.R.S., secondary radiation as a therapeutic agent, quoted, Electr. 13
Thomson, Sir StClaib.—D iscussion on angeioma of left arytenoid, Laryng. 150
-*, discussion on case of sarcoma of nose, Laryng. 168
-on dilatation of the oesophagus without anatomical stenosis, Laryng. 63
-on foreign bodies impacted in food and rospiratory passages, Laryng. 18
-on radiograms showing absence of right frontal sinus, Laryng. 169
-on sphenoidal sinus empyema in cerebro-spinal meningitis, Laryng. 252
Thorax, actinomycosis of (V. Z. Cope), Clin. 1
-, wall of, streptothrix invasion of, Clin. 1, 2
-, tuberculous infection of, rarely dependent on pulmonary disease, 1 Clin. 3
Throat cutting, principal mode of suicide among soldiers, Psych. 49
Thrombosis of intertubular vessels in cases of puerperal anuria, Obst. 29, 30, 31
-of internal jugular vein as far as clavicle, following acute mastoiditis, recovery (W. M.
Mollison), Otol. 10
-of sphenoidal sinus ending fatally, following septic dermatitis of nose, Ophth. and
Laryng. xxxvii
Thumb-nail, leuconychia totalis of, multiple leuconychia striata associated with, case
(George Pemet), Derm. 28
Thumbs and great toes, symmetrical deformity ; see Polysyndactylia, symmetrical
Thyro-fissure, adenoma of vocal cord removed by, case (A. L. Macleod), Laryng. 148
Thyroid extract in treatment of adenoids and enlarged tonsils, Laryng. 217
-in young children, Laryng. 217, 219
-gland, adeno-carcinoma of, disseminating as a polymorphic-celled sarcoma, Path. 4-8
-, defective action in malaria, Med. 38
-, tumour of, metastatic deposit in cervical lymph-gland, characters of, Path. 5, 8
- f microscopical appearances, Path. 6, 7
Thyroidectomy, partial, followed by alopecia areata, Derm. 42
Tibia as bone-graft, Surg. 23
-as transplant graft, advantages of, Odont. 97
-in ununited fractures of mandible, Odont. 97
Index
cxli
Tibia, bone-grafts from, in treatment of gunshot fractures of mandible, Odont. 03
-, effect of removal of graft from, in bone-grafting operation, 8urg. 26
-, inner surface of, as bone-graft, Surg. 25
-, transplantation of bone from, to fix spinous processes of diseased vertebra?, Surg. 23
Tibial graft, separation of, Odont. 97
Tilley, Herbert.—A cute osteomyelitis of right temporal bone in a boy, operations,
recovery, Otol. 1
-, case of adenoma of right ventricular band, quoted, Laryng. 149
-, child from whom a suppurating dermoid cyst has been removed from the lower central
region of forehead, Laryng. 193
-, discussion on alternatives to operations for adenoids in young children, Laryng. 220
-on bilateral ankylosis of vocal cords, Laryng. 162
--— on case of adhesions and contracture of faucial pillars following complete enucle¬
ation of tonsils, Laryng. 180
-of bony nasal growth, Laryng. 213
-of nasopharyngeal growth, Laryng. 209, 210
-of tonsillectomy in man weighing 23 stone, Amesth. 20
-on cyst of larynx, Laryng. 195
-on delayed breaking of voice, Laryng. 197
--on epithelioma of palate and anterior faucial pillar, Laryng. 183
-— on foreign bodies impacted in food and respiratory passages, Laryng. 17
-on glycophylic method of treating atrophic rhinitis with ozsena, Laryng. 232
--on injuries and inflammatory diseases affecting the orbit and accessory sinuses,
Ophtb. and Laryng. lx
--on pituitary tumour, Laryng. 178
--on sarcoma of maxillary antrum, Laryng. 23
-on treatment of wounds of nose and nasal accessory sinuses, Laryng. 133
-on two cases of choanal polypi, Laryng. 154
-, large submucous lipoma of palate and pharynx, Laryng. 189
——, specimens of dilatation of oesophagus from University College Hospital, Laryng. 75, 76
-, spreading submucous emphysema following injury to mucosa of Eustachian tube, quoted,
Path. 59
Tissue lymph, question of liberation of gas from, Path. 68
Tit, nestling, trilobed upper limits of air-sacs at root of neck in, Path. 61, 62
Tod, Hunter.—C ase of left eyeball dropping through floor of orbit, quoted, Ophth. and
Laryng. xii
-, discussion on acute osteomyelitis of right temporal bone, Otol. 23
-of chronic adhesive otitis, Otol. 97
-of double facial paralysis due to bilateral tuberculous mastoiditis, Otol. 7
-, pin in bronchiole of posterior lobe of right lung, failure to remove it by bronchoscope,
pin coughed up eighteen months later, Laryng. 10
- f septic infection of lateral sinus accidentally injured during the operation of mastoid¬
ectomy, Otol. 62
-, tooth-plate in oesophagus ; oesophagoscopy, removal, Laryng, 11
Toes, great, and thumbs, symmetrical deformity ; see Polysyndactylia , symmetrical
Tongue, epithelioma of, treatment by diathermy, Electr. 27
-by fulguration, Electr. 27
- forceps and depressor, combined, for use in enucleation of tonsils (James Douelan),
Laryng. 188
-, lymphangioma of (B. Whitchurch Howell), Child. 78
-, malignant disease of (?), case for diagnosis (W. Douglas Harmer), Laryng. 198, 199
-, tumour of base of (G. W. Dawson), Laryng. 183
-, see also Frcenum linguae
Tonsil and fauces, epithelioma of, in woman (W. Hill), Laryng, 210
-, epithelioma of, two years and nine months after treatment by diathermy, case (Frank
Rose), Laryng. 170
cxlii
Index
Tonsil, eft, endothelioma of, operation performed (Andrew Wylie), Laryng. 101
-(?) sarcoma of (Andrew Wylie), Laryng. 26
-, sarcoma of, case (G. W. Dawson), Laryng. 177
-(?) case (W. M. Mollison), Laryng. 211
-snare, Lermoyez’, use of, in staphylectomy, Laryng. 239
Tonsils, enlarged, and adenoids, removal in preventive treatment of acute otitis media,
Otol. 55
-, association of adenoids with, Child. 33
_ 9 in young children, treatment, operative, suggested alternatives to (J. Donelan),
Laryng. 216
-by vaccines, Laryng. 217
_or diseased, enucleation during menstrual period contra-indicated, Laryng. 247
_, removal by intra-capsular operation, Laryng. 246
-, treatment, by chemical methods, Laryng. 244
-, by electrical methods, Laryng. 245, 247
_, in cases where surgical procedures are contra-indicated (Irwin Moore),
Laryng. 243, 244
-, surgical contra-indications, general, Laryng. 244
-, local, Laryng. 243, 244
-, types of, Laryng. 246
-, pathogenesis of, Laryng. 217
_ f enucleation of, combined tongue forceps and depressor for use in (James Donelan),
Laryng. 188
-, complete, followed by adhesions and contracture of faucial pillars (Irwin Moore),
Laryng. 180
-, voice-training in singers after, Laryng. 180, 181
- # instruments to simplify control of haemorrhage in difficult cases (Sydney Scott),
Laryng. 215
Tonsillectomy, case, in man weighing 23 st. (F. E. Shipway), Anaesth. 18
-, method of anaesthetization employed, Anaesth. 19
Tonsillitis during convalescence from diphtheria, Child. 89
-, frequency of, Child. 89
Tooth, nerves of, mode of distribution anomalous, Odont. 12
Toothbrush and antiseptics, use of, in mouth, Odont. 29
-, dental caries not prevented by use of, Odont. 30
-, sterilization impossible, Odont. 30
Tooth-plate impaction in oesophagus, death following, Laryng. 18
-, divided by Irwin Moore’s cutting shears (Somerville Hastings), Laryng. 7
_for eight weeks; three unsuccessful attempts at removal, death from perfora¬
tion into pleural cavity (C. E. Woakes), Laryng. 8
-, oesophagoscopy, removal (Hunter Tod), Laryng. 11
Tooth-plates, three, removed from oesophagus (A. Brown Kelly), Laryng. 27
Toxfemia and otosclerosis, Otol. 130
- f gastro-intestinal, and adenoids, relation between, Child. 56
-in experimental shock, suggested test for, R.S.M. Disc. (Shock), 30, 34
-in pregnancy, one cause of maternal mortality in childbirth, Obst. 82
-, misuse of term, Neur. 2
-, oral, due to feeding on salivary depressants, scurvy in relation to, Odont. 37
-, traumatic, R.S.M. Disc. (Shock), 9
- f virulence of, in influenza, Med. 67
Toxic influence on retinal cells, causing defective vision, Ophtli. and Laryng. lvi
-origin of contraction of visual fields, Ophth. and Laryng. xlix
-products of shock not always recoverable from damaged structures, R.S.M. Disc.
(Shock), 27
Toxins, injection of, experimental, followed by injections of mineral waters, Bain. 6
Index
cxliii
Toxins, injection of, experimental, following injection of mineral waters, reault, Bain. 6
Trachea, engorgement of, found post mortem in influenza, Med. 61
-, glands at bifurcation of, enlargement and engorgement in influenza, Med. 65
-, post-mortem appearances in fatal cases of influenza, R.S.M. Disc. (Infl.), 54
Transplant grafts, fixation of, Odont. 98
-, good, essentials for, Odont. 97
-, in ununited fractures of mandible (C. Ernest West), Odont. 95
-, essentials for, satisfactory results, Odont. 98
-, fate of, Odont. 98-100
-, operative technique, Odont. 96
-, source of, Odont, 96
Transports, outbreaks of acute respiratory disease among American troops aboard, R.S.M.
Disc. (Infl.), 74, 75
Trans-sphenoidal operation for pituitary tumour, great improvement in pressure symptoms,
(H. Lawson-Whale), Laryng. 169
Traumata, physical, as predisposing cause of war psychoses, Psych. 39
Tremors in malaria, Med. 38
-, chronic malaria, Med. 33
Treneh fever, cutaneous hyperalgesia in, Med. 25
-, temperature in, measurement by electrical methods, Electr. 58
Trendelenburg position in spinal anaesthesia, Antesth. 3, 12, 14
-, vaginal examination under, entry of air during, Path. 53
Trichorrhexis nodosa, aetiology, Derm. 60
-, case of (Mrs. Addison), Derm. 59
Trophoedema of leg (E. A. Cockayne), Child. 105
-and Milroy’s disease, connexion betwben. Child. 106
Tropics, obscure fever in, blood-cultures in, Med.,40
- 1 examination of blood-film for parasites before treatment, Med. 39, 40
Trotter, W., gregarious impulse, quoted, Psych. 7
-, suggestion and herd-instinct, quoted, Psych. 20
Tubercle bacillus, extraction of waxes and other substances from, Therap. 2
-, replacement by lipolized granular forms, Therap. 2
-, sensibilization by lipase, Therap. 1.
-, waxes of, dissolution, Therap. 2
-, waxy or fatty envelope of, Therap. 1
Tuberculin, effect on temperature of normal individual, Electr. 61, 62
-, testing of temperature of tuberculous patients with, Electr. 56
-tests of temperature, experimental, Electr. 57, 59
Tuberculosis, acquirement at advanced age, Derm. 19
-cutis, senile, case (W. Knowsley Sibley), Derm. 18
-of six years’ duration in male patient aged 53 (report on case communicated by
J. H. Stowers), Derm. 9
-, senile, treatment by X-rays, Derm. 18
-, increase among Highland crofters, presumed cause, Odont. 29
-, patients with, variations in temperatures measured by electrical method, Electr. 57
-, pulmonary, body-temperatures in, study of, Electr. 55
-, diagnosis in early stage in human subjects, Electr. 59
-- } early cases mistaken for and treated as aphonia, Laryng. 31
--— injection of new anti-tuberculous medicament in, by intratracheal route, Therap.
3, 5
-, examination of sputum, Therap. 5
-, results in patients, Therap. 5
-patients with, temperature of, testing with tuberculin, Electr. 56
-, tuberculinized, and pre-tuberculinized, highest and lowest temperatures
of, Electr. 56, 57
cxliv
Index
Tuberculosis, pulmonary, temperature in subjects of, reproduction of condition present in
tuberculinized calves, Electr. 59
-, temperature in, measurement by electrical methods, Electr. 55, 58
-, tuberculous infection of ohest wall rarely dependent on, Clin. 3
-, squamous epithelium on vocal cord protective against, Laryng. 207
-•, weakness of lobule in subjects of, Otol. 26
Tuberculous disease of spine, treatment by bone grafting, Surg. 23
-glands, suppurating, treatment by diathermy, Electr. 27, 29
-infection of chest wall rarely dependent on pulmonary disease, Clin. 3
- lymphangitis following injury to tuberculous wart of long standing (W. S. Haudley),
Clin. 19
-mastoiditis, bilateral, double facial paralysis due to (W. M. Mollison), Otol. 7
-in children, due to infected milk, Otol. 7, 8
Tumours, human, study of, conclusions as to, in relation to those drawn from experimental
tumours, Path. 4
-mixed, Path. 4
-. distinct, from complex embryomata, Path. 3
-, multiple, in same individual, polymorphic growth in. Path. 2, 3
-yielding best results from radium treatment, nature of cells of, Clin. 5, 6
Tuning-fork, testing with, pricking-up ears during, Otol. 26
Turbinal, anterior, removal of soft tissue from lower border of, in treatment of epiphora,
Ophth. and Laryng. lv
-, middle, left, removal in case of left-sided optic neuritis with left-sided nasal obstruction,
result, Ophth. and Laryng. xxvii.
-, swelling of, in acute frontal sinusitis, Ophth. and Laryng. lviii.
Turnbull, H. and Digby, Sir Hugh. — Specimen of dilatation of oesophagus without
anatomical stenosis, from Pathological Institute of London Hospital, Laryng. 77, 90
Turner, J. G. and Drkw, Aubrey H.—Experimental inquiry into the bacteriology of
pyorrhoea, Odont. 104
Turner, Philip. —Case of double imperfectly descended testicle operated upon in 1914, when
the left testicle was transplanted to the right side and the right testicle to the left side
of the scrotum, Child. 61
-, case of imperfectly descended left testicle four-and-a-half years after operation. Child. 60
-, cases of operation for undescended testes, Child. 61
- and Iredell, C. E.—Treatment of malignant disease by diathermy and fulguration,
Electr. 23
Turtle, G. de Bbc.—D iscussion on syphilitic bone disease. Child. 85
Tuscany, plague prevented entering, by Grand Duke Ferdinand, Epid. 69, 70
Tympanic cavity, curettage in radical mastoid operation, Otol. 34
-, microscopic examination in case of fracture of base of skull involving middle and
inner ear, Otol. 106
- membrane, condition as noted on operated and non-operated sides at modified radical
mastoid operations, Otol. 45
-, good hearing without, Otol. 91, 92
-, microscopic examination in case of fracture of base of skull involving middle and
inner ear, Otol. 106
--with fracture dislocation of incus and rupture of
roof of right mastoid antrum, Otol. Ill, 112
-in case of otosclerosis associated with otitis media, Otol. 117, 122
Tympanites, intestinal, mucosal perforation in, actual site determined experimentally,
Path. 75
-of rumen in cattle, Path. 55
Tympanitic abscess, closed, without perforation of intestinal or respiratory tract, due to gas¬
forming bacteria, Path. 49
Tympanum, findings in, at radical mastoid operations, Otol. 37
Index
cxlv
Typhoid and paratyphoid fevers, fatality rate among civilian population of Flanders in area
occupied by Allies, compared, Epid ^27
--- f proportion in outbreak of enteric among French soldiers in Flanders, Epid. 25
-of occurrence among Allied Armies, Epid. 26
-fever, cases of, excess of cases of paratyphoid over, in British Army, Epid. 33
-outbreak among inoculated soldiers of (J. G. Hopkins), Epid. 9
--, blood cultures, Epid. 9
--- — , case histories, Epid. G, 7
-- > cases by date of onset, chart showing, Epid. 7
-clinical study (Clinton B. Hawn), Epid. 1
—-, date of onset, Epid. 2
-, diagnosis by atropine test, Epid. 3, 5
-, epidemiology (F. M. Meader), Epid. 5
-_- $ isolation of Bacillus typhosus from blood and stools in,
Epid. 4, 9
---, laboratory findings, Epid. 9, 13
-, leucocyte count in, Epid. 2
--, post-mortem findings in fatal cases, Epid. 9
----, severity of type, Epid. 10, 12
-, source of infection discussed, Epid. 11
-- --, strains of Bacillus typhosus isolated from, Epid. 13
-, symptoms, Epid. 2
- -——-, vaccination record, Epid. 10
-, see also Enteric fever
Ulna, bone-graft in, fate of, Surg. 31
-, fracture of, ununited, treatment, Surg. 24
Unconscious mind, conception of, Psych. 9, 10
Unconsciousness, following direct concussion from explosives, Neur. 47
United States, advanced mental hygiene movement in, Psych. 51
-, death-rate from child-birth in, no definite decrease, Obst. 78
University College Hospital, Museum of, specimens of dilatation of oesophagus exhibited
from (H. Tilley), Laryng. 75, 76, 87-89
Ureter, female, catheterization, Kelly’s speculum for, modus operandi , upon what dependent,
Path. 53
Urethra, anterior, irrigation with solution of potassium permanganate as prophylactic
against venereal diseases, R.S.M. Lect. 9
-, stricture of, operations for, under spinal auaesthesia, Anaesth, 13
Urethroscopy, fatal case of air-embolism occurring during, Path. 63, 64
Urine, Bacillus coli infection of, in extra-uterine pregnancy, Obst. 184
-, hysterical incontinence of, and hysterical paraplegia following concussion of spinal cord,
with organic physical signs, cured by psychotherapy, Neur. 28
-, increased secretion in migraine, Ophth. 50, 51
— of pregnant women, examination by students, Obst. 38
Urotropin, benzoate of ammonium and salicylate of sodium, mixture of, in treatment of
encephalitis lethargica, Med., Path, and Epid. xxi
Urticaria, lichen urticatus not identical with, Derm. 74
-pigmentosa, case (J. L. Bunch), Child. 1; Derm. 1
Uterine horn, rudimentary, full-time pregnancy in, case (Clifford White), Obst. 138
-sepsis, puerperal, problem of, Obst. 93
-, treatment, Obst. 93, 100
Uterus, adeno-carcinoma of, polyp showing areas of squamous-celled carcinoma associated
with a sarcomatous growth. Path. 13-17
-cervix, cancer of, history of supravaginal cervix in, Obst. 19
10
cxlvi
Index
Uterus, cervix, cancer of, how rendered inoperable, Electr. 16
-, in case of decreased length of abnoi^nally long supravaginal cervix, report on
specimen (J. Braxton Hicks), Obst. 20
-, inoperable, treatment by diathermy, Electr. 40
-, treatment by diathermy, Electr. 16
---, before Werthehn’s operation, Electr. 40
-, dilatation of, followed by severe retro-peritoneal bleeding (H. R. Andrews), Obst. 199
-, means for facilitating, Obst. 204
-, elongation of, operations for, Obst. 18, 21
-supra-vaginal, caus33 of, discussed, Ob3t. 20, 21, 22
-, disappearance after replacement of uterus, Obst. 19
-in cases of procidentia, Obst. 19
-, fibromata of, removal, method adopted (1884), Obst. 5
-, gravid, foreign body in, skiagram of (G. Drummond Robinson), Obst. 17
-in which changes had taken place as result of procidentia (G. Drummond Robinson),
Obst. 18
-, see also Pneumatosis , uterine
Uveitis, sympathetic, case of, Ophtli. 28
Vaccines in prophylaxis against influenza, R.S.M. Disc. (Infi.) 83, 84, 96
-in treatment of adenoids and enlarged tonsils, Laryng. 217
---of influenza, R.S.M. Disc. (Infi.) 29, 30, 35, 86, 78, 82, 83; Med. 72
--, composition, R.S.M. Disc. (Infi.) 83
-, dosage in relation to distance of generation from human body, R.S.M.
Disc. (Infi.) 96
- 1 useless in virulent cases, R.S.M. Disc. (Infi.) 101
-, when contra-indicated, R.S.M, Disc. (Infi.) 83
-, mixed, in treatment of broncho pneumonia complicating influenza, R.S.M. Disc. (Infi.) 79
---of influenza, R.S.M. Disc. (Infi.) 78, 79
-, dosage, R.S.M. Disc. (Infi.) 79
-of pleurisy complicating influenza. R.S.M. Disc. (Infi.) 79
-, multivalent, in treatment of influenza, R.S.M. Disc. (Infi.) 92
Vagina, entry of air into, Path. 52
-, associated with defective development of labia and nymphse and prolapse of
anterior wall of vagina, Path. 53
-, presence of air in, early allusions to, Path. 53
-, wall of, posterior, abdomino-perineal excision for carcinoma recti followed three years
after by recurrence in (VV. S. Handley), Proct. 46
Vaginal examination, in Trendelenburg position, entry of air during, Path. 53
Vaginitis emphysematosa, Path. 49
-, gas-production in vaginal wall in, Path. 49
Vagus, paralysis of; see Paralysis, vagal
van der Hoeve and de Kleyb, deafness due to otosclerosis as an accompaniment of brittle
bones and blue sclerotics, quoted, Otol. 130
Variation, degree of, upon what dependent, Otol. 23
-, heredity in relation to, Otol. 28
-, tendency to, hereditary, Otol. 23
Variations, minor, determining factor in, Otol. 24
Varrier-Jones, P. C. —Discussion on electrical methods of measuring body temperature,
Electr. 59
Vasoular lesions of angeioma serpiginosum, Derm. 61
Vaseline and ichthyol, application in atrophic rhinitis with ozcena, Laryng. 186
Vaso-constrictor drugs unsuitable in shock, R.S.M. Diso. (Shock) 3
Vaso-motor symptoms in war neuroses, Psych. 55
Index
cxlvii
Vaso motor theory of shock, R.S.M. Disc. (Shock) 28, 29
Vegetables, fresh, want of, cause of scurvy among adults, Odont. 24
Veils, wearing of, by those in attendance on influenza cases, R.S.M. Disc. (Infl.) 18
Vein, experimental introduction of air into circulation through, without fatal results in dog,
Path. 64
Venereal disease in women, recognition of ( teaching as to, Obst. 55
-diseases among Australian troops at Port Said, prophylactic measures against, R.S.M.
Lect. 8, 9
-, campaign against, in Australia, R.S.M. X»ect. 1, 2
-in Egypt, management of, during war (Sir James W. Barrett), R.S.M. Lect. 1
-*-, percentage of Australian troops in Egypt suffering from, R.S.M. Lect. 6
--- f prophylaxis against, after exposure to risk, R.S.M. Lect. 2
--, primary, R.S.M. Lect. 9, 10
--, attitude of moralists towards, R.S.M. Lect. 10
-, warning to Australian troops in Egypt respecting, R.S.M. Lect. 5, G
Venesection in influenza, useless in virulent cases, R.S.M. Disc. (Infl.) 101
Ventilation, bad, factor in causation of adenoids, Child. 45
Ventricle and auricle, contractions of, delay between, Electr. 66; see also Heart-block
-, sequence in, Electr. 66
Ventricular band*, right, adenoma of, case, Laryng. 149
Ventrifixation, accidents and fatalities following, Obst. 218, 219
-, reason for, explained, Obst. 219
•-, advocacy of, when properly performed, Obst. 219 ,
-, contra-indicated in those capable of becoming pregnant, Obst. 218, 219
-, obstructed labour due to (W. Gilliatt), Obst. 216
-, substituted for Alexander’s operation, Obst. 220
Vernon, H. M.— (’ausation and prevention of industrial accidents, Epid. 47
Version, external, demonstration to students, Obst. 37
Vertebrae, diseased, spinous processes of, fixation by transplanted bone from tibia, Surg. 23
Vertigo, case of, labyrinthotomy ; obliteration of semi-circular canals and part of cochlea by
bone (R. Lake), Otol. 77
-due to sudden alteration of tension in middle-ear, Otol. 100
-(?) labyrinthine or cerebellar (J. F. O’Malley), Otol. 79
Vestibular apparatus, state of, in chronic suppurative otitis media, Otol. 33
-, testing of, after modified radical mastoid operation, Otol. 45
-symptoms in labyrinthitis complicating chronic middle-ear suppuration, Otol. 48
Vestibule and semi-circular canals, microscopic examination in case of fracture of base of
skull with fracture dislocation of incus and rupture of roof of right mastoid antrum,
Otol. 114
-, microscopic examination in case of fracture of base of skull involving middle and inner
ear, Otol. 109
Vestibules, microscopic examination in case of otosclerosis associated with otitis media,
Otol. 121, 125
Vichy waters, administration per os, influence as regards leucocytosis reaction, Bain. 3
Victoria Infirmary, Glasgow, Pathological Department, unmounted specimen of dilatation of
oesophagus without anatomical stenosis from (A. Brown Kelly), Laryng. 78, 91
Villi, avascularity of, in syphilitic placenta, Obst. 209, 210
Vincent and Muratet, proportion of paratyphoid fevers A and B among Allied Armies, quoted,
Epid. 26
Vincent's powder, application after radical mastoid operation, Otol. 39
Violet-green, sterilization of birth-area by means of, Obst. 89, 101
Viscera, displacement of, causing aspiration of air into stomach, Path. 55
——, see also Pain , visceral
Vision, binocular, and uniocular, stereoscopic perception of, differentiation between, reasons
against, Ophth. 63, 64
CXlVlll
Index
Vision, binocular, importance of, in surgeon and X-ray worker in stereoscopic radiography,
Electr. 2
-, mechanism of, Ophth. 63
-, defective, due to nasal conditions, classes of cases, Ophth. and Laryng. lvi
-to toxic influence on retinal cells, Ophth. and Laryng. lvii
-, disturbances of, accompanying case of malignant disease of pituitary body, Ophth. 47, 48
-, due to inflammatory affections of nasal accessory sinuses, Ophth. and Laryng.
xlvii
-, improvement in, in disseminated sclerosis, how explained, Neur. 22
-, loss of, following retrobulbar neuritis, Ophth. and Laryng. xlii
-of observer, condition of, in stereoscopic radiography, Electr. 1
-, perceptive axis of, Ophth. 63
-, physiological axos of, Ophth. 63
-, stereoscopic, factors in, Ophth. 63, 64
-, physiological optics of, Electr. 5
-application of respective association of convergence and divergence with
near and distant objects to, Electr. 5, 6
-, sudden loss of, in young women, Ophth. and Laryng. lxv
Visual fields, changes in, in inflammatory affections of nasal accessory sinuses, Ophth. and
Laryng. xlviii
-in inflammatory diseases of uasal accessory sinuses, prognosis, Ophth. and
Laryng. xlviii, xlix
-, contraction of, in case of suppurative conditions remote from nasal cavities,
Ophth. and Laryng. 1
-, origin discussed, Ophth. and Laryng. xlix
-•, toxic theory of, Ophth. and Laryng. xlix
-with retrobulbar neuritis, Ophth. and Laryng. xlix
-perception of solid form (E. M. Eaton), (abstract), Ophth. 63
Vital capacity, best way of measuring, Epid. 38
---of air pilots, Epid. 38
— - energy, minimum loss of, at operations, important, Anrcsth. 11
-, statistics, England, Wales and Scotland, in connexion with maternal mortality of
child-bearing, Obst. 75, 76
Vitaminos, defect of, diseases produced by, Odout. 23
Vitreous, hiemorrhage into, in acute stage of encephalitis lethargica, Neur. 64
Vocal cord aud ventricle of larynx, normal histology of, in connexion with development of
adenomata, epidiascopic demonstration (Irwin Moore), Laryng. 199
-, adenoma of, cases recorded in literature, Laryng. 200
--removed by thyro-fissure, case (A. L. Macleod), Laryng. 148
--- f microscopic specimens and report on sections, Laryng. 148, 149
-, sections showing, Laryng. 202, 203
-, definition, histologically, Laryng. 203, 207
-, distribution of gland tissue, in relation to squamous-cclled area and elastic tissue,
Laryng. 205, 206
-, extent of elastic tissue on, Laryng. 203, 204, 205
-, left, paralysis of. in woman aged 49 (James Donelan), Laryng. 181
-, squamous epithelium on, Laryng. 203, 205
-cords, bilateral ankylosis of, case for diagnosis (Andrew Wylie), Laryng. 160
-. infiltration aud ulceration of, case (W. H. Jewell), Laryng. 113
-, ulceration in influenza epidemic in Macedonia, Med. 59
Voice, delayed breaking of, case (W. Jobson Horne), Laryng. 196
-, training in singers after enucleation of tonsils, Laryng. 180, 181
Vomiting after spinal amesthesia, rare, Ansesth. 13
-during anaesthesia, Anaesth. 11
-operation, under stovaine amesthesia, Antesth. 6
Index
cxlix
Vomiting in influenza, R.S.M. Disc. (Infl.) 78
-, of pulmonary type, Med. 55
-in shock, R.S.M. Disc. (Shook) 12
-, post-ansesthetio, following stovaine anaesthesia, rarity, Anaesth. 7
Voorhoeve, conditions due to hereditary inferiority of mesenchyme, Otol. 129, 130
de Vries, H., deviation from type in one or more characters, quoted, Otol. 23
Vulva, teratoblastoma, congenital of (rhabdomyoma) in infant (Gordon Ley), Obst. 190
-, autopsy, Obst. 191
Vulvo-vagina, infection of, demonstration to students, Obst. 38
Waggett, E. B.—Discussion on choanal polypi in two children, Laryng. 155
-, discussion on new theory of hearing, Otol. 89
Waldron, C. W., and Risdon, E. F.—Mandibular bone-grafts, Surg. 11
Walker, Kenneth. —Discussion on shock, R.S.M. Disc. (Shock) 21
Wallace, Sir Cuthbert, K.C.M.G.—Discussion on shock, R.S.M. Disc. (Shock) 17
Wallace, J. Sim. —Discussion on adenoids, Child. 35
Wallace, William.— Fundus changes resulting from war injuries, Ophth. 24
Waller, A. D., F.R.S., first demonstration of development of electric potentials in heart
deflecting sensitive galvanometer, Electr. 64
War, influence on virulence of influenza, R.S.M. Disc. (Infl.) 16
-injuries, fundus changes resulting from (William Wallace), Ophth. 24
-, loss of man power from ear diseases, through, Otol. 51, 52
-, mental breakdown in, factors combining to bring about, Psych. 36, 37
-disease in, cannot be compared with that in civil life, Psych. 51
- f factors contributing to onset of, Psych. 39
- # recovery-rate, Psych. 51
-, stress of, exhaustion psychoses not due purely to, Psych. 38
-surgery, influence of evolution of preventive surgery on, Obst. 6
-, methods of, why unsuitable in treatment of major wound of labour, Obst. 94, 95
- time, difficulty of preventive measures against influenza in, R.S.M. Disc. (Infl.) 12
-, unaccustomed iron discipline of, conducive to unhealthy mental reactions, Psych. 36,37
-, see also Neuroses (war), Neurosis (war)
Ward, G. E. S.—Discussion on the electrocardiograph, Elect. 69
Ward, Gordon.— Apyrexial symptoms in malaria, Med. 15
Warfare, opportunities for mental conflict in, Psych. 40, 41
Warm climate, adenoids not prevalent in, Child. 36
Warmth in avoidance of surgical shock, R.S.M. Disc. (Shock) 29, 30
Wart, tuberculous, of long standing, injury to, followed by tuberculous lymphangitis;
complete excision in continuity of primary focus, infected vessels and glands (W. S.
Handley), Clin. 19
Wassermann reaction, becoming negative in syphilitic infants under treatment, Obst. 11,12,15
-for syphilis not affected by attack of malaria, Med. 47
-, maternal, syphilitic placenta with, Obst. 213
-, negative in syphilitic infants, average dose of galyl necessary to bring about,
Obst. 10
-test in suspected cases of syphilis in infants. Obst. 9
---, in mothers, Obst. 9
Wasting in malaria, Med. 34
Water at same temperature, reason for different sensations caused by, Neur. 10
Waterbrash, see Pyrosis , extreme
Water supplies, Belgian, sterilization by calcium chloride, Epid. 31
-supply, sterilization as measure against spread of enteric fever in Flanders (1914-1915),
Epid. 30, 31
cl
Index
Watson, Sir C. Gordon, K.B.E.—Discussion on gunshot wounds of great bowel and rectum,
Proct. 47
Watson-Williams, P.—Case of chronic adhesive otitis; myringotomy and partial
ossiculectomy, Otol. 95
-, discussion on alternatives to operation for adenoids and enlarged tonsils in young
children, Laryng. 217
-on case of chronic adhesive otitis, Otol. 97
-on glycophilic method of treating atrophic rhinitis with ozsena, Laryng. 234
-on large antral polyp, Laryng. 167
-on sphenoidal sinus empyema in cerebro-spinal meningitis, Laryng. 251
-, latent sinusitis, in relation to systemic infections, Laryng. 220
-, radiograms showing absence of right frontal sinus, Laryng. 168
Wax, see Cerumen
Weakness, estimation of, in malaria, Med. 34, 35
Weber, F. Pabkeb. —Acute leukaemia and so-called mediastinal leucosarcomatosis, quoted,
Child. 92
-, discussion on aplastic anaemia, Child. 74
-on case for diagnosis, Derm. 39, 46
-of adrenal growth and case of multiple glandular swellings, Child. 92
-of aplastic anaemia, Child. 4
-of chronic priapism, Child. 11
-of erythrodermia with lymphatic leukaemia, Derm. 55
-of idiopathic multiple haemorrhagic sarcoma of Kaposi (miscalled), Derm. 50
-of multiple benign tumour-like new growths. Derm. 21, 23
-of multiple epulides, Child. 70
-idiopathic haemorrhagic sarcoma, Derm. 7
--leuconychia striata associated with leuconychia totalis, Derm. 29
-of myoclonus multiplex, Child, 19
-of pigmentation of mucous membrane, Derm. 28
-of severe rickets, Child. 104
-of thoracic actinomycosis, Clin. 3
-of trophoedema of leg, Child. 106
-on sarcoma of scapula treated by radium, Clin. 5
-on sclerodermia with calcification, in mongol, Child. 98
-on shortening of limbs on one side of body, Child. 7
-on syphilitic bone disease, Child. 85
-on unilateral band sclerodermia and morphoea-sclerodermia, Derm. 45
-on white-spot disease (morphoea guttata), Derm. 27
-, occurrence of pneumonia in those taking arsenic, quoted, Clin. 18
-and Gunewardenr, T. H.—A new case of lipodystrophia progressiva, Child. 13
Weight, loss of, not marked in dilatation of oesophagus without anatomical stenosis, Laryng.
43
Wells, F. M., Major, C.A.M.C.—Food deficiencies as a factor influencing the calcifiation and
fixation of teeth, Odont. 23
Wertheim's operation for cancer of cervix, preceded by diathermy, Electr. 40
West, C. E.—Discussion on case of circumscribed labyrinthitis, Otol. 100
-of labyrinthectomy, Otol. 102
-, experiences with transplant grafts in ununited fracture of the mandible, Odont. 95
Whale, H. Lawson. —Case of pituitary tumour ; trans sphenoidal operation ; great improve¬
ment in pressure symptoms, Laryng. 169
-, discussion on adenoids, Child. 49
-on bilateral ankylosis of vocal cords, Laryng. 161
-on case of bony nasal growth, Laryng. 214
-of infiltration and ulceration of vocal cords, Laryng. 113
-- —— of labyrinthectomy, Otol. 101
Index
cli
Whale, H. Lawson. —Discussion on case of nasopharyngeal growth, Laryng. 208
-discussion on delayed breaking of voice, Laryng. 197
-on injuries and inflammatory diseases affecting the orbit and accessory sinuses,
Ophth. and Laryng. lxi
-on dilatation of the oesophagus without anatomical stenosis, Laryng. 65
-on epithelioma of epiglottis, Laryng. 104
-on removal of bone impacted in oesophagus, Laryng. 172
-on treatment of wounds of nose and nasal accessory sinuses, Laryng. 133
-on tumour of right submaxillary region and of floor of mouth, Laryng. 215
-, lachrymal sac removed entire by the intranasal route, Laryng. 179
-, pituitary tumour ; sellar decompression and removal of endotheliomatous tissue ; great
improvement, Laryng. 178
-, unilateral perithelioma of maxillary antrum, upper jaw, and ethmoid, removed at one
operation from a woman, aged 55, after ligature of the external carotid, Laryng. 179
Whipple, Robert S.—Electrical methods of measuring body temperature, Electr. 54
-, some notes on the electrocardiograph, Electr. 64
Whistling, laryngeal, case (L. H. Pegler), Laryng. 173
-, how performed, Laryng. 173, 174
White, Clifford.— Case of full-time pregnancy in a rudimentary uterine horn, Obst. 138
-, foetus undergoing spontaneous evolution removed by laparotomy during labour, Obst. 135
-, two cases of puerperal anuria in which the renal capsule was incised and portions of the
kidney substance removed for examination, Obst. 27
White-spot disease, confusion relating to meaning of, Derm. 4
-, see also Morphaa guttata
Whitfield, Arthur. —Discussion on case for diagnosis, Derm. 34
-, discussion on case of Delhi boil, Derm. 72
-of Dercum’s disease, Child. 36
-of dermatitis herpetiformis, Derm. 73, 74
-—of keratosis follicularis, Derm. 69
-of melanotic nsevo-carcinoma. Derm. 42
Whittingham, Harold E. — Discussion on influenza (abstract), R.S.M. Disc. (Infl.) 34
Wholey, psychology of suicide, quoted, Psych. 50
Whooping-cough and measles, relationship to influenza, R.S.M. Disc. (Infl.) 25
Wilkinson, W. Camac.— Discussion on adenoids, Child. 39
Wilks, Sir Samuel, specimen from case of dilatation of oesophagus with anatomical stenosis,
quoted, Laryng. 72, 84
Williamson, Herbert.— Discussion on changes in uterus as result of procidentia, Obst. 22
-, discussion on teaching of obstetrics and gynaecology, Obst. 65
-, specimen of a lower limb of a mature foetus contained in an osseous cyst, and remaining
in the abdomen of the mother for fifty-two years, Obst. 171
Wilson, T. G.—Discussion on teaching of obstetrics and gynaecology, Obst. 70
Wind instruments, players on, suffering from painful inflation of cheeks, Path. 59
Wingbave, Wyatt. —Microscopical demonstration in Museum Room, Summer Congress,
Section of Laryngology, Laryng. 255
Winter and summer, death-rate of wounded during, compared, R.S.M. Disc. (Shock) 31
Withdrawal movement, how controlled, Neur. 5
Woakes, C. E.—Scarf-pin in the stomach ; gastroscopy, expelled by vomiting, Laryng. 10
-, tooth-plate impacted in the oesophagus for eight weeks, three unsuccessful attempts at
removal, death from perforation into pleural cavity, Laryng. 8
Women and men, frequency of accidents to, in different factories, compared, Epid* 51, 52
-, capacity for industrial work, Obst. 63, 64
-, during pregnancy, Obst. 64
-, clinical type of dysphagia in (D. R. Paterson), Laryng, 235
-, death-rate due to pregnancy and labour in England and Wales and Scotland, Obst. 64,
69, 74
clii
Index
Women, diseases of, department for, Obst. 43
-, department for, reception of cases of puerperal infection into, Obst. 43
-of early cases of gonorrhoea into, Obst. 43
-, hospitals for, utilization of clinical material at, Obst. 71
-, venereal disease in, recognition of, teaching as to, Obst. 55
-, young, sudden loss of vision in, Ophth. and Laryng. lxv
Woodhbad, Professor Sir Sims, K.B.E.—Discussion on electrical methods of measuring body
temperature, Elect. 56, 62 '
Woodman, E. M.— Discussion on atrophic rhinitis with ozaena undergoing treatment by
glycophylic methods, Laryng. 186
Woods, Sir Robert.—D iscussion on new demonstration of hearing, Otol. 87
Woolf, A. Mortimer. —Discussion on sclerodermia with calcification in mongol, Child. 98
-on undescended and imperfectly descended testes, Child. 63
Wording ham, C. H.—Discussion on electrical methods of measuring body temperatures,
Electr. 62, 63
-, discussion on the electrocardiograph, Electr. 65, 71
-, opening remarks at joint meeting of Section of Electro-Therapeutics with Institution of
Electrical Engineers, Electr. 53
Worthington, R. A.—Case of epithelioma of the epiglottis treated by diathermy, Laryng. 158
-, dilatation of the oesophagus without stenosis, Laryng. 95
-, discussion on case of sarcoma of nose, Laryng. 164
-on glycophylic method of treating atrophic rhinitis with ozeena, Laryng. 232
-on spasm at entrance to oesophagus and clinical type of dysphagia, Laryng. 238
-on treatment of gunshot wonnds of nose and nasal accessory sinuses, Laryng. 135
--foreign body removed from the nose after thirteen years, Laryng. 159
Wound shock, changes in brain in, R.S.M. Disc. (Shock), 20
Wounded, death-rate during winter and summer compared, R.S.M. Disc. (Shock), 31
Wounds, asepticity of, every method of attaining, embraced under Lister’s definition of
antiseptic treatment, Obst. 3
-causing loss of bridge of nose and nasal and septal supports (pug-nose type), repair of
Laryng. 126
-and nasal supports without marked deformity of the tip (bird-beak
type), Laryng. 128
-of nasal cavities and nasal accessory sinuses, cases, casts, &c., illustrating some methods
of repair of (G. Seccombe Hett), Laryng. 115
-of war, massive injury of tissues, shock a condition of chemical poisoning set up by,
R.S.M. Disc. (Shock), 29
-, punctured, local subcutaneous emphysema at site of, Path. 59
-, resulting in injury and inflammation 6f sinuses, cases, Ophth. and Laryng. li
Wrightson, Sir Thomas, Bt.—Demonstration on a new theory of hearing, Otol. 84, 90
Wylie, Andrew.— Bilateral ankylosis of the vocal cords, case for diagnosis, Laryng. 160
-, discussion on case of adenoma of vocal cord removed by thyro-fissure, Laryng. 148
-on functional aphonia, Laryng. 30
-, endothelioma of left tonsil, operation performed, Laryng. 101
-, sarcoma of the nose, modified external operation (Moure’s lateral rhinotomy), Laryng.
162
-(?) of the left tonsil, Laryng. 26
-and Ryland, Archer.— Chronic unilateral laryngitis for diagnosis, Laryng. 164
Xanthelasmoidea (urticaria pigmentosa) (?), case for diagnosis (E. Bronson), Child. 21
X-ray and radium treatment of breast cancer compared, Electr. 50
-demonstration of gall-stones in patient, Electr. 80, 81
-diagnosis between gall-stones and renal calculi, Electr. 81
-of dilatation of msophagus with anatomical stenosis, from functional, Laryng.
34, 42
Index
cliii
X-ray diagnosis of functional phreno-cardiac stenosis, Laryng. 44-47
-of gall-stones from empyema, radiogram showing, Electr. 82
-of ileal stasis, Electr. 11
-examination in chronic appendicitis, Electr. 10
-of liver, important, Electr. 76
-of vermiform appendix (E. I. Spriggs), Electr. 9
-treatment of cancer of breast before operation, Electr. 50, 51
-, position of patient during, Electr. 46
-, prophylactic, Electr. 47
-of Delhi boil, Derm. 72
-of keratoma senile, Derm. 65
--of keratosis follicularis (Darier's disease), contra-indicated, Derm. G9, 70
—-of lichen planus, Derm. 17, 18
-of mediastinal new growths, Clin. 5, 6
-of oriental sore, Derm. 34
-of senile tuberculosis cutis, Derm. 18
-tube, kind best suited for taking radiograms of gall-stones, Electr. 85
-worker and surgeon, correctness of binocular vision in, important in stereoscopic radio¬
graphy, Electr. 2
-workers, danger to, of metals of high atomic weight in contact with skin, Electr. 16
X-rays, determination of position of Gottstein’s balloon by, Laryng. 54
-, over-exposure to, resulting in malignant disease of skin, Derm. 66
-radium and excision in treatment of carcinoma of right antrum and orbit (Norman
Patterson), Laryng. 194
-, secondary, anadrastic, Electr. 14
--, causing burning, personal experiences (J. Metcalfe), Electr. 13
-, effect on tissues, Electr. 13
-- f various types of, technical terms for, Electr. 14
-, site of application to growths of breast, Electr. 45
-, see also Radiation
Yeo, I. Burney, alopecia areata in association with Graves’ disease, quoted, Derm. 41
Ypres, cases of enteric fever at, Epid. 24, 25
Yule, G. Udny.— Discussion on periodicities of epidemics of measles, Epid. 118
Zenker and von Ziemssen, pathogenesis of oesophagectasia, quoted, Laryng. 38
Ziehen, Professor, psychology of, Psych. 3
Zinc, chloride of, application to cavity after removal of suppurating dermoid cysts, Laryng. 193
John Bat,e, Sons b Danielsson, Ltd., 83-91, Great Titchfield Street, London, W.l.
PROCEEDINGS
, KDITED' BY
Sir JOHN 1 W; Mac A LISTER
UHve.n raG c-e
THE EDITORIAL COMMITTEE
VOLUME THE TWELFTH
z - : . SESSION 19R.-1S \
SECTION OF THE HISTORY OF MEDICINE
LONDON
LONGMANS, GREEN & 00.. PATERNOSTER ROW
191.9
’ v) >•* wV \r!
• J1; * i»J
* , •-').,•{ ,* J M\ • * \ \\\
* v
Section of the trtetors of flDeMdne,
OFFICERS FOR THE SESSION 1918-19.
President —
Sir D’Arcy Power, K.B.E., F.R.C.S.
Vice-Presidents —
Henry Barnes, M.D.
Raymond Crawfurd, M.D.
C. G. Cumston, M.D.
Sir Norman Moore, Bfc., M.D.
Sir William Osler, Bt., M.D., F.R.S. (the late).
Hon. Secretaries —
Charles Singer, M.D.
Arnold Chaplin, M.D.
Other Members of Council —
James Berry, F.R.C.S.
7 m
William Bulloch, M.D., F.R.S.
Dudley W. Buxton, M.D.
F. W. Cock, M.D.
B. Glanvill Corney, I.S.O.
T. Vincent Dickinson, M.D.
Sir James Galloway, K.B.E., C.B.,
M.D.
Leonard G. Guthrie, M.D.
R. W. Leftwich, M.D. (the late).
E. Muirhead Little, F.R.C.S.
R. 0. Moon, M.D.
J. A. Nixon, M.B.
George C. Peachey.
Herbert R. Spencer, M.D.
C. J. S. Thompson.
C. E. Wallis.
F. Parkes Weber, M.D.
Representative on Library Committee —
J. D. Rolleston, M.D.
Representative on Editorial Committee —
Charles Singer, M.D.
SECTION OF THE HISTORY OF
MEDICINE.
CONTENTS.
December 18, 1918.
F. G. Crookshank, M.D. page
A Note on the History of Epidemic Encephalomyelitis ... ... 1
October 16, 1918.
Sir D’Arcy Power, K.B.E., F.R.C.S.Eng., F.S.A.
President’s Address ... ... ... ... ... ... 28
March 19, 1919.
The late Ralph Winnington Leftwich, M.D.
The Evidences of Disease in Shakespeare’s Handwriting ... ... 28
April 16, 1919.
Leonard Mark, M.D.
The Medical Aspects of Montaigne : A Study of the Journal which he
kept during his Voyage to Italy, with an Account of his Renal
Troubles and Experiences of Mineral Waters ... ... ... 43
November 20, 1918.
Charles Greene Cumston, M.D. (Geneva).
Note on Celsus’s Operation of Lithotomy
62
IV
Contents
January 15, 1919.
Charles Greene Cumston, M.D. (Geneva).
A Contribution to the History of the Surgical Treatment of Aneurysm
from the Notes of Dr. Charles T. Maunoir, of Geneva, made durin
the year 1802
PAGE
63
March 19, 1919.
G. R. J. Fletcher, M.R.C.S.
St. Isidore of Seville and his Book on Medicine ... ... ... 70
February 19, 1919.
Dorothea Walky Singer.
Survey of Medical Manuscripts in the British Isles dating from before
the Sixteenth Century ... ... ... ... .. 96
Robert Steele.
Dies Aegyptiaci
December 18, 1918.
108
November 20, 1918.
C. J. S. Thompson.
Note on Some Old Pewter Bowls in the Royal Mineral Water Hospital .
at Bath ... ... ... ... ... ... ... 122
May 15, 1918.
Charles Singer, M.D.
The Lorica of Gildas the Briton (? 547). A Magico-medical Text
containing an Anatomical Vocabulary ... ... ... 124
The late Sir Marc Armand Buffer, C.M.G.
On the Physical Effects of Consanguineous Marriages in the Royal
Families of Ancient Egypt (with prefatory note by Lady
Rufifer)... ... ... ... ... ... ... 145-190
The Society does not hold itself in any way responsible for the statements made or
the views put forward in the various papers.
John Bale, Son* A Danielmon, Ltd., S3-91, Great Titchtield Street, London, W. 1,
Section of tbc Ibiotorp of flDebieme.
President—Sir D’Arcy Power, K.B.K., F.li.C.S.
A Note on the History of Epidemic Encephalomyelitis.
By V. G. Chookshank, M.D.
“ On l'a dit justement, les memos questions renaissent a chaque
epidemie catarrhale, et leurs solutions diverses se reproduisent chaque
fois a pen pros les memos.”
BnUYIEK (.bin. tl'HmfiriiP Pub. rt dr. Mrd. Le<jale, 1837).
The clinical manifestations which of late years have become
associated with the names of encephalitis acuta haemorrhagica, polio¬
encephalitis, poliomyelitis and so forth, have, there is little doubt,
prevailed from time to time, during many centuries, in epidemic form.
The occurrences are not new ; they have been described again and
again in unmistakable language : but, since the overlying nosological,
pathological, and aetiological conceptions have been ever-varying, we
have failed to recognize the historical continuity of the realities. The
history of epidemic encephalomyelitis is, therefore, not that of “ one
disease,” but of many; for what we call “diseases” are not natural
objects, but conceptual.
We may indeed apply to encephalomyelitis in some degree the
words employed by Michel Levy, in the Gazette Medicate de Paris ,
or 1849, concerning cerebro-spinal meningitis :—
. . point une nouveaute: confondue avec* les fievres cerebrates
ataxiques, nerveuses : perdue dans les enumerations banales et dans
les generalities graphiques des epidemistes et dos chroniqueurs de la
medecine : melee a d’autres epidemies plus considerables, comme le
tvpbus, et rattachee a ses manifestations, a titre d’anomalie ou de
1
2 Crookshank : History of Epidemic Encephalomyelitis
variety anafcomique . . . elle £chappe a une determination historique
rigoreuse k cause de Tinsuffisance ou de l’ambiguite des documents, de
l’absence ou de l’imperfection de l’anatomie pathologique.”
Nevertheless, though, like Levy, we may not wish “ nous exposer
a juger aujourd'hui sous l’optique d’une preoccupation synthetique,”
we must, as did he when observing the almost concurrent outbreaks
of cerebro-spinal meningitis and influenza at the Val-de-Gr&ce, declare
that “ lorsqu’on voit . . . des combinaisons morbides qui deroutent
P observation vulgaire, l’idee de la continuity des ^pidemies se presente
derriere le fait incontestable de leurs connexions/’
This however is true: since the prevalences of encephalomyelitis
have been irregular and intermittent, and the clinical pictures “protean,”
almost every epidemic has been hailed as a new disease by many, and
described in new terms by someone. Nevertheless it is surprising that
only one author, Ozanam, appears to have attempted the history of
epidemic encephalitis, and that his work should have been ignored by
those who have written the history of poliomyelitis, or the Heine-Medin
disease, as well as by medical historians in general. The fact is that
those who have written the history of diseases have persistently confused
names, notions and realities.
Julien Le Paulmier, writing at Paris, in 1578,“de morbis contagiosis,”
observed that the epidemic pestilences due to heavenly influences, are,
some grave, and some mitigated, while some are familiar and others
unusual, or unaccustomed. And he gave three instances of unaccus¬
tomed pestilences, appearing suddenly, as if new diseases.
The first, said Le Paulmier, is the sydropyreton (or sudor Anglicus of
1529) “quae nostro hoc seculo Britanniam mire afflixit ” : the second,
“ destillatio quaedam popularis nostris vernaculi Coqueluchc appellata
quae in nostram hanc Galliam anno 1551 primum suevire cooperta sit ”
(in other words, the influenza which afflicted France during the time of
the fifth and last “sweat” in England): and the third, “paraplegia
maudita sed lethalis quae in Thaso contigit, flagrantes ardores ^ravedines
anhelosae aliique non pauci veterum oblivione deleti.”
Of the two first, presently.
But what was this paraplegia in Thasus ?
Hippocrates, in writing on epidemical diseases, says that in Thasus—
I quote from Clifton’s translation :—
“ During this state of the weather, in the winter. Paraplegias began
ami attacked many, some of whom dy'd in a short time, for the disease
3
Section of the History of Medicine
was very epidemical. In other respects they were well. But, in the
Very beginning of the Spring, Burning Fevers came on, and continued to
the Equinox, and even to the Summer. Most of those escaped who
were seiz’d presently after the beginning of the Spring and Summer,
and some few dy’d : but when the Autumn and wet weather set in,
they prov’d mortal to many. These fevers were of such a nature that
where any one bled freely and plentifully at the nose he was sav’d by it
more than by anything else.”
The Hippocratic constitution for this year was, it is obvious, almost
identical with that of 1918 ; epidemic paraplegia taking the place of
our epidemic encephalitis “ lethargica.” The observation of Hippo¬
crates was doubtless just: for the prevalences of encephalomyelitis
have invariably stood in a certain relation to epidemics, and endemic-
epidemics, of the “ burning-fevers ” that we call influenza.
I do not, however, wish to occupy your time with citations from the
ancients: it is more convenient to begin with the century of da Vinci
and Buonarrotti—in what doctors think the dark ages, when, however,
as Hallam suggests, “ some parts of physical science had already
attained a height which mere books do not record.”
*****
In the last 450 years four periods seem to be indicated in respect of
epidemic encephalomyelitis: four periods marked by different phases of
medical thought and observation.
During the first, which closes with the era of Willis and Sydenham,
wide epidemic prevalences were observed and compared, as a rule,
without resolution into component “ diseases ” ; and symptoms, obviously
due to forms of meningitis, encephalitis, and myelitis were described
in relation to vast occurrences that we would now call “ disease-groups.”
In the second period, which roughly coincides with the eighteenth
century, systems of nosology were based upon symptoms; and symptom-
groups due to encephalitis and myelitis, as well as to meningitis, were
referred to nervous, comatose, lethargic, stuporose, convulsive, apoplectic,
and paralytic fevers, usually considered as different elements of special
epidemic constitutions.
During the third period, which commenced about the year 1800,
persistent efforts were made to distinguish specific diseases by the
findings of morbid anatomy. Cerebritis, encephalitis, meningitis, and
myelitis were then described, sometimes as “ specific entities,” some¬
times as characteristic lesions of specific fevers such as “cerebral
la
4
Crookshank: History of Epidemic Encephalomyelitis
typhus ” and the like; sometimes again as evidences of metastasis of
disease from one part of the body to another.
The fourth period, which commenced some thirty years or more
ago, is characterized by the distinction of many specific diseases by
association with specific organisms. It is to be hoped that this period
will prove one in which medicine will so far profit by biology as not
to neglect synthetic research in the pursuit of purely analytical
investigation.
There is, however, throughout the whole history of these 450
years one tendency in continuity that is manifested by the persistent
ascription of certain odd, detached prevalences of encephalomyelitis to
varieties of food poisoning.
The Germans in 1529 ascribed some of the maleficent forms of the
sudor Anglicus to the eating of fish ; and, in 1820, Justin Kerner,
of Weinsberg, attributed outbreaks, clinically identical with polio¬
encephalitis, to the eating of Swabian sausages ; thereby laying the
foundation of the myth of botulism. But it has long been also tlje
custom in Germany to incriminate ergot of rye as the cause of certain
acute, epidemic, and generally febrile maladies, characterized by
respiratory and gastro-intestinal catarrhs, and exhibiting, as their
cardinal symptoms, delirium or stupor, paralysis or convulsions and
tremors, and interference with the special senses. These maladies
frequently entailed permanent paralysis and withering of limbs, since
they affected the young at least as frequently as (according to some
authorities more frequently than) their elders.
This was the affection or group of affections known popularly
in Germany (inter alia ) as Kriebelkrankheit : called Raphania in
Sweden by Linnaeus, since he thought it due to radish-seeds and
not to ergot; and, during the last fifty years replaced in the minds
and text-books of Swedish physicians by cerebro-spinal meningitis,
poliomyelitis and polio-encephalitis.
The unravelling of its tangled history is no easy task, yet lightened
by detection of the mystification and suppression of facts practised by
some of the German writers whose works have attained renown at
the expense of far greater French and Italian epidemiogfaphers. It
is in great part this belief in the existence of an acute, epidemic,
protean, febrile, paralytic, and spasmodic, non-gangrenous form of
ergotism that has so long confused the history of encephalo-myelitis :
and the mystery of its alleged restriction to Germany, Scandinavia
and Russia entirely disappears when we find the same malady described
Section of the History of Medicine
5
in England, in France, in Spain and in Italy, under different names.
For, it was not the disease so much as the setiological conception that
had a restricted area of distribution.
It is worth recalling, too, that Reusner of Frankfort, when writing
of the scurvy in 1600, spoke of the Kriebelkrankheit as characterized,
when it appeared in 1595, by “ veternus, mania, lumbago, paralysis, con-
vulsiones et morbus Herculeus,” and declared that: “ ob symptomatum
insolentiam novum esse suspicatum fuit.”
To revert however to the first of Julien Le Paulmier’s unfamiliar
pestilences, I will only remind you that, while we know very little of the
clinical features of the English sweats (save that stupor was a prominent
feature of the grave cases) Dr. Hamer has clearly shown the epidemi¬
ological features to be those of influenza. The myth that the sweats
were, save for that of 1528-29, confined to Englishmen, may be con¬
sidered now exploded, for each sweat in England corresponded very
closely in time to an epidemic, in every European country, that can
be demonstrated , to have been either influenzal, or encephalitic, or
both. It was the name that had so restricted an application; the
nature of the coqueluche or trousse-galant in France, the Hauptkrank-
heit in Germany, and the mal mazzuco in Itkly cannot be seriously
disputed. Nor is it difficult to place the strange disease that,
according to Jean de Troyes and de MAzeray, spread through France
in 1481-82.
This epidemic, “ qui attaquoit aussi bien les grands que les petits,”
“ qui mettoit le feu a la teste,”—this “ maladie de fievre et rage de
teste,” if Zeviani’s interpretation of an allusion by Alessandro Bene¬
detto is well founded, was contemporaneous, not only with the epidemic
encephalitis (Hecker) or Hauptkrankheit that afflicted Germany and is
mentioned in the Frankfort Chronicles, but with a catarrhal and
pleuritic epidemic in Italy. It was soon followed by the first “ sweat ”
in England.
I do not propose now to deal at length with the English “ sweats.”
It must suffice to say that a fresh examination of many early conti¬
nental authors makes it abundantly clear that Dr. Hamer’s contentions
are just.
It is beyond reasonable doubt that the absurd legends which
represent the “ sweats ” as a disease “ sui generis ” and, save in
1528-29, afflicting Englishmen only, would not have attained their
present currency had the laborious but wrong-headed erudition of
Gruner, Hecker, Haeser, and Hirsch been called in question by some
6 Crookshank : History of Epidemic Encephalomyelitis
one conversant with practical and historical epidemiology before
Dr. Hamer delivered his Milroy Lectures (1906). The “sweats”
to ere “ influenzas ” of malignant and nervous type in some years and
places, but often ephemeral, and of the nature of the summer epidemic
in 1918.
Since however the sweat of 1529 was so copiously described in
Germany, it is worth recalling that, according to Schiller and others
who gave contemporary accounts, the disease was of an extremely
variable character, assuming different guises in different places; and
of all grades of malignancy. It commenced with short shivers, and, in
malignant cases, with convulsions; whilst dizziness and tinnitus were
common. Formications, cramps, and weariness, muscular weaknesses,
affections of the nerves, of the brain, pain in the head and stupor
(“ somnolentia inevitabilisque sopor ”) were amongst the symptoms in
some places of a malady which struck all classes of society and carriqfl
off some victims in even a few hours. The breathing was “ as if the
lungs were seized with incipient paralysis,’’ whilst later “ the spinal
marrow was affected.”
" Contra, quibus sudor non satis fluxit aut repulsus fuit, mortui
sunt, vel asphyxia vel tabe et decidentia membrorum vel paralysi et
obnigratione manuum atque pedum.”
In those who escaped with their life, paralytic consequences of
various kinds were noted.
The very clear indications, in Schiller’s tract, that epidemic
encephalomyelitis prevailed in Germany during the “ English sweat ”
of 1529 in that country, have by most authors been either slurred
over or treated as evidence of “ ergotism,” much in the same way as
some Patagonian historian, in years to come, may write of the
prevalence of “ botulism ” in England during the “ Spanish ” influenza
of 1918.
And it is interesting to note that, although Gruner, Hecker, Haeser,
and Hirsch all declared France to have been spared the "sweat ” in
1529, there is nevertheless the clearest evidence, in Paradin’s “ Histoire
de Nostre Terns,” of a malignant and neurotoxic influenza—“ une
nouvelle maladie et inconnue aux m4decins ”—which ravaged France
in that year.
“ A cette nouvelle maladie fut nouveau nom impost, et fut nomm6
Trousse aaland pour la contagieuse rnort qui s en ensuivoit, avec grande
et impourvue soudeinnete.”
Section of the History of Medicine . 7
“ Stop-gallant,” be it noted, was the name given to our later
“ sweats ” in England.
It is perhaps true that it was only during times of epidemic, and
not always then, that the relation of the “ nervous ” cases and case-
groups to the sudoral and catarrhal cases and cases-groups was recog¬
nized; but-Benedetto, when writing “ de destillatibus sive catarrhis”
(i Omnium a vertice ad calcem morborum signa ), showed that he, at any
rate, connected the signs and consequences of what we now call
polio-encephalitis and poliomyelitis with the oftentimes epidemic
catarrh. Fernel, moreover, who had written of new diseases in much
the same strain as Le Paulmier (De abdit. rerum causis : lib. ii, cap. xi)
had come to much the same conclusion.
I can only mention in passing, and without comment, the stuporose
epidemic in Piedmont and Savoy during 1545-46, described by Sanders
and by Ambroise Pare. It too, like the 1529 affair, was called Trousse-
galant, and it was moreover contemporaneous with a “Haupt-weh”
in Germany (1543-44-45-46) and a camp-disease at Boulogne.
“Trailers,” in Leichtenstern’s terminology, straggled on during
the fifties, and even later, whilst the great pandemic influenza of
1580 had an avant-coureur in 1576, described by Ballonius, the French
Sydenham. In Yvaren’s translation we read thus: “ Durant tout
l’hiver et au commencement du printemps, il y eut une quantile
innombrable de paralyses, et elles ne ddpendaient pas seulement d’une
fluxion froide partie de la t6te ... on rapportait celle-ci k l’^tat
du ciel.”
And Ballonius observes: “ Les affections catarrhales se portent-elles
a l’ext6rieur, ou de la t6te au organes sous-jacents, on voit nattre des
parapl6gies et des hemipl6gies.”
The great influenza of 1580 was, in some places, so sudoral that many
declared it the English sweat come back again, and so cephalic that
Brunner called it too the Hauptkrankheit. Sennert himself said of it:—
“ Nonnullis infestavit perpetua in somnia propensio ut in peste
fieri solet.”
By pestis he meant, of course, the Pestis Britannica of 1529. The
next year, 1581, however was marked at Liineburg, in North Germany,
by an epidemic of palsies in the head and limbs (described by
Bonsseus) that, like an outbreak in Belgium during the “ influenzas ”
of 1557-58, has found a place in the later chronologies of “ convulsive
ergotism.” Of this notable epidemic an admirable account is given
8 Crookshank : History of Epidemic Encephalomyelitis
by Schenkius, copied almost verbatim from Ronsseus, in which are
used the very adjectives “novus,” and “ inauditus,” employed by
Reusner for the same disease when it reappeared fifteen years later.
Schenkius said that it was difficult to determine whether the malady
was epidemic or endemic: and made no suggestion whatsoever of
ergotism. The illness began with spasticity and palsy of the hands and
feet: the patients, sometimes delirious, were often slumberous. The
half closed eyes and open mouth filled with ropy mucus, and the
tongue, affected as if paralysed, all remind us of the descriptions of the
botulists : but the statement that sometimes those who recovered found
the hands and feet to have lost their office as if the limbs were
luxated, makes it clear that flaccid palsies were no unusual sequelae.
Comparison of this account with one of the “ spasmodic ” form of
Heine-Medin disease described in Australia by Breinl in 1917, forms
one of the most instructive parallels in medicine. The coincidence
extends even to the occurrence, in both groups of cases, of severe
gastro-intestinal disturbances, as in some of ours during 1918.
In the last decade of the sixteenth century scattered prevalences
now recognized as influenzal were freely interspersed by great trailing
epidemics Very similar to this at Liineburg, but generally known
popularly as Kriebelkrankheit, or Erampfsucht. It is clear from the
accounts of both Sennert and Horst that no symptom nor sign of polio¬
encephalitis, poliomyelitis, or cerebro-spinal meningitis was lacking;
and Sennert is emphatic that while “ nunc cum febre, nunc sine febre,”
“ neque contagio hoc malum carebat.”
Neither Horst nor Sennert paid attention to the vulgar aetiology of
ergot, chick-peas, bad bread, sour apples, mushrooms and the like. They
regarded the malady as a “malignant fever with spasms.” And, in
1772, Schleger, in a delightful but rhetorical essay, exposed clearly the
repeated statement of Baldinger and others that this epidemic had been
shown to be ergotic by those who, at the time, described it.
Now, in 1597, whilst this malady was raging, or trailing in
Germany, the mal mazzuco appeared in Italy as it had already in
1529—the year of the sudor Anglicus. Zeviani, in 1804, brought
forward evidence in favour of the view that this mal mazzuco was
an intensely “ nervous ” form of influenza, and showed clearly that
stupor, and katatonia (malum attonitum), were prominent amongst its
symptoms.
To reinforce the point, that “ epidemic catarrh ” was widespread
in 1597, he cited Schenkius who, writing contemporaneously, appears
Section of the History of Medicine
9
to identify the Italian epidemic of 1597 with one which invaded
Germany “ ipso tempore." Zeviani, whose monograph on the epidemic
catarrh is one of the best accounts of influenza ever written, identified
realities, and refused to be a slave to names and notions. *
A few more words are necessary on this question of the mal mazzuco.
Zeviani cites, from Brassavola (Index in Galen), a passage which,
though doubtless authentic, I have failed to find in those prodigious
folios. It runs thus : “ Pulsus affectus ex phrenitide et lethargo quern
nos vocamps malum Mazuchi.” Pretty clearly then, this mal.mazzuco
was a “ clinical entity.” It occurred in Sicily, and elsewhere, about
1504-5, at the same time as “encephalitis” in Germany, and shortly
before our second “sweat” in England. It was notoriously present
in Italy during 1529, when, according to the Teutonic epidemiographers,
that peninsula escaped the “ sweat,” and it recurred at intervals until
1597.
Zeviani was right: the mal mazzuco was an epidemic nervous
“ disease,” closely allied to influenza, of which he considered it a form,
or derivative. The clinical picture was variable : occasionally “ menin¬
geal,” sometimes convulsions, and at others stupor, lethargy, and
catalepsy were characteristic symptoms.
It was compared vulgarly, at times, to the cysticercus disease of
the sheep, and hence became known as “ morbus ovinus,” and “ morbus
arietis.” The contemporary name in Germany for influenza was
“ Schaffkrankheit ” ; an appellation which, by a happy confusion, was
in 1712 given by Camerarius as “ Schlafkrankheit.”
There is, after 1600, a long, almost silent, period in the history both
of influenza and of all forms of encephalomyelitis. But the famous
prevalences of 1657-58, described in England by Willis, and marked in
the autumn of the latter year by a strange fever “ whereby men were
grievously affected in their brains and nervous stocks,” was signalized
at Copenhagen, in 1657, by an epidemic of lethargy, or lethargic
encephalitis, that makes the constitution for that year of an even juster
parallel with that of 1918 than was that of Hippocrates already
mentioned.
I do not think Bartholin’s account has been referred to for a
hundred years, and therefore cite it, almost in full:—
“ Hyems frigida quidem, sed sine multa nive, in urbe nostra affectus
soporoso8 excitavit, accuratis periodis molestos. Non panci nostra cura
soporem perpetuum evasere. A meridie sopor mensis spacio obrepabat,
et ab astantibus excitati in somnum relabebantur. Expurgato capite
10 Crookshank : History of Epidemic Encephalomyelitis
et exsiccato, imprimis cucurbitulis dorso affixis convaluerunt. Vere
ejusdem anni Pleuritides Epidemiae grassabantur, cum febre acuta
doloribus pungivitis.Declinante verb testate, febres ephemerae
invaluerunt, spacio 24 horarum desinentes, invadentesque cum vomitu,
calore intenso perdurante.
Ecstasi quadem correpti de capitis, doloribus conquerebantur.
Nonnullis morbilli sociabantur, aliquibus petechiae.”
(. Hist. Anat. et Med. Rar., cent, v, hist, vi.)
Four years later, in 1661, there occurred in England the famous
fever “ chiefly infestous to the brain and nervous stock,” described
by Willis, identified by him with the German Kriebelkrankheit
of 1595-96-97, and recognized by Saillant, in 1776, in a wonderfully
lucid paper, as the convulsive epidemic malady wrongly attributed
by some to ergotism, and confounded with the gangrenous ergotism
of Sologne.
Saillant, in this paper, which has somehow escaped the German
bibliographers, in accordance with their wont, makes it clear that,
though called by him the Morbus Convulsivus Epidemicus, this malady
was as protean as only epidemic encephalomyelitis (or influenza) can
be, and that in different years, and in different places, different clinical
types occurred.
The famous “ feavour ” of Willis, and the “ comatose fever ” described
by Sydenham, were shown by Dr. Charles Creighton, thirty years ago,
to stand for a definite form of illness that, when Dr. Creighton wrote,
was not recognized by nosographers.
The riddle is now resolved. Willis’s fever represented a convulsive,
and Sydenham’s a lethargic form of encephalomyelitis occurring
epidemically. The details of the argument were given by me in the
Chadwick Lectures (1918), as yet unpublished, but it may here be
said that Willis’s fever was exactly reproduced in Queensland during
1917 (cf. Breinl), where even the flexor spasms, so long and so errone¬
ously held to be characteristic of “ ergotism,” were observed, as was
sometimes the case in London, during 1918, amongst our cases of
“ encephalitis lethargica.”
The European influenzas of 1674-75 were preceded or accompanied
by “ epidemic psychoses ” in Sweden (1673), the Kriebelkrankheit again
in Germany (1672-75), malignant fevers with spasms in France (1673),
and the comatose fever of Sydenham (Willis’s fever of 1661), in
1673-74-75.
Section of the History of Medicine
11
Henceforward, until 1800, the history of epidemic encephalo¬
myelitis is that of Kriebelkrankheit (or Raphania, as it came to be
called) in Germany, Scandinavia and Russia, of nervous fevers in
Britain, of epidemic apoplexies and paralyses in Italy, and of nervous,
comatose, lethargic, apoplectic, paralytic, spasmodic and convulsive
fevers, as well as of spontaneous “ hydrophobias,” described by Werlhof,
Saalmann, de Sauvages, Selle, Vogel, Andry, Hillary, Wintringham,
Gilchrist, Grant, and many other epidemiologists and systematists.
Much material has been collected : much more perhaps remains for
investigation. But one or two landmarks may be pointed out. For
example : Albrecht of Hildesheim had, in 1695, described a typical case
of encephalitis lethargica in these words ( Miscell. Curios ., an. ix and
x, obs. i) :—
“ De febre Lethargica in Strabismum utriusque oculi desinente.”
“ Afano 1695, virgo hujus loci, viginti circiter annorum, honesti cujus
tam civis I.F. filia, in febrem incidit continuam, acutissima cephalalgia
siccitate oris et aliis, quae in ejusmodi morbis acutis notari sunt,
symptomatibus stipatam, quorum tamen praecipuum circa, hoc sub-
jectum in summa ad somnum propensione consistebat, quae quo
magis capitis remittebat dolor, majus majusque capiebat incrementum,
ita, ut quoties a somno excitaretur toties in eundem relaberetur
profundissimum.
14 Scilicet, a quo tempora meliori praedita erat valetudine, oculorum
talis advertebatur distortio, quae pupillam in utroque versus palpebram
adigebat superiorem, inferiori bulbi parte ultra ejus dimidium non nisi
album referente.”
Later, the famous influenza of 1712, notoriously cephalic and
nervous, was signalized at Tubingen by the epidemic, of which so much
has been said lately, usually referred to as the “ Schlafkrankheit.” It
is not generally stated that R. J. Kammermeister, who described it,
called it an epidemic febrile catarrh, and identified it with the pandemic
of 1580, of which I have spoken. I cite some salient passages :—
“ Haec autem pleraque omnia quadrabant iterum in febrem catar-
rhalem hujus anni 1712. Fuit haec universalis, popularis maxima
gravis capiti, sub concursu forte trium, febris, catarrhi, vomitus, magis
afflicto; sive contagiosae vel epidemiae predicatum meruisse dicenda
sit. .... Gravedo ista quondam Germanis die ‘ Schlafkrankheit’
dicta fuit, nunc agrypnia, nunc veterno molestior. Hac vice nomen
illud non audii. Nec dormivisse multum nemini, praeterquam paucos,
opiatis quidein non usos. Noctes utique graves, turbatae phantasiis
12 Crookshank : History of Epidemic Encephalomyelitis
frequens etiam per diem querela de afflictis oculis, utut non inflammatis,
segre tamen aperiendis, nec lucem ferentibus.Eadem Gallia olim
audrit ‘ Coqueluohe.’ ”
{Ephemerides, cent, iii and iv, t. xxvii, oba. lviii.)
It is on this account' that von Economo relies, when suggesting
that encephalitis lethargica was recognized, as a “ clinical entity,’’ by
Camerarius and by precedent observers. Whatever we may think as
to the identity of the cases seen by Camerarius with those seen at
Vienna during 1917 (and Professor Netter is inclined to be critical,
though accepting Albrecht’s case), there can be no doubt that influenza
prevailed at Tubingen during 1712, and was accompanied by ence¬
phalitic manifestations.
I have, however, failed to find any evidence that the name “ Schlaf-
krankheit ” had previously obtained currency, and am inclined to
believe, as already stated, that there had been a perversion, not without
significance, from the earlier nicknames of “ Schaffkrankheit ” and
“ Schaffhusten.” There may even have been a printer’s error!
Much more important, however, than Camerarius’s short essay is
the account given by Guidetti (in Bianchi’s Historia Hepatica, 1725,
p. 718) of the epidemic constitution for 1712 as observed at Turin.
The parallel with that of 1918 at London is extraordinary, and, clearly,
“ epidemic stupor ” is no “ new disease.”
Some passages may be given from Guidetti:—
“ Ad Januari principium nebulae adhuc contumaces in tenuem
pluviam liquescebant et statim inter morbos catarrhales varios puta
tusses raucedines et ptyalismos irrepsere febres frequenter soporosae,
proveetis aeque ac juvenibus infensae cum frigido ad caput decubitur,
quern febris quidam imminuta prosequabatur. Aegri interim lente
moriebantur vel comatosi vel cataleptici vel aphoni. Phirimi ante
obitum convulsionibus torquebantur.”
It is moreover interesting to note that Heusinger, in his Commentatio
Semiologica, actually connoted Guidetti’s account with that of Willis,
and that, according to Guidetti, the “ rheumatic epidemic,” for so he
termed the influenza of 1712, spread, in the late autumn, “ inequaliter
sed celeriter, per totam Italiam.”
The still more famous influenza of 1729-33 was, singularly enough,
marked at Tubingen in 1729 by an undoubted encephalomyelitis of
convulsive type. Elias Camerarius, who described it (Act. Phys. Med.,
ii, obs. cli) clearly recognized the essential unity of the nervous
Section of the History of Medicine
13
disease and the catarrhal cases. This seems rather to have baffled
the writers on ergotism, for they have left the account of Camerarius
on one side. The common people, as always, he said, accused the
weather, the grains, the bread, and the unripe fruits. But he himself
thought these but vague conjectures, and expressed no opinion of
his own.
In the latter part of 1727, however, Scheffelius had published what
is now a somewhat rare essay, entitled, “ De Morbo Epidemio Con-
vulsivo, per Holsatiam grassante oppido raro.” The malady, evidently
the same as that which occurred at Tubingen in 1729, had been
observed by Scheffelius in the spring and summer of 1727. Identified
by not a few as the old Kriebelkrankheit, it was claimed by others as
certainly due to ergotism, though Scheffelius declared many to have
been affected who had not eaten questionable bread. The nature of
Scheffelius’s powerful argument may be inferred from some of his
rubrics :—
“ An morbus novus sit ? ”
“ Epidemici paucissimi sunt novi : exemplo febris catarrhalis 1712.”
“ Et morbi nostri convulsivi, teste Willisio et aliis, Horstius eundem
morbum descripsit.”
“ Natura ipsa non est causa.”
“ Morbum hunc a panis vitio apud nos productum esse non est
verosimile sed ex aeris peculiari quadam constitutione.”
“ Yerum istud contagium non est absolutum.”
The identification with Willis’s fever is remarkable enough, but it
is even more noteworthy that Scheffelius found traces of the “ same
disease ” as this of 1727, in some particular accounts of the influenza
of 1580, and his insight was vindicated by the recurrent waves of
influenza that continued from 1729 to 1733 throughout the world.
A few years later Kriebelkrankheit, both convulsive and paralytic,
was in Brandenburg (1741) the forerunner of influenza in Germany
(1742), and the pandemic of 1743; while, in 1745, the same or a
similar meningeal, encephalitic and myelitic malady trailed through
Sweden, giving rise again to vague conjectures, but being, on the whole,
identified clinically with its German congener.
Sequential paralyses were noted: the acute cases were stuporose,
mute, and had ocular disturbances.
1754-55-56 and 1757 saw a recurrence in Sweden, again with
stupors, delirium, psychoses and mutism, but with convulsions rather
than paralyses. This terminated, in 1758, in a peculiar kind of
“influenza” (Ozanam).
14 Crookshank: History of Epidemic Encephalomyelitis
Bostrom indeed, at Upsala, had, in 1757, triumphantly identified
the endemic-epidemic of these years, known as the Upsala fever and
marked by head-retraction, with a “ long known protean fever, every¬
where prevalent from time to time, sometimes in one form, sometimes
in another.” “ Hie morbus non est novus,” he declared. Nevertheless,
the trailing epidemics in the rural districts had again been identified on
clinical grounds with the Kriebelkrankheit, though shown clearly not
to be due to ergot. This being so, Bothman, a pupil of Linne, and
with that great man’s approbation, elaborated the hypothesis that
this stuporose, delirious, paralytic and convulsant “ fever,” possibly
contagious, was caused by radish seeds in the threshed grain. It was
therefore christened Baphania: and the disease was known as such for
nearly a hundred years. Meanwhile the first case of botulism (or
encephalitis due to sausage poisoning) is said, by Kerner, to have been
described in Germany in 1755, while Baphania, as we must now call it,
there occurred at the same time.
The influenzas of 1762 were catarrhal rather than nervous; but
Baphania was again severe in Brandenburg and Zell in 1770, and
was held by Selle, amongst other German physicians, to be feebly
contagious, a fever, and different, by all the heavens, from true ergotism ;
while 1771 saw a genuine and severe influenza in Hesse, and 1772
influenza and epidemic convulsions in North America. About this
time Leidenfrost and Schleger protested vigorously against the notion,
again gaining ground, that the acute paralytic, spasmodic malady had
something to do with the gangrenous, and the chronic forms of ergotism,
but in vain ; though Haberkorn, earlier, had properly defined it as “ die
N ervenkrankheit. ’ ’
However, 1773 was the year of Sir Walter Scott’s infantile paralysis
and, in 1772-73-74, the so-called miliary fever prevailed extensively
in France, accompanied by nervous manifestations such as coma and
convulsions (Baraillon). In 1775 Andry described admirably what must
have been acute bulbar encephalitis in a young woman—he called it
“ hydrophobia without the bite of a dog ”—and, in London, Grant
declared that, during the influenza of that year he had lost several
patients with the “ Comatose Fever ” of Sydenham.
During the influenza years 1780*81-82, Butter, under the name of
“ infantile remittent fever,” observed what was clearly the acute stage
of encephalomyelitis, describing it as a complaint both epidemic and
sporadic, and affecting adults as well as children, while, two years
later (1784) Michael Underwood first noted, as “ debility of the lower
Section of ttie History of Medicine 15
extremities,” the deformities resulting from what must have been the
same acute illness.
A celebrated institutional outbreak in Turin, in 1789, has been
handed down by copyists as Raphania; but the accounts given by
Corradi indicate, I think, clearly either an encephalitis or a cerebro¬
spinal meningitis; moreover influenza was raging in the city at the
time.
The third chapter of my story may perhaps be taken to commence
in 1800, when Chardel, of Paris, described cerebral fever, or primary
inflammation of the brain, as a definite entity: 1799 and 1800 was an
influenza season. The world-wide influenza prevalences of 1800-03
were noted as extraordinarily “ cerebral ” in Russia ; and Raphania was
recorded there (as again in Scandinavia) in 1804.
The Italian influenza of these years was also very “ cerebral,” and it
was his then experiences, apparently which led Zeviani to consider the
old “ mal mazzuco ” as “ influenzal,” or at least derived from the
“ epidemic catarrh.” The celebrated “ cerebro-spinal meningitis ” at
Geneva was in 1805 ; that of Massachusetts in 1806.
A very interesting point now arises. Influenza prevailed extensively
in Hindostan about 1800-03, and John Shaw, of London, writing of
deformities in 1823, described the case of a young man whose disability
dated from an attack of paralysis, evidently poliomyelitic, that he
suffered during his infancy in India. Shaw went on to say that he had
been told that such “ sudden attacks ” were common among children in
India.
Dr. Ager, of Brooklyn, in a recent paper, lays it down, on the
strength of this suggestive remark, that infantile paralysis prevailed to
some extent amongst Anglo-Indian children in 1800, and hints that it
is really an Asian malady. The coincident appearance of epidemic
influenza in India, about the year 1800, does not appear to-have struck
him as noteworthy. Feiler, however, writing from Salzburg in 1814,
described a case of “ shank-shrinking,” as he called it, in a girl aged 12
or 13, afflicted since infancy. She too must have suffered about 1802,
the year of the so-called sweating-sickness at Rottingen, which was
identified, in the midst of influenza, as the mediaeval sweating sickness
come back again (Hecker).
Influenza in Europe occurred only in the endemic-epidemic form,
though severely, between 1819 and 1824; and many outbreaks were
in France and Germany described as miliary fever, or “ sweating-
sicknesses.” It was during these years that Kerner, in Wiirtemberg,
16 Crookshank: History of Epidemic Encephalomyelitis
first described the “Sausage Disease,” afterwards.known as botulism,
and that Abercrombie in Britain and Hutin and others in France and
Germany, gave so much attention to encephalitis.
Epidemic influenza was severe in the United States in 1824-25-26 ;
indeed, in 1824 Baphania was diagnosed clinically in a certain prison in
New England, while, in 1826, Jones declared he had noted the severity
of “phrenitis” as well as other nervous affections in the “late
influenzas.”
The influenzas, in Europe, of 1831, 1833, and 1836-37, gave rise to
a perfect exuberance of literature concerning encephalitis and myelitis
in France, while, in Germany, we hear again of Baphania, by now being
examined critically.
In Wurtemberg, botulism and acute encephalitis were described
within a few miles of each other, in 1834 and 1835. In the same
years and in the same kingdom Heine noted his first cases of infantile
paralysis, while 1835 saw Badham’s cases of the same malady in
England, and the publication of lectures by Byan, a long forgotten
London physician, describing, inter alia, cerebral, bulbar, and spinal
forms of encephalomyelitis in children.
The medical history of these years is indeed remarkable. Lombard,
writing from Geneva to the Gazette Medicate de Paris (1831 and 1837)
drew attention to an unpublished paper by Peschier (1820) describing
the cerebral and nervous forms of the influenzas of that period when
Kerner was then ascribing to “ sausage poisoning ” certain like “ clinical
entities ” that Stoker, afterwards, declared he had seen, in the same
year, at Dublin. But Lombard expressed an aphorism that is worth
recording, since it embodies the experience of Hippocrates, of Ballonius,
of Bartholin, of the two Kammermeisters, and of Guidetti.
He said: “ La grippe est souvent pricedee par une constitution
eminemment nerveuse, dont les caracteres principes sont de porter le
trouble dans les fonctions du cerveau et des nerfs encephaliques.”
Ducros, Mon tain, P6trequin and Becamier made clinical observations
in the same sense, and Gintrac, of Bordeaux, in a paper that I have
not seen, described “ epidemic stupor in children ”—“ coma sans
danger ”—as prevailing in the early spring of that notable influenza
year, 1837. Malcorps, of Brussels, went further. He divided the
historic influenzas into two categories: one, vernal, catarrhal, and'
benign, as in 1658, 1742, 1743, 1762, and 1780; the other, autumnal,
or hiemal, and marked by “ prodromes nerveux, caractere adynamique,
gravite plus grande,” as in 1580, 1676, 1730, 1737, 1775, and 1837.
Section of the History of Medicine 17
Surely our “encephalitis lethargica” of 1918 should be reckoned
amongst the “ prodromes nerveux ” of the influenza of 1918, which,
in point of fact, combined Malcorps’s two categories.
The influenzas of 1841-45 were evidently accompanied by much
infantile paralysis in the British Isles, described by West, Kennedy,
and MacCormac: much encephalitis, cerebro-spinal meningitis and
“ cerebral typhus ” in France; encephalitis, botulism and more
infantile paralysis in Germany; and, in Italy, the extraordinary
“ Tifo apoplettico-paralytico-tetanico,” which, though now thought to
have been cerebro-spinal meningitis, was, at the time, identified
clinically (1) as the sweating sickness of the Middle Ages (Agosti-
nacchio), (2) Baphania (Semmola), and (3) encephalitis and influenza.
In Scandinavia and Russia, Baphania and epidemic psychoses pre¬
vailed throughout these years, while the influenzas in the United
States during 1842-43 had been preceded by the outbreak of infantile
paralysis described by Colmer in 1841, and Dunglison had noted the
great increase of encephalitis everywhere at home and abroad.
The great influenza pandemic of 1847 was mainly catarrhal, but
the lesser waves of 1850-51, 1855, and 1857 were very “nervous.”
In Wiirtemberg, in 1850-51, there were again outbreaks of botulism
and encephalitis; and the famous epidemic of Calw, in Fritz’s essay
glorified as one of the spinal and bulbar forms of typhoid, was either
Heine -Medin disease or nothing.
Baphania was flickering out in Sweden in the “ fifties,” for it then
and there was beginning to be called cerebro-spinal meningitis, but,
at the same time south-western Germany and Bavaria, with Hesse-
Nassau, again suffered an extraordinary medley of outbreaks of
botulism, Baphania, localized influenzas, encephalitis and the like
diagnostic “ entities.” In 1856 Heusinger, of Marburg, studied the
question of acute and chronic ergotism in the light of actual experience
and came to the conclusion that some of the old epidemics had been
probably typhus—i.e., “ cerebral typhus,” or cerebro-spinal meningitis
and encephalitis.
But this medley dissipated until influenza came back, not as a
great pandemic, but diffusedly, in 1866-67. There had been some
infantile paralysis at Paris just before: but botulism and Baphania
again appeared in Wiirtemberg and adjacent districts in these years,
during which Stuttgart suffered severely from influenza.
The last trace of Baphania and epidemic psychopathy in Sweden
(1868) coincided with the first recognized outbreak of poliomyelitis in
Norway (Ruhrah).
18 Crookshank: History of Epidemic Encephalomyelitis
Poliomyelitis was epidemic on quite a large scale in Philadelphia in
1871-72-73-74; influenza was “ universal ” in the States in 1873, and
continued diffused therein until 1875, reaching France in 1874-75 ;
and the first recorded epidemic of poliomyelitis in that country was
in 1875.
1880-81 is a year now generally recognized as one of scattered
influenzal prevalences—it was then that Wernicke and Etter first
described cases of “ polio-encephalitis acuta hsemorrhagica.”
Poliomyelitis was then epidemic in Sweden and noticeable in
England also, while in 1884 Striimpell enunciated his now well known
views on the essential identity of polio-encephalitis and polio¬
myelitis.
The pandemic influenza of 1889-90 was immediately preceded by
the Swedish outbreaks of “ infantile paralysis ” studied by Medin, and
by the scattered diffusion in the Mediterranean basin of • a “ new
disease,” afterwards decided to be cerebro-spinal meningitis (Bezly
Thorne). It was followed by the famous “Nona” of Lombardy and
Hungary, identified by Netter with the “ encephalitis lethargica ” of
last year and this—the newest of new diseases! Yet surely it
was none other than the old mal mazzuco!
We reaped an aftermath of the great 1889-90 pandemic in minor
waves of influenza, accompanied by encephalitis throughout the
world, till 1895. In 1895 there was not only the Stockholm polio¬
myelitis, but, very curiously, an epidemic of “ grippe ” and acute
encephalomyelitis at Toulouse, studied by Andr6, who described it in
his book on influenza, declaring that polio-encephalitis had proved
to be a contagious malady, and suggesting that it represents a local
and intense form of “ grippe nerveuse.”
About this time, too, Oppenheim and Cassirer had rediscovered
Wernicke’s “ encephalitis acuta hsemorrhagica ” and had shown it to
be, in the main, influenzal.
Moreover, it was also in 1895 that van Ermengem observed the
Belgian outbreak which, while clinically polio-encephalitis, was declared
to be the old Swabian “ botulism,” and ascribed to an organism which
has not been found more than once, if ever, in the body of anyone dying
of this alleged “ disease.” It is true that this bacterial botulism of van
Ermengem cannot be distinguished clinically from the older sausage
disease of Justin Kerner, but it is also clinically identical with the
stuporose forms of the mal mazzuco and Raphania.
The convulsive forms of the mal mazzuco and of Raphania, on
Section of the History of Medicine
19
the other hand, are indistinguishable clinically from the convulsive, or
spasmodic forms of Heine-Medin disease described by German and
Austrian observers a few years ago, and from the “ mysterious
disease ” epidemic in Australia during the spring of 1917.
The events of the last twenty-five or thirty years have, however,
not yet attained the dignity of history. Still, without doubt, cul¬
minating as they do in the recent world-cycle of poliomyelitis, polio¬
encephalitis, cerebro-spinal meningitis and influenza, they amply
vindicate the view as to the epidemiological relation at least between
these diseases, expressed, for poliomyelitis by Brorstrom in 1910 and
for cerebro-spinal meningitis by Dr. Hamer, on many occasions.
In this connexion reference should be made to the important paper
by Looft, which may be found in the Nord. Medic. Arkiv for 1901,
(afd. ii, Haft i). Looft, while professedly giving the history of cerebro¬
spinal meningitis in Norway between 1875 and 1897, throws into high
relief the extraordinary clinical and epidemiological relationship between
polio-encephalitis, poliomyelitis, cerebro-spinal meningitis, and epidemic
catarrh. For, without doubt, many of the cases ascribed by him to
the third of these diseases, and shown to be connected with the fourth,
would, more justly, have been attributed to either the first or the
second : a point that has been suggested also by Foster and Gaskell
But the relationship between these “ diseases/' and some others as
well, is, to those who have examined the evidence, not superficial and
based upon any confusion. The confusion has arisen by reason of well-
meaning attempts to establish an artificial, even if convenient, set of
distinctions as something which corresponds to realities in nature.
Independent observers, such as Lewis in America ( Interstate
Medical Journal , 1918, v, p. 896) and Saunders of Grahamstown, are
everywhere now contributing their quota, and formulating their con¬
clusions, in support of the synthetic tendency. The recent experiences
of Marcus at Stockholm (Berliner klinische Woclienschrift , 1918, lv,
pp. 1151-2) and the observations of Sainton, and of Chartier (Presse
Medicate , 1918) should not pass unrecorded.
In the recent Chadwick lectures I dealt at greater length than is
now possible with the history of all these affections : and I then tried
to show, as to-day, that their epidemiological association (if we have
regard to realities and not to names, or to concepts) has been repeatedly
recognized since the time of Hippocrates.
This association, recognized by Bostrom in 1757 and by Zeviani
in 1804, will undoubtedly be again discovered in the near future.
20 Crookshank : History of Epidemic Encephalomyelitis
In the meantime the position may perhaps be thus summarized:—
(1) Clinical occurrences of the nature that we now ascribe to
encephalomyelitis, or encephalo-myelo-meningitis, have been recorded
in modern times for at least 450 years.
(2) In great part these occurrences have been noted as incidental
to major prevalences, known historically as the sweating sicknesses, the
influenzas, or epidemic catarrhs, and the like.
(8) But special epidemics of these occurrences have also been
described as manifestations of special diseases. These special epidemics
have usually appeared shortly before or shortly after major “ influenzal ”
prevalences, or else in geographical proximity to endemic-epidemic
and endemic influenzal prevalences.
(4) Epidemic encephalo-myelo-meningitis may represent an extensive
specialized reaction that has perhaps the same epidemiological relation
to pandemic influenza as have the prevalences and epidemics of
“ septic ” pneumonia and of gastro-intestinal illness, described before
and after that affection.
(5) In any case, owing to the relative infrequency of the prevalence. s*,
and their marked variation in type, historical investigation is necessary
in order that contemporary occurrences be viewed in a correct
perspective.
One detail deserves mention, here and now, for it shows the difficulty
of historical investigation at short range. The great epidemic of polio¬
myelitis in and about New York during 1916 followed closely upon
a prevalence of “ grip ” in the States, the like of which had not been
known since 1889-90. Yet this wave w r hich “ sw r ept through ” a
continent has completely eluded the attention of those who have
written the “history'’ of our recent influenza! It was, however,
well described by Capps and Moody, as well as by others, in the
Journal of the American Medical Association for 1916.
Once more, there is nothing new in these notions. Many writers,
but perhaps most notably Dr. Hamer in our time, have recognized the
clinical aflinities and epidemiological liaison between what we now call
forms of epidemic encephalomyelitis and meningitis, on the one hand,
and the epidemic catarrhal fever, or influenza, on the other.
Section of the History of Medicine
21
Bibliography.
An introduction to the literature is afforded by the bibliographies
in many of the following treatises and papers:—
Breinl. Med. Joum . of Austral ., 1918, i, pp. 209, 234.
Brochin. Dictionnaire Encycloptdique aes Sciences Medicates, 1878-4, articles : “Catarrhe”
and “ Grippe.”
Collins and Finkler. ‘‘Twentieth Century Practice of Medicine,” x, xv, 1897, 1898,
articles: “Encephalitis” and “Influenza.”
Corradi. “ Annali delle Epidemie occorse in Italia,” Bologna, 1867*1895.
Creighton. “ A History of Epidemics in Great Britain, from a.d. 664 to the Extinction of
the Plague,” 1891.
Crookshank. Lancet , 1918 (i and ii) and 1919; Proc. Roy. Soc. Med., 1918, xii (Sects. Med.,
Path., Epid.) pp. iv, xii, xiv, xxi.
Gruner. “ Scriptores de Sudore Anglico superstites,” 1847.
Haeser. “Bibliotheca Epidemiographica,” 1862.
Hamer. Report of the Medical Officer to the London County Council (1917), 1918.
Hecker. “The Epidemics of the Middle Ages,” 1864.
Hir8CH. “Geographical and Historical Pathology” (English translation, 1883-1886).
Nothnagel’s “Encyclopaedia of Practical Medicine,” article “Influenza,” (?) 1905.
Oppenheim. “Text-book of Nervous Diseases,” and (with Cassirer) article: “Ence¬
phalitis,” in Nothnagel’s “Handbuch.”
Ozanam. “Histoire m^dicale generate et particulaire des maladies epidfoniques,” 1835.
Saillant. “R6chercbes sur la maladie convulsive £pid6mique, attribute,” &c., Hist, et
mem. de la Soc. Roy. de Mtd. (1776, m4m. p. 303), 1779.
Schleger. “ Programma . . . clavos secalinos . . .,” 1772.
Wickman. “Heine-Medin Disease” (New York Nervous and Mental Monograph Series),
1913.
Zeviani. “ Sul Catarro Epidemico ” (Memorie di Matematica e di Fisica della Societa
Italiana della Scienze, xi, p. 476).
Zibms8en’s “Cyclopaedia of Practice of Medicine,” articles: “Influenza” (ii, 1875),
“ Botulismus,” “Ergot Poisoning” (xvii, 1878).
$
16
Vol. XII., No. 8.]
[June, 1919
PROCEEDINGS
OF THE
ROYAL SOCIETY OF MEDICINE
SECTION OF THE HISTORY OF MEDICINE.
CONTENTS.
PAGE
Sir D’Arcy Power, K.B.E., F.R.C.S.Eng., F.S.A.
President’s Address ... ... ... ... ... ... 23
Ralph Winninoton Lbftwich, M.D. (The late)
The Evidences of Disease in Shakespeare’s Handwriting ... 28
Leonard Mark, M.D.
The Medical* Aspects of Montaigne : A Study of the J ournal which
he kept during his Voyage to Italy, with an Account of his
Renal Troubles and Experiences of Mineral Waters ... 43
Charles Greens Cumston, M.D.
(1) Note on Celsus’s Operation of Lithotomy ... ... ... 62
(2) A Contribution to the History of the Surgical Treatment of
Aneurysm, from the Notes of Dr. Charles T. Maunoir, of
Geneva, made during the year 1802 ... ... ... 63
G. R. J. Fletcher, M.R.C.8.
St. Isidore of Seville and his Book on Medicine ... ... 70
Dorothea Waley Singer.
Survey of Medical Manuscripts in the British Isles dating from
before the Sixteenth Century ... ... ... ... 96
Rorert Steele.
Dies Aegyptiaci ... ... ... ... ... ... 108
C. J. S. Thompson.
Note on Some Old Pewter Bowls in the Royal Mineral Water
Hospital at Bath... ... ... ... ... ... 122
Charles Singer.
The Lorica of Gildas the Briton (? 547). A Magico-medical Text
containing an Anatomical Vocabulary ... ... ... 124
Sir Marc Armand Buffer, C.M.G. (The late).
On the Physical Effects of Consanguineous Marriages in the Royal
Families of Ancient Egypt ... ... ... ... 145
Title, Contents and Index.
Section of tbe IMetors of fl>et>icine.
President—Sir D’Arcy Power, K.B.E., F.R.C.S.
PRESIDENT’S ADDRESS. 1
By Sir D’Abcy Power, K.B.E., F.R.C.S.Eng., F.S.A.
My first duty on taking the President’s Chair this afternoon is to
thank you for placing me in it. I do so very heartily, not only for the
honour you have conferred upon me personally, but because it shows
that the surgical side of our profession has at last been thought worthy
to share in the more humane and polite studies which have long been
associated with medicine. To a large extent this apparent isolation
has been our own fault. Literary merit has never been very marked
amongst surgeons, and without a good general education there can be
very little interest in history. A few highly cultivated surgeons, like
Cheselden, Brodie and the Pagets, have existed in each generation, but
with a few exceptions surgeons have chosen to devote their talents
rather to practical and scientific than to historical subjects. Mr.
Pettigrew and Sir James Y. Simpson, who were endowed with literary
attainments of no mean order, chose to direct their energies to the
antiquarian rather than to the historical aspect of medicine. But,
having once made a beginning, I look forward to the time when in this
Section, as in many medical societies, a surgeon will take his turn as
President in rotation with a physician and a general practitioner.
The training of a surgeon leads him to face facts and apply radical
measures. I may be excused, therefore, if I offer a few suggestions
tending to make this Section even more useful and certainly no less
interesting than it has been hitherto.
1 At a meeting of the Section, held October 16, 1918.
2
24
Power : President's Address
Looking back upon the work which has been done in the six
years of its existence I find that the communications have ranged over
a wide field. Some of the papers have dealt with biography, others
with art; some have treated of anthropology, others of superstitions.
All are valuable, and so much is to be learnt from them incidentally
about the progress of medicine, that they will no doubt serve as
sources from which future historians will draw many of their facts.
But, if I may say so without giving offence or belittling what has already
been done, it seSms to me that we have been too discursive and have
dissipated our energies until we have hardly fulfilled the object for
which this Section was established—viz., to promote the study of
the history of medicine—for we have made no attempt to write
history itself. We are, in fact, very much in the condition of the
Royal Society during the early years of its existence when it took
all knowledge as its province.
Destructive criticism is useless and often harmful because it is
depressing and leads to no good results. I would therefore venture
to offer a few suggestions as to what might be done in the future
to advance the history of our art and to make this Section permanently
serviceable. In surgery we know very little of the times when the
various surgical diseases became prominent in the text-books, nor when
the different operations for their relief were devised, modified, crystallized
in their present form or abandoned. Something, indeed, has been done
in connexion with the history of the modern operation of cutting for
stone, of ovariotomy and of anaesthesia, whilst Mr. Alban Doran has
patiently collected materials for a history of surgical instruments. A
very little investigation shows that few operations were devised de novo,
but most have passed through a gradual and interesting process of
evolution. When did surgery cease to be an itinerant profession ? For
many years a surgeon lived in the patient’s house after an operation and
passed from one house to another, seemingly without a fixed home ;
whilst the baser sort operated one day and fled the next, always receiving
the fee in advance. Of both these conditions vestigia still linger in
the profession.
It would, I think, make the work of this Section more useful if
in future years we could turn to our Proceedings and find a readable
account of the history of the operation for the cure of fistulas, of
piles, of urethral stricture or even of the larger subject of amputa¬
tions, for we are only now beginning to learn from pathology why
our forefathers in septic days preferred the circular flush amputation
Section of the History of Medicine
25
to the flap methods which seem at first sight to be so much more
satisfactory. Equally on the speculative side of surgery we know very
little of the theories which have been advanced at different times to
account for the common surgical conditions. Such theories were not
necessarily based upon the tenets of the particular sect in vogue and
each contained some germ of truth which might be serviceably
extracted.
In medicine, too, there still remains much to be done. We need
that interesting paper on the medical uses of human blood which
was promised by Dr. Frank Payne, but was never even begun by
him. When was the tongue first employed as an aid to diagnosis,
and who first said “Put out your tongue?” We require an historical
paper on the various phases in the treatment of phthisis and of
empyema; upon the value attached by physicians at different times
to the pulse in disease, and of the means adopted for its measurement;
of the origin, rationale and decline of bloodletting and, perhaps, no less
valuable a disentangling of the various conditions grouped together by
the older writers under the terms “ miserere ” and “ ileus.” The
materials for all these communications lie ready to our hand and are
available for anyone who chooses to employ himself upon them.
Midwifery abounds in subjects requiring historical treatment. The
whole story has still to be told of the remarkable idea that the uterus
was an animal with independent movement, so that it was possible to
have “ a rising of the mother ” or a “ suffocation of the womb.” The
views held at different times as to the actual cause of labour and why
the foetus assumes particular positions in the womb might meet with
scientific treatment at our hands. And in this connexion we ought to
be able to discover the source of those birth figures which run through
the mediaeval manuscripts until they appear at last as copper-plate
illustrations in “ The Woman’s Boke ” of Eucharius Bhodion. The
figures resemble each other so closely generation after generation that
they must have a common origin.
There is ample room for a paper on the views held at different times
upon the determination of sex and the means used to influence it, and
for another upon the conduct of labour and the use of birth chairs.
What was thought of the placenta ? What treatment did it receive,
and on what grounds ? Why is the placenta always drawn so large
and the foetus so infinitesimally small in the older treatises on mid¬
wifery? When did the caul get its reputation as a specific against
drowning, and why? What were the social conditions during the
26
Power : President's Address
sixteenth century which led to so great an interest being taken in the
physical signs of virginity as is shown by the treatises of Pinaeus and
Melchior Sebizius? Is there any literature about puerperal fever
before the time of Semmelweis, or was it considered to be such an
integral part of the primeval curse as not to be worthy of consideration?
Particular branches of medicine and surgery also require detailed
historical consideration. It is generally stated that the treatment of
rupture and ophthalmic surgery were in the hands of specialists by
whom the public were badly served. This may have been true in part,
but it is certain that the regular surgeons in England gave directions
for the treatment of both conditions in their books and showed no
disinclination to take under their care patients who suffered from them.
As regards physiology much remains to be done, for we are still in
need of a succinct account of the Oxford physiological school in the
seventeenth century—meteoric in its course and producing such men as
Lower and Mayow—which was quite as wonderful as the rise of a
similar school at Cambridge in pur own time.
Anatomy is still an almost unworked mine for the medical historian.
In every large library there are numerous treatises in manuscript which
should be examined with greater care than they have yet received, and
we know but little of the methods of teaching by plates and models
when dissection was hedged round with difficulties.
The subject of medical education itself will repay further study ./
Its history in this country usually begins with the foundation of the
Royal College of Physicians on the medical side, and with the Union
of the Fraternity of Surgeons with the Company of Barbers on the
surgical side. More than a hundred years before this union an elaborate
attempt was made to establish what is now called “ The Conjoint
Scheme,” by requiring a knowledge of medicine and surgery from
everyone who practised. We should like to know more of the project.
With whom did it originate ? How long did it last ? What wrecked
it ? Then, too, there is the long period of the Wars of the Roses.
How was education carried on during this neglected historical period,
for carried on it must have been as is shown by the completeness of the
methods found in use when the light of history shines upon them again
in 1540.
All this I venture to think is unknown and gives promise of work
for years to come. But the papers should be presented properly
documented not only by references but by actual quotations, partly to
enable the reader to draw his own conclusions, which may differ from
Section of the History of Medicine
‘21
those of the writer; chiefly because the passages from authors—especially
if they have not previously been printed—can only be isolated with an
infinity of trouble by those who have access to first-class libraries. If
the passages are quoted in full no one need spend time afterwards in
verifying them, whereas a mere reference soon becomes incorrect if it
is copied from book to book.
I would stipulate further, that the papers should not be of the
dry-as-dust variety as would be the case if they consisted entirely of
extracts. The author should not be afraid of working up his material
into a continuous story, and he can easily make it interesting by the
introduction of such personal details as may present themselves. All
the older writers interpolate incidental remarks which lend a human
and often a humorous aspect to the matters with which they deal.
There is one other matter to which I should like to draw attention
in order to obtain information. The Section contains many members
who are competent bibliographers and bibliophilists. Do we know or
does anyone know the riches of our Library ? What incunabula do we
possess ? What are our desiderata ? There is a good subject catalogue
in which the books are arranged with their date of publication, and
some of the more interesting books are exhibited in show-cases in the
Library. I venture to think that more than this could be done. Books
printed in the fifteenth, sixteenth and first half of the seventeenth
century might be singled out and placed in cases or perhaps in a room
by themselves. It is probable that they would not often be required,
but we should then know in what way we were deficient and Fellows of
the Society might be stimulated to fill up gaps by the presentation of
volumes which were obviously wanting. Something has already been
done in this direction, but when printing is cheaper and paper is more
plentiful a catalogue of books in our possession bearing dates, say 1480
to 1650, would probably well repay the cost of its issue. With these
few words, gentlemen, I make an end, for I know that we have many
satisfying Wednesday afternoons before us, thanks to the indefatigable
industry of our honorary secretaries who have provided a full programme
for the session.
Section of tbe Irtotors of flDebidne.
President—Sir D’Arcy Power, K.B.E., F.R.C.S.
The Evidences of Disease in Shakespeare’s Handwriting . 1
By the late Ralph Winnington Leftwich, M.D.
The subject of Shakespeare’s handwriting has long been of interest
to me. When I was getting up the Shakespeare Memorial in Southwark
Cathedral, the Chapter complained to me that they were much worried
by the Baconians. I undertook to give them reasons for the faith that
was in them, and did so in a pamphlet written in answer to that of Sir
E. Durning Lawrence. In this I brought in the subject of evidences
from the handwriting. . Since then I have spoken at Shakespeare
societies in favour of the view to be propounded in this paper, and I
made it the subject of my address as chairman of the Fifty-ninth
Annual Shakespeare Dinner. I was stimulated to further effort by
reading the remarks made by our honoured president in seconding
the vote of thanks to Sir StClair Thomson for his address on
“ Shakespeare and Medicine,” at the Medical Society. Colonel D’Arcy
Power made some very shrewd remarks on that occasion, and appealed
to physicians to decide the question of the influence of disease in the
handwriting of Shakespeare. To do this successfully, however, it is
not enough to be a physician, one must also be a Shakespearean. As
vice-president of three Shakespearean societies, I seem to have been
thought worthy of this title; while as the author of a work on
“ Symptoms ” which has arrived at its sixth edition, I may perhaps
claim, without immodesty, to be familiar with the symptomatic
evidence necessary.
At a meeting of the Section, held March 19, 1919.
Section of the History of Medicine
29
We have in all six signatures of Shakespeare : that on the Mountjoy
deed, discovered by Professor Wallace and preserved at the Record
Office, dates from 161‘2 ; that on the Blackfriars purchase deed at the
Guildhall, and one of a mortgage deed of the same property, at the
British Museum, date from 1613 ; while three on the will at Somerset
House date from 1616. Consequently, they are all specimens of his
writing late in life. Besides these, the name occurs in two books : an
Ovid’s “Metamorphoses” (150*2) and a Florio’s Translation of
Montaigne” (1603) (see Note 1). These, if genuine, might have been
written earlier, and this would explain why they show no sign of the
disease with which I shall deal later. The best authorities, however,
do not believe that they are genuine. In any case, as there is a doubt
about them, I shall leave them out of consideration. Now, although
these signatures have been closely examined and scrutinized by
palaeographists and others, they have never been systematically examined
and analysed by any one with a medical training; and nothing but
speculative suggestions have been made with regard to their association
with disease.
In Shakespeare’s time, two styles of writing prevailed, the Gothic
{see Note 2) and the Italian. He had been taught the Gothic, which
bears a close resemblance to German cursive script. It was gradually
ousted by the Italian for the good reasons that this was easier both to
read and to write. The Germans are very much behind the times in
this respect for they still cling largely to the old style both in print
and writing characters, and pay for it by the almost universal use of
spectacles.
Before going farther I must mention a peculiarity, which has been
no doubt noticed by all of you, the abbreviation of the second syllable
of the surname as shown in the signatures of 1612 and 1613. The
practice seems extraordinary to those who are unfamiliar with the
subject; but, as a matter of fact, it was quite common, at that time,
with persons whose names ended in “ per ” and the like, such as Couper,
Draper, Roper, and even Shepherd. If you doubt this examine the
writing of John Shakespeare’s name by the second law clerk and you
will see that he wrote it in the same way. The name stops short at the
“ p,” and this may have a mark or be crossed to indicate abbreviation.
Some years ago I devised an International Alphabet of equivalent
sounds and I then learnt that, in phonetics, the vowel preceding an “r” in
an unaccented syllable is known as the “ indeterminate vowel ” because
the sound is much the same whatever vowel is used. Thus, in the
30
Leftwich : Shakespeare's Handwriting
following words we have all the vowels, each preceding an r: attar,
otter, nadir, horror, murmur, zephyr. For this reason I feel sure that
the second syllable in Shakespeare was unaccented, and that the name
was pronounced, at any rate by his fellow townsmen, as Shaxper, as
indeed it was written by the second law clerk. But this by the way.
Next, I will draw your attention to points which have been
commented upon by lay palseographists, and especially by Sir E.
Maunde Thompson, formerly Keeper of the MSS., and later Principal
Librarian of the British Museum. In an article in “ Shakespeare’s
England,” to which my attention was drawn late in my investi¬
gation, he says that the curve of the capital S in the full will-
signature is “ angular.” Dr. Martin, a well-known Shakespearean, who
is by profession a barrister, is more explicit and describes the letter as
being made up of eight straight lines. Other points noted by Sir E.
Maunde Thompson are (2) that the capital S of the signature on the
second page of the will is made in two sectional strokes with a gap
between them. (3) That the first “ a” in the 1612 autograph is open
at the top : to ordinary eyes, however, the fact is hidden by the
unwieldy loop of the “ h ” preceding it, and I think the point is
still more evident in the second “ a ” of the full will-signature. (4)
Thompson describes the last syllable of the surname on the third
page of the will as “ almost a breakdown.” (5) That the “ s ” in the
1612 signature has been omitted.
In the absence of a knowledge of medicine, on the part of these
observers, no particular significance was attached to the peculiarities;
but when I come to show you, as I shall do, that they are recognized
signs of a certain diseased condition, such evidence, unbiased as it was by
technical knowledge, becomes of much increased value. Now it would
lighten my task very much if we possessed a specimen of the writing
before disease had set in (see Note 3). Unfortunately this is not the
case; but, in compensation, we have two testimonies to its excellence.
In the introduction to the first folio, the editors, Hemyng and Condell,
say: “ His mind and hand went together, and what he thought he
uttered with that easiness that we have scarce received from him a blot
upon his papers”—(i.e., even a blot). Five years earlier, Ben Jonson,
in conversation with Drummond of Hawthornden, said : “ I remember
that the players have often mentioned it as an honour to Shakespeare
that in his writing (whatsoever he penned) he never blotted out a line.”
Now, a bad writer makes both blots and corrections; but we are not
dependent upon the testimony of others for we have under our own
Section of the History of Medicine
31
eyes a proof that he was able to write at least a word or two well.
Look at the “ By me, William ” of the full will-signature. It cannot
be denied that this is exceedingly well written, and I have no doubt
that it represents the standard of writing to which the editors alluded.
Further, his large output shows that he was a rapid writer, and the
combination of speed with clearness accentuates his skill in penmanship.
Lastly, whereas, up to 1610 he wrote hundreds of pages of MS. with
scarcely a blot, in those before us he made, as you can see, four blots in
writing fourteen words (see Note 4).
Now, examine the six signatures before you and tell me : Do they
in general confirm the favourable testimony of the actors ? It must be
confessed that they do not; and the verdict must be that had Shake¬
speare supplied them with their parts written in the general style
of the autographs, no such appreciation would have been shown.
Moreover, every signature appears so laboured and consequently so
slowly executed that it is impossible to believe that the writer of
them could have penned with his own hand the great volume of
work of which he was the author if his earlier writing had been no
better.
In considering the question of morbid influence we are handicapped
by two further difficulties. First, that Shakespeare wrote in a script
that is strange to us, and I have therefore furnished you with two
specimens of the surname as written by law clerks to serve as a
standard for comparison. Secondly, that we have to base our conclu¬
sions upon three capital and eleven small letters. For this drawback,
however, we have the very great compensation that the writing
extends over a period of no less than four years. Consequently, it
represents different stages of the malady and yields us many more
symptoms than any letter of a single date however long. The
signature on the first page of the will is so damaged as to be nearly
useless to us, and not much importance can be attached to the copy of
it made by George Steevens in 1778, since it is impossible that the first
stroke of the W could ever have been shorter, or the other strokes finer,
than they now are. As far as it goes, however, its characters confirm
the conclusion to which I shall come later. The specimen here
represented has been magnified. There can be no doubt that the
full will-signature on the third page was signed first, as Sir Frederick
Madden and Sir Maunde Thompson agree and as indeed is the case even
now with testators.
The idea that the signatures show signs of disease is very old, and
32
Leftwich: Shakespeare's Handioriting
some have gone so far as to evolve or concur in a pathetic little account
of the scene that took place when the will was signed. It had already
been drawn up two months when the poet is said to have developed
alarming symptoms; witnesses were hurriedly summoned, and in an
almost dying condition he just managed to append these trembling
signatures. Now, there is not a shadow of foundation for all this
(see Note 5). Shakespeare survived the signing a whole month; two
witnesses would have sufficed, yet five attended ; no solicitor’s presence
was necessary, yet to bring Francis Collins there, the messenger would
have had to travel sixteen miles! Lastly the other signatures would
be still unexplained.
Some have suggested that the defects in his writing may have been
due to locomotor ataxy, or one or other form of chronic paralysis ; but
the preamble to Shakespeare’s will negatives constitutional illness.
The will begins thus : “ In the name of God, amen! I, William Shake¬
speare, of Stratford-on-Avon, gentleman, in perfect health and memorie,
God be praised.” This is a statement which, if not true would be
blasphemous (see Note 6). But we are not dependent upon its truth, for
the only account of his death, which took place a month after signing,
that of the Rev. John Ward, a later vicar of Stratford, is that it was
due to a fever—i.e., a disease of short duration. Further, we can
exclude as causes of bad writing such conditions as defective education,
disablement of the hand through rheumatism or injury, as well as
such diseases as are characterized by rhythmic tremor by the fact that
the writing, as I observed before, is not uniformly bad or tremulous (see
the William at the end of the will). Many diseases also can be excluded
by considerations of age, duration, and association with impaired mental
capacity. As regards the last, there is no sign of it during the years
that remained to him. Our knowledge of him at that period is
very limited, but we know that in 1612 he was a competent
witness, that in 1613 he received from the Earl of Rutland a good
fee for designing (but not drawing) a symbolic jiournament-badge
or “ impresa ” and also bought and mortgaged house property ; that in
1614 the Town Council of Stratford directed their clerk to ask Shake¬
speare to support their action in the matter of the Welcombe enclosures;
that in 1615 he not only associated himself with some neighbours in
an action to protect their joint rights in the Blackfriars freehold, but
that he was specially consulted in London by the solicitor to the
Stratford Corporation. Finally, we know that in 1616 he was of
testamentary capacity. Moreover, there is no evidence of gradual
Section of the History of Medicine 33
mental deterioration in his works. “ The Tempest ” was produced
in November, 1611, about six months before the date of the earliest
signature, and far from showing any falling off this play is perhaps
unsurpassed in the realm of pure imagination by any other. It is not
known when he last acted.
Now, is there any morbid condition in which the handwriting
exhibits the abnormalities shown in the Shakespeare autographs
without being barred by any collateral considerations? There is one,
and only one. It is that known as scrivener’s palsy or writer’s cramp.
I have seen a considerable number of cases in my time, but, since
the introduction of the typewriter, the condition has become rarer.
Fortunately, we have very close and accurate descriptions of the
handwriting of the victims by such authorities as Sir Charles Bell,
Sir William Gowers, and Drs. Robins, Poore, Head, Oppenheim,
Smith-Jelliffe, Campbell Thomson, Meige, Erb, Romberg, Wilfrid
Harris, Aldren Turner, Bury and E. Church, and we cin thus draw
up a perfectly clear picture of the changes that take place and seek
for their presence in the Shakespeare signatures. I have consulted
many other writers on the subject, but some deal only with treatment
and others describe the writing in general terms only.
Gowers divided writer’s cramp into four varieties : spastic, tremulous,
neuralgic and paralytic ; but it is generally agreed that the classification
involves much overlapping. Shakespeare suffered essentially from the
spastic form. In this, the pen is not completely under the control of
the writer. Against his will, it makes little jerks, unduly long strokes
or unintended marks; and though a good beginning may perhaps be
made, the hand very soon tires and refuses to write at all. Sir William
Gowers says that the general effect is that of a letter written in a
jolting carriage, and this, you will agree, is precisely what Shakespeare’s
writing suggests.
The recognized signs of writer’s cramp are very numerous and
I will now give them in detail and point out where they can be seen in
the signatures. No single writer of the fifteen named gives all the
signs; but, in order to make my proof exhaustive, all those mentioned
by them collectively have been included, for, favoured by the long
period over which Shakespeare’s writing extends, all stages are
represented. It is no answer to the conclusion to which I shall come,
to point to the presence of one or two of the symptoms in other
diseases, for a diagnosis is made from the ensemble or totality of
the signs, and of course we never expect to get them all. We
34 Leftwich : Shakespeare's Handwriting
will take signs derived from predisposing causes in the following
order:—
(1) Age and sex. Smith-Jelliffe scheduled 194 cases of writer’s
cramp, and of these forty-five, or about one-fourth, were between 40
and 50; Gowers, in 151 cases, found thirty-two between these ages.
Now Shakespeare was 46 or 47 at the onset. The preponderating sex
is of course male, even apart from the occupation fallacy.
(2) Writer’s cramp is commonest in those who have written
habitually in a cramped hand. In writing Gothic characters the hand
is necessarily cramped.
(3) It affects those who have written voluminously. Shakespeare
did. The first folio alone contains 1,000 double-column pages and, in
addition, there were the sonnets, the poems, and the actors’ parts.
(4) The condition may persist for many years. Poore mentions a
case of ten years’ duration and Gowers one of twelve. In Shakespeare’s
case, it is stilhpresent at the end of four.
(5) The general bodily and mental health is unaffected. This has
been already dealt with.
We will next take the signs of writer’s cramp as exhibited in the
specimens of the handwriting before us. And, here, let me add that
even in the living subject there are few other objective signs.
(6) The writing is sprawled across the paper (Head, Gowers).
This is very marked in the 1612 and 1616 a and b signatures.
(7) The letters are coarsened (Robins, Erb, Campbell Thomson).
The feature is evident in the 1612 and 1616 a letters as well as in the
initial letters of 1613 a.
(8) The downstrokes are thickened (Gowers, Oppenheim, Thomson).
Notice the W and the two “ 11’s ” of the 1612 autograph.
The next four signs are very important because they were pointed
out by lay palaeographists :—
(9) The upper part of a or u may be open (Robins, Head, Thomson).
We have no “o,” but an uncompleted “a,” according to Maunde
Thompson, occurs in the 1612 autograph, following what looks like
a great O. This may not be clear to inexpert eyes, but the open “a’
in the surname of the full will-signature is clear enough ( see Note 7).
(10) A curve may be made in two strokes instead of one (Poore).
This point is clearly shown in the capital S of the second will-signature,
where it consists, according to Maunde Thompson, of two sectional
strokes with a gap between them. The initial S of the 1613 b signature
is also suspicious.
Section of the History of Medicine 35
(11) A curve may be made by a succession of short strokes (Robins,
Poore, Gowers, Church). Maunde Thompson says that in trying “ to
accomplish the outer curve ” (of the capital S), “he failed, the curve
becoming angular.” William Martin, as I have said, is much more
explicit. In a lecture given before the Shakespeare Reading Society, he
counted in the capital S eight distinct little strokes, which, combined,
formed the curve. Now, how does this compare with a medical
description of writer’s cramp ? Thus: the American neurologist,
Dr. Robins, with no thought of Shakespeare present to his mind,
says that he counted thirteen of these little strokes in a capital N
and fourteen in a capital T. The coincidence is remarkable. The
peculiarity is not however confined to this instance for it can also be
recognized more or less throughout.
(12) The letters at the end of a word may get more and more
slurred till they become illegible (Head, Romberg, Campbell Thomson).
Gowers and others describe this as the “ sign of the tired hand.” The
following is the description given by Sir Maunde Thompson: “ By me
William,” he says, “ is good ; but the hand then begins to fail, the first
three letters of the surname are still clearly legible, but are somewhat
deformed ; then ensues almost a breakdown, an imperfect k and a
long s ending in a tremulous finial.” This feature, which is perhaps
the most striking characteristic of all the signs of writer’s cramp and is
all but pathognomonic, is especially evident in the full will-signature.
(13) The spasm drives the nib through the paper (Gowers, Wilfred
Harris, Meige, Bury, Smith-Jelliffe and Aldren Turner). Now, a quill
would not succeed in penetrating parchment and the result would be a
blotted letter or a splutter. This sign is plainly visible in the last letter
but one of the 1612 signature, in the W of 1613 a, and in the bottom
loop of the “ h ” in the full will-signature.
(14) A stroke may be too high or too low (Gowers, Erb). The
point is not of much importance, especially in this Script; but it is too
low in the first I of 1616 a, both here and in the drawing made by
George Steevens in 1778 when it was less damaged; while it is too
high in what looks like a colossal O in the 1612 autograph, but which
is really the upper loop of a Gothic “ h.”
(15) An unintentional mark may be made (Gowers, Wilfred Harris,
Erb). There is one below the S of the 1612 signature. It is not a
blot, for if you examine it closely, you will see that it is semicircular.
The dot within the W is not a displaced dot of the “i ” as some have
thought, for it is found where an “ a ” follows the W.
36
Leftwich : Shakespeare's Handwriting
(16) The effects are not uniform ; a word or two may occasionally
be fairly well written and the same letter may be written sometimes
well, sometimes ill (Gowers, Erb, Oppenheim, Campbell Thomson).
This feature excludes a large number of conditions in which the hand¬
writing is defective. It is seen in the difference between the William
and the Shakespeare in the third page signature and in that between
the two “ ll’s ” in the 1612 and the first 1613 signatures.
(17) A letter is often unlinked to the next (Meige, Campbell
Thomson, Oppenheim). This feature is not of much importance.
I do not mind confessing that I am sometimes guilty myself; but
unlinked letters can be seen in the second 1613 rnd the second and
third page will-signatures, while, that Gothic script is consistent with
joined letters is evident in the writing of the first law clerk.
(18) Tremor (every writer mentions this). Tremor is more or less
evident everywhere; but is best seen in the second 1613 signature.
It is of the spastic variety, for passive tremor is practically absent and
its absence excludes a large number of diseases.
(19) Omitted letters. None of the medical writers I have referred
to mentions this point as a feature of writer’s cramp; but considering
the labour of writing in these cases, it is only what one might expect.
Certainly Shakespeare sometimes omitted letters; for the small “ s,”
which in this script is represented by a long straight or curved line,
as in the two 1613 autographs, is absent in that of 1612 ( see Note 8).
Some have thought that it is also absent in the full will-signature;
but this is not the case, though the shaky “ s ” and the “ k ” are mixed
up together.
(20) The pen is dropped (Wilfred Harris and many others). This
may or may not have happened, but at any rate the blur over the “ 1 ”
in the first page will-signature is consistent with its occurrence.
Few people are familiar with the Gothic script of the period and to
meet the objection that other Elizabethan writers may show the same
caligraphic peculiarities, I have examined the writing of Ben Jonson,
Marston, Peele, Bacon, Daniell, Donne, Massinger, Stowe, and many
others, and I am certain that none of them suffered from writer’s
cramp. Moreover, you have before you, as evidenced by the writing of
the law clerks, the proof that the vagaries to which I have alluded are
absent. Nor is there any evidence of it in the writing of the Warwick
solicitor who drew up the will, Francis Collins. The will contains
many interlinear corrections and on my visit to Somerset House,
I noted that some of these, as well as the signatures, were in paler ink
Section of the History of Medicine
37
than that in which the body of the will was written. On waking one
morning, perhaps as a consequence of unconscious cerebration, the
brilliant idea flashed across my mind : Is it possible that some of these
corrections were made by Shakespeare himself during the two months
that elapsed between the drawing up and the signing of the will, when
it was perhaps left in his posession ? In journalistic parlance, what a
gigantic scoop would this be for me if it proved true! I hastened to
pay another visit to Somerset House; but in the interests of Truth
I had to confess to myself that the corrections were not consistent with
a diagnosis of writer’s cramp and therefore were not written by the
testator himself. Moreover, the ink of the most important alteration,
that of the date, is quite black. Perhaps the sand, which at that period
took the place of blotting paper, was used more promptly where the
writing is brownish.
Thus, every one of the nineteen signs collected by me is present and
I submit that a diagnosis of writer’s cramp is unimpeachable. Every
condition precedent, whether of age, of occupation, of chronicity, or of
freedom from bodily or mental disease is fulfilled in the history of the
case and every objective sign in the handwriting has been demonstrated.
It should be a source of satisfaction to us that any misgivings as to
Shakespeare’s illiteracy have been set at rest by these investigations,
for Baconians and others have been hard to argue with.
In our days, the victim of this disorder sometimes succeeds in
teaching himself to write with the left hand ; but the rule is that this
soon shares the same fate as the right and it would be frankly impossible
with Gothic script. I may be also asked : Why did he not dictate his
plays ? Well, it is not given to everyone to dictate even a letter with
any facility and many that we receive and that read so well and so
glibly, have had as much editing as a parliamentary speech; and you
may remember that Goldsmith, having engaged an amanuensis for his
“Animated Nature,” found himself mute when he wanted to start
dictating. Apart from that, only a very clumsy and unreliable form of
shorthand was available in Shakespeare’s time. Thus, John Heywood,
complaining of the piracy of his plays, wrote in 1605 :—
“ Some by stenography draw the plot, put it in print, scarce
one word true ! ”
And it is one thing to dictate a letter and quite ariother to dictate
a play; for a play, with its frequent changes of scenes and players,
presents something like a maximum of difficulty. Possibly Shakespeare
38
Leftwich : Shakespeare's Handwriting
tried and failed and incidentally this may be the explanation of the fact
that when the masque portion of “ The Tempest ” was added in 1613,
it was written by another, probably Chapman. Milton’s task, that of
dictating an epic was far easier and he, moreover, had had the advantage
of a secretarial training.
This, then, is the explanation of the mystery. This, the reason that
a healthy man who had devoted himself with the greatest regularity
to playwriting suddenly and finally gave it up at the age of 46,
notwithstanding that his business interests in the theatres continued.
It was nothing less than a tragedy; but he had already given us the
finest works in all literature and we can never be too grateful to him
and never do too much honour to his memory.
BIBLIOGRAPHY.
Bell, Sir Charles. “ Nervous System,” 1830.
Bbistowe. “Medicine,” p. 1115.
Bury. “Diseases of the Nervous System,” 1912.
Church and Peterson. “ Nervous and Mental Diseases,” 1914.
Dana, C. L. “Text-book of Nervous Diseases,” 8th cd., 1916.
Duchenne. “ Selections from his Clinical Works,” Syd. Soc. Trans. , 1883.
Erb. “ Ziemsscn’s Fhicyclopcedia,” xi, 1876.
Gowers. “ Diseases of Nervous System," 2nd ed., 1893, ii.
Harris, Wilfred. “ Medical Encyclopredia,” viii.
Head, H. “ Occupation-Neuroses,” “Allbutt's System of Medicine,” viii, 1910.
Meige, H. “ Crampes fonctionelles et profcssionelles,” TraiU de Med. (Charcot).
Oppeniieim, H. “ Diseases of the Nervous System.”
Poore. “Craft Palsies,” “Allbutt's System of Medicine,” viii, and Med.-Chir. Trans.,
1887, lxx, p. 301.
Power, D’Arcy. Trans. Med. Soc., 1916, xxxix, p. 323.
Robins. “ Writer’s Cramp,” Amer. Journ. Med. Sci., 1885, lxxxix, p. 452.
Romberg. “Nervous Diseases of Man” (Sydenham Society), 1853.
Smith-Jelliffe. “ Osier and McCrae’s System of Medicine.”
Thomson, H. Campbell. “Diseases of Nervous System,” 1915.
Turner, W. Aldren. “Nervous Diseases,” 1910.
Madden, Sir F. “ Observations on an Autograph of Shakespeare.”
Maunde Thompson, Sir E. The chapter on “Handwriting” in Shakespeare's England,
1916, i, pp. 297-309.
Nisbet. “The Insanity of Genius." Edited by B. Hollander, 1912.
Saunders. “Ancient Handwriting,” 1909.
Steevens, George. “Shakespeare's Plays,” 1778.
Thoyts, E. “ ^w to Decipher Old Documents.”
Wright’s “ Coui T andwriting.”
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40
Leftwich : Shakespedre's Handwriting
DISCUSSION.
Tho PRESIDENT : it is a great pleasure to me to hear that a few random
remarks I made at a meeting of the Medical Society has led to the production
of this paper by Dr. Leftwich, of which the Section may well be proud. I
have long wondered why a man of 47 or 48, who had been very successful in
London, should have gone back voluntarily to a small provincial town, obviously
with the intention of ending his days there, unless he had had some premoni¬
tion of illness. In the case of Shakespeare there appeared to be no sufficient
reason. His intellect was certainly unimpaired, and it is clear from the
engagements into which ho had entered that he was not brain-weary. Sitting
there in the church where he is buried, instead of listening to the sermon, as I
should have done, I recalled all the autographs I could remember, and the
varying position of the dot over the i was ever present. When he was fresh
the dot of the i was placed in the terminal curve of the W in William, but as
the writing became more tremulous the dot was placed without certainty.
When I got back to London I looked again at the signatures, and it then
appeared that the bad writing was the result of disease rather than of illiteracy.
I asked my friend Dr. Leonard Guthrie, as a skilled neurologist, with a decided
antiquarian bias, to look into tho matter with a critical eye, but before he
could do so he has been forestalled by Dr. Leftwich, whose paper leaves
nothing to be desired. I hope that amongst those who are present this evening
there may be some who can speak of writer’s cramp from personal knowledge,
not because I wish them ill, but because they can then speak for or against
Dr. Leftwich’s arguments from personal experience.
Dr. F. G. CROOKSHANK : The paper wdiich Dr. Leftwich has just read is one
of great interest and importance to the antiquarian and to the Shakespearian
student alike. With their points of view I have no competency to deal: but
the subject of writer’s cramp itself has interested me much since the days when
I was house physician to the late Dr. V. Vivian Poore: and the interest has
not been diminished by reason of something more than a tendency to the
disability itself, which was first manifested after an examination twenty-five
years ago. Very probably what we call “ writer’s cramp ” is susceptible of
different pathogenic explanations in different cases : but it may be not without
relevance to the question of Shakespeare’s disability (for disability there
undoubtedly was) to recall that, in certain cases at least, the exhaustion is
definitely cortical rather than “ peripheral,” and that writer’s cramp, like other
professional cramps, palsies and spasms, is apt to obtain when there is a greater
measure of conscious cerebration accompanying the carrying out of what, like
writing, may be at other times a more or less automatic act, or series of acts.
It is the concomitance of (1) attention to writing and (2) thought in composi¬
tion that exhausts : moreover, writer’s cramp, like other so-called neuroses,
sometimes manifests itself, almost without precedent warning of overstrain or
Section of the History of Medicine
41
over-exhaustion, in those who are the subject of w 7 orries and anxieties. One
other point: It is a little curious that exhaustion of the cortical writing centres
should so frequently, if not always, first show itself by illegibility of the
signature—almost the most ** automatic ” act of calligraphy. It is usually
said, by the bye, that writer’s cramp was first differentiated as a “ clinical
entity” in the early years of last century: but it might be worth while inquiring
into the frequency of literary allusions to writing disabilities during the
centuries when quill pens only were used. Dr. Leftwich certainly has brought
before us an extremely interesting subject for discussion and thought: and his
paper calls not only for our most grateful thanks but for our quiet attention at
leisure.
Dr. E. HlNGSTON Fox : Remembering how personal experience colours
creative literature, onte would expect to find allusions in Shakespeare’s later
writings to the symptoms or phases of nerve trouble, if he was himself a
sufferer.
Editorial Note.
(1) The “ Ovid ” and “ Florio ” signatures have been recently examined and
pronounced to be forgeries by Sir E. Maunde Thompson in The Library of
July, 1917.
(2) The style of handwriting which is here termed “ Gothic ” was the
English cursive handwriting of Shakespeare’s time, which had developed
from the cursive writing brought into England from the Continent after
the Norman Conquest. It superseded the native Anglo-Saxon script. In
the course of the sixteenth century it was gradually giving place to the
Italian cursive.
(3) Dr. Leftwich was apparently unacquainted with the monograph
“ Shakespeare’s Handwriting ” (Oxford, 1916), by Sir E. Maunde Thompson,
in which Shakespeare’s extant signatures are analysed, and a claim is made
in favour of an addition to the MS. play of “ Sir Thomas More ” in the
British Museum, being in the handwriting of Shakespeare.
(4) The editors of the First Folio, when they stated that “ we have scarce
received from him a blot upon his papers ” evidently referred to the general
freedom from corrections in Shakespeare’s autograph MSS. (in Ben Jonson’s
words “ he never blotted out a line ”) and not to accidental blots.
(5) There can be little doubt that there was urgent cause for prompt
execution of the will, for the rough draft was used for the purpose instead of
waiting for a formal engrossment.
(6) The words “ in perfect health,” &c., were a common formula in wills of
the time ; and, moreover, when the draft was written (two months before the
execution), it may be presumed that Shakespeare was in good health.
42
Leftwich : Shakespeare's Handzvriting
(7) Two forms of the letter a were in use in the English hand : the closed
a like our modern cursive letter, and the open or u-shaped a. The latter is
used in the 1612 signature (it is the open form but not “ uncompleted ”). The
closed a is used in the full will-signature, but the ring of the letter is not
perfect through bad writing—it is not the open or u-shaped letter. What Dr.
Leftwich calls a “ great O ” is caused by the tail of the h being carried up
above the line and forming an arch which links with the u-shaped a.
(8) Shakespeare in most instances made use of the Italian long s (/) in
the middle of his surname. (In the second will-signature he uses the English
long letter.) It was a common practice at the time to mix the Italian and
English styles of letters, but the long s (/) is the only Italian letter found in
Shakespeare’s handwriting.
j
Section of tbe Ibietorp of flDebidne.
President—Mr. D’Arcy Power, F.R.C.S.
The Medical Aspects of Montaigne : A Study of the Journal
which he kept during his Voyage to Italy, with an Account
of his Renal Troubles and Experiences of Mineral Waters . 1
By Leonard Mark, M.D.
“ A pleasant fantazie is this of mine ; many things I would be loath to tell
a particular man, I utter to the whole world. And concerning my most secret
thoughts and inward knowledge, I send my dearest friends to the stationer’s
shop.
“ Executienda damns procardia —Pers. Sat., V. 22.
“ Our very entrailes wee
Lay forth for you to see.”
Essays, Book III, Chap. IX.
Florio's translation.
SYLLABUS.
He starts from liis Home near Bordeaux— The Discovery of the Journal — Across France
to Vitry-le-Fran<?ois and Plombi£res—In Switzerland he stops at Basle and Baden—
Frequency of his Urinary Troubles—Across the Alps into Italy—Rome—Across Italy
to the Shrine of Loretto— First Season at the Baths of La Villa—Excursion in
Tuscany—A Second Season at La Villa—Farewell to Rome—Journey Home by Milan
and the Mont Cenis.
The Voyage of Montaigne.
In the year 1580 the Seigneur Michael de Montaigne had reached
the age of 48. For some time past he had been much troubled about
his health, and had paid visits to several baths in the South of France
At a meeting of the Section, held April 16, 1919.
44 Mark: The Medical Aspects of Montaigne
to get relief from frequent attacks of renal colic and gravel. He now
thought he would like to try some of the other famous baths of Europe.
He also thought this would give him a way of satisfying the craving
he had for more knowledge of other lands, other towns and other
people, and that he might perhaps even realize the dream of his life, to
see Borne, while his health held out, and while he was still at an age to
enjoy life.
The opportunity seemed to have come. The country was just then
at peace. There was a pause in the wars of the League, there was a
truce between the Catholics and the Huguenots. The peace had allowed
Montaigne’s financial position to be more prosperous, and he was ready
to undertake what would be a costly journey, and to carry it out as
comfortably as travelling could be done in the latter days of the
sixteenth century. The dangers of the road would be very great,
and travelling could only be undertaken in company with a large
party, but he soon found some friends ready to join him on the
journey.
He Starts from his Home near Bordeaux
and goes across France, through Switzerland and Italy as far as Borne,
and makes various excursions and visits to baths in Italy, and then
returns direct from Borne after seventeen months’ absence. All the
while he is away he keeps a most copious diary, written in the best of
veins, and if it could be, more full of charm than his famous Essays.
The personal note runs through it all; no detail, whether about his
dealings with mankind or the actions of his own flesh and blood, seems
out of place in his pages.
The Discovery of the Journal.
Montaigne’s journal was first published at Borne ip 1774, one
hundred and eighty-two years after the author’s death. The manu¬
script was found by Monsieur de Prunis, a regular canon of Chancelade,
in Pdrigord, who was scouring the country in search of material for a
history of P6rigord. He visited the ancient Chateau of Montaigne,
then in the possession of one of Montaigne’s descendants, the Comte de
Segur de la Boquette, to search any archives that might be found. He
was shown an old chest which contained papers long since condemned
to oblivion. Amongst them he came across the original manuscript.
Part of the volume is in Montaigne’s own hand, but about one-third of
Section of the History of Medicine
45
it is in the hand of his domestic or secretary, to whom he dictated it
from day to day, and then put in corrections and additions in his own
writing. A few pages of the beginning were missing, and have been
lost unfortunately.
It is no exaggeration to say that every page of this work teems with
interest. Montaigne is so frank about himself, and so ready to give
his reasons for every occurrence, that one is presented with a most
perfect picture of him by his own brush. Yet one cannot resist trying
to read through the lines and see more thoroughly into his character and
habits. One soon learns for instance from the book, that the author is
a gourmand, a big eater, although he spends little time over his meals.
It is only when he reaches Switzerland that he acquires the habit of
sitting a longer time over a repast, both for the greater pleasure of taste
and the more serious calls of his digestion. His food is that of the
gentry of his time, when meat was the essential basis of a meal. Great
quantities of fleshy food were eaten with the help of condiments and
mustard, conducive to a good appetite, but likely to favour the formation
of gravel. Very few vegetables were eaten. But fruits and wines
were taken in abundance, spirits hardly ever except as medicine. At
Padua, where he suffered from an excruciating toothache, he used
brandy as a mouth wash and gargle to get relief. It has to be noted
that Montaigne hardly ever diets himself; even when attacked with
fever, he is only happy if he can have a good meal, by way of getting
some comfort.
To medical men this journal or diary is especially interesting, as
almost from day to day Montaigne mentions the state of his health,
mixed up with the other copious details of his travels. This-he does to
such an extent that it has been said of him that during his journey
abroad he spent more time in scrutinizing the contents of his chamber
utensil than in going into raptures, like other travellers, over the
beauties of the scenery and the interests of the towns which he
visited.
The book contains a series of observations of his physical troubles,
written with all the preciseness we generally find in a hypochondriac,
but the interest generally lacking in such accounts is here redeemed
owing to its being compiled by one of the most keen and subtle analysts
that the world has ever known. It is easy to see all through what he
writes that Montaigne has a great liking for medicine, but a loathing
for those whose business it is to practise it. A singular fortune seems
to have been his. Here was a man who spent a lifetime in finding
46
Mark: The Medical Aspects of Montaigne
fault with doctors, speaking evil of them, yet one may say that he has
been more appreciated by the doctors than by any other class of readers.
None know him better or appreciate his writings to the same extent.
Montaigne’s company was made up of some young men who were
highly connected, who wanted to see something of the world, and go on
what was then “ the grand tour.” His youngest brother and his brother-
in-law were of the party, so that, including Montaigne’s confidential
valet or secretary (to whom he used to dictate his observations), there
were six horsemen. They had with them five or six servants, who
followed on foot or went ahead, as the case might be, and were in charge
of the mules carrying the luggage. They went long distances each
day at a walking pace, so their progress must have been rather slow.
One can but be sorry that Montaigne had not a more interesting set of
fellow travellers. They appear to have had their time taken up with
fencing and the pleasures of life, to have shown a marked dislike for
books or learning of any sort, and to have been in a great hurry to push
on to Rome, where they wanted to enjoy its fascinations according to
their own tastes.
Across France to Vitry-le-Francois and Plombieres.
Starting from the neighbourhood of Bordeaux in the beginning of
September, 1580, the travellers made their way towards Germany by
Plombieres, the first baths which Montaigne wished to see. After
passing Chalons they reached Vitry-le-Fran§ois, and here our
inquisitive traveller started in earnest his discourses upon what he
sees and hears. One of his observations, that of the maid who changed
her sex, still bears repeating, although so often quoted, and one
cannot do better than give you a translation of Montaigne’s own
words:—
The story is that of a man still living called Germain, of low condition,
without any trade or office, who was a girl up to the age of twenty-two
years, seen and known by all the inhabitants of the town, noticed on account
of her having a little more hair on her chin than other girls; known for this
as the bearded Marie. One day when making an effort to jump she produced
male organs, and Cardinal Lenoncourt, then Bishop of Chalons, gave this
person the name of Germain. He has not however been married, he has a
big and very thick beard. There is still in this town a song in vogue amongst
the young girls, who are advised not to take long strides, for fear of becoming
males like Marie Germain. They say that Ambroise Par6 has put this fact
in his book on Chirurgery, as it is quite certain and was also certified to
M. de Montaigne by all the most important officers of the town.”
47
Section of the History of Medicine
The baths of Plombieres are the first important ones that he visits,
and he spends eleven days there, takes the waters quite to his own
idea or liking without consulting any doctor. The custom here is to
take two or three baths each day and have meals brought to the
baths. The waters are not much taken by the mouth, and then it
should only be after a purge. He, however, takes the waters fasting,
and gets through as much as nine large glasses a day. He prefers the
Bath of La Heine, where the waters taste of liquorice. He only takes a
bath every other day, lasting one hour. After the bath he goes in for
gentle perspiration. On that day he goes to bed supperless. The only
effect of the treatment, according to him, was that he made more urine,
as the appetite and digestion were good, and he slept well; but on the
second and third days he passed two small calculi, and on the sixth day
he had an attack of colic lasting four hours. No doubt, he says, a
calculus had passed the ureter and had stopped in the bladder for his
further trouble. He adds a copy of the rules prescribed by the Bailiff
of the Vosges for the conduct of the baths.
(Montaigne's Journal , p. 57.)
“ M. de Montaigne accosted in the said church after mass M. Maldonat, a
Jesuit, whose name is famous on account of his erudition in theology and
philosophy, and they talked together during and after dinner at M. Montaigne’s
lodging where the said Maldonat came to see him. Amongst other reasons,
because he came from the baths of Spa which are at Liege. He informed him
that the waters were extremely cold and that the colder they could be taken,
the better. They are so cold that some who drink them shiver and feel horror;
but soon after a great heat is felt in the stomach. He took for his part a
hundred ounces; for there are provided glasses which hold the measure
anyone wishes for. The waters are drunk not only when fasting, but also
after a meal. The action of the waters which he described is similar to those
of Gascony. As to himself, he said he had observed what strength they had
for harm which they had not done him, having drunk them several times while
sweating and flushed. He saw by experience that frogs and other small
animals thrown into it, die at once; and said that a handkerchief placed over
a glass of the said water becomes yellow. They are drunk for fifteen days or
three weeks at least. It is a place where accommodation and lodging are very
good, and suitable for anyone suffering from obstruction and gravel. All
the same neither M. de Nevers nor he himself had become any more healthy
by their use.”
[Montaigne s Journal , p. 62.)
“ Mauv^se, four leagues. A small village where M. de Montaigne had to
stop on account of his colic, which was also the cause of his giving up the plan
48
Mark: The Medical Aspects of Montaigne
which he had made of seeing Toul, Metz, Nancy, Joinville, and St. Disier,
which are towns scattered along the route, so as to reach the baths of
Plombteres in all haste.”
(Montaigne's Journal , p. 66 ct seq.)
“ Plombieres .—We arrived Friday, 16th September, 1580. The place is
situated on the frontier of Lorraine and Germany in a depression between
several high and jagged hills, which shut it in on all sides. At the bottom of
this valley are several springs which are naturally both cold and hot; the hot
water has neither smell nor taste, and is so hot that we can just bear to drink
it, so that M. de Montaigne was obliged to shake it from one glass to another.
The waters of only two of the springs are drunk. The one which is turned
away from the east and which supplies what is called the queen’s bath, leaves
in the mouth a sort of sweet taste like liquorice and nothing worse, unless
one observes very attentively when it seemed to M. de Montaigne that it
returned I do not know what taste of iron. The other one which shoots
out of the foot of the hill opposite, which M. de Montaigne only drank on one
day, is more bitter and one detects a taste of alum in it.
“ The custom of the country is only to use the waters for bathing and to
bathe two or three times a day. Some take their meals at the bath, where
they generally get themselves blistered and scarified, and only use them after
being purged. If they do drink, it is one or two glasses in the bath. They
considered strange the way in which M. de Montaigne, without taking any
medicine beforehand would drink nine glasses, which came to about one pot,
every morning at seven o’clock ; dined at midday ; and the days when he
bathed, which was on alternate days, about four o’clock, only stopping in
the bath about one hour. And that day he was quite content to go without
supper.
“ We saw men who had been cured of ulcers and other eruptions of the body.
The custom is to spend at least a month there. They specially praise the
spring season in May. The baths are little used after the month of August, on
account of the coldness of the climate; but we still found company there,
owing to the dryness and the heat having been greater and more prolonged
than usual.
“ This bath was once frequented by the Germans only ; but for some years
people from Franche-Cont6 and some Frenchmen come in great crowds. There
are several baths, but there is a big and principal one, oval in shape and built
in an ancient style. It is thirty-five paces long and fifteen in width. The hot
water rises below from several springs, and from above cold water is poured
to suit the bath to the wish of the bathers. Places are distributed divided by
suspended bars, like in our stables, and planks are thrown over them to keep
off the sun and the rain. There are all round the baths three or four stone
steps like in a theatre, where the bathers can sit or rest themselves. A
singular amount of modesty is observed, and it is indecent for the men to be
Section of the History of Medicine
49
otherwise than quite naked, except with a small linen napkin, and for the
women except with a chemise.
“ We stopped at the said place (Plombteres) from the 16th to the 27th Sep¬
tember. M. de Montaigne drank the said waters eleven mornings, nine glasses
on eight days and seven glasses on three days, and he bathed five times. He
found the water pleasant to drink and always passed it before dinner time.
He found it had no other effect than to make him urinate. He had a good
appetite; as regards his sleep, and his belly, nothing out of the ordinary v%s
aggravated by drinking the water. The sixth day he had very violent colic,
more than usual, and he had it on the right side, where he had never had
pain except a very slight one at Arsac, without any operation. This pain
lasted four hours, and he clearly felt the operation and the passage of the stone
through the ureters and the lower belly. The first two days, he passed two
little stones which were in the bladder and then occasionally some sand. But
he went away from the said baths, believing that he still had in his bladder
both the stone which had caused the above mentioned colic, and some other
small ones, whose descent he thought he had felt.”
In Switzerland he stops at Basle and Baden.
Leaving France, Ke passed through Mulhouse and goes to spend
some days at Basle. He is much interested here when he is present
at an operation for umbilical hernia on a small child, and observes
that the patient is very roughly handled by the surgeon.
The only bathing place he visits is Baden, where he drinks plenty
of water but only takes a single bath. He is astonished to find such
comfort at the baths, and such a luxurious inn to put up at. One
day, he says, “ there were three hundred guests to he fed .”
He is now in a foreign country, and his curiosity is roused at
every step. He even makes a note of some of the smallest* things
which catch his eye; the heating stoves, the windows, the feather
beds in the houses, the preparation of sour-crout, the various ways
of drawing water from a well or of turning a spit.
South Germany.
To avoid Zurich, where the plague has broken out, he pushes on to
Schafifhausen and then enters Germany. His interest in what he sees
increases at each stage and becomes keener to get the best insight into
the habits and ways of the people. He tries to obey the customs of the
country. He even goes so far now as to give up adding water to the
wine he drinks as he always did in France, where in the South it is the
universal custom. Could his now drinking his wine pure have had
50
Mark: The Medical Aspects of Montaigne
anything to do with the aggravation of his urinary and dyspeptic troubles
during the next few months ?
Frequency op his Urinary Trouble.
A perusal of Montaigne’s diary leaves one astonished at the number
of references to his health it contains. He carefully mentions that the
journey lasted seventeen months and eight days. On twenty of these
days he expelled stones of various sizes, and on sixteen days he mentions
the passage of gravel or sand in various quantities. If to these thirty-
six days are added some fourteen others when he talks of his colic (some
references deal with several days), we find that during a period of
four hundred and twenty-three days there were fifty bad ones for him.
About one day in eight must have been a black one or would have been
considered such by an ordinary mortal. One is left with all the greater
astonishment at his capacity for enjoying life in spite of his sufferings,
his indomitable pluck and constant cheerfulness. Some of his attacks
of colic were very severe. He talks of one big stone which got
impacted for five or six hours, so that it became necessary to call in
the doctor. Turpentine was prescribed with very good effect, also a
well-prepared milk of almonds. This seems to have been one of the few
occasions when he took any drugs. He goes on in the same page to
mention an excellent prescription which was given to him by a Greek
patriarch, but which did not prevent him from suffering pain and passing
plenty of stones.
Across the Alps to Italy.
After visits to Augsburg, October 15, and to Munich, he starts south
and takes the main road to Italy across the Alps. He goes up the valley
of the Inn and, on leaving Innsbruck, he takes “ a ride of ten hours,” in
spite of an access of colic, after which he passes a stone “ of average
size." Nevertheless he enjoys going over the Brenner Pass. He is
much struck by “ the mountains, the inaccessible roads, the insupportable
air, the strange customs of the natives and the savage places they
live in.” He reaches Italy with the greatest delight, which is only
marred by some altercations (as one gathers on reading through the
lines) which he must have had with his travelling companions, who
wanted to reach Rome as quickly as possible, and to whom he has to
declare that when he went travelling “ he had but one project, which
was to wander about unknown places.”
Section of the History of Medicine
51
Our travellers push on towards Rome, pass along the lake of Garda,
visit Venice, Padua, Florence, and on November 30 they make their
entry into the Eternal City.
Rome.
Here they settle down with the intention of making a long stay,
and soon find the accommodation they wanted, in quarters rather more
“ comfortably furnished than at Paris.” Each day Montaigne now
makes long notes about what he has seen, or about the people he
meets with.
It is often said that a traveller’s first impressions of Rome are
disappointing, because it takes him a while to grasp the grandeur and
the beauty of the place without becoming overwhelmed. Montaigne’s
diary shows that he did not escape such a disappointment. The first
pages, after reaching Rome, contain no account of his raptures about
the place, he is too much taken up with his annoyance at the reception
he receives in this city, the centre of wisdom and learning. All his
books have been seized by the customs “ for examination," and amongst
them are two volumes of his essays. These were retained, and only
returned to him four months afterwards when they had been “ chastised
by the opinion of the Monkish Doctors ” ; a censure he took into little
account. The essays were not burnt or put on the Index Expurgatorius,
which might have added to their fame, but could not have made the
world the poorer for their loss, for they were already published and
becoming known in France. Just before starting on his journey
Montaigne was proud to learn that a copy of his work had been
graciously accepted by King Henry III of France.
The sufferer’s complaint soon recurs, we must again give his own
words. It ought to be mentioned that the first portion of the diary
is written in the third person, as it was dictated by Montaigne and
transcribed in the hand of his confidential valet or secretary. Here is
what was written :—
“ Twelve or fifteen days after our arrival in Rome, he was very ill, and on
account of an unusual flow from his kidneys he put himself under the care of
a French doctor, in the suite of Cardinal Rambouillet (the French Ambassador)
who with the dextrous help of his apothecary, one day made him take some
cassia in large pieces on the end of a knife previously dipped in water, which
he swallowed quite easily, and passed in two dr three stools. The next day he
took some turpentine of Venice, which comes, they say, from the Mountains
of Tyrol, two big pieces enveloped in a cachet, on a silver spoon, washed down
with one or two drops of a certain syrup with a nice taste; the only effect he
52
Mark: The Medical Aspects of Montaigne
noticed was that the urine smelt of March violets. After this he took on
three occasions, but not all following, a certain sort of beverage which had
exactly the colour and the taste of almonds: he was told by his doctor that
it was nothing else. All the same he thinks that it contained some of the
four cold ingredients [cucumber, melon, citral, pumpkin]. There was nothing
extraordinary in this attack of malaise but the early hour of the morning, all
taking place three hours before his meal. He did not feel what good the
almond mixture could have done him; for the same condition went on
afterwards ; and he had another severe colic on the 23rd [December] for
which he went to bed about midday and was there until the evening when he
passed a quantity of gravel, and later a large stone, which was hard, long and
smooth, and which was five or six hours in its passage through the urethra.
“All this while, since his baths, his stomach had been acting well, and this,
he thought, had preserved him from several worse accidents. So he deprived
himself of several meals, sometimes dinner, sometimes supper.”
He was well enough on Christmas day to attend the Pope’s mass
at St. Peter’s.
He spends nearly five months in Rome, and some 270 pages of his
book are devoted to his doings, his impressions, his interviews with the
many distinguished persons that he mixes with, for he has brought
with him the best of introductions. He of course pays a visit to the
Pope Gregory XIII and is much struck by the appearance of this fine
old man “of eighty years, as full of vigour as one could wish, free
from gout, free from colic, free from stomachache and free from any
other trouble; of a kindly nature, showing little passion for the affairs
of the world.”
The personal note keeps appearing in these pages. One feels
for him on several occasions when he mentions how an attack of
colic did not stop him from his ordinary actions although he may
have passed a calculus.
Across Italy to the Shrine of Loretto.
On April 19 he resumes his peregrinations and goes a long journey
across the Appenines towards the Adriatic coast. It is not that he
wishes to see any baths, but Loretto, the famous pilgrimage resort,
some fifteen miles from Ancona. Here he sees the Chiesa della Casa
Santa built over the legendary “ sacred house ” where Jesus Christ
was born, which had been brought here by angels from Nazareth.
One cannot gather from the diary whether it was the curiosity of a
traveller or the hope of a cure of his ailments which had attracted
him to this place. He mentions some of the cures alleged to have
Section of the History of Medicine
53
occurred on the spot, and does not depart without leaving a memento
of his visit in the shape of a tablet with four silver figures inlaid on it,
representing Our Lady, himself, his wife and his daughter.
After a visit to some antique remains at Ancona he starts back
across the Appenines, this time by a more northerly route, in the
direction of Florence, and pushes on to Lucca where he starts his cure
at the principal baths of La Villa. He spends a first season here,
lasting a month and a half and makes a thorough study of the waters.
{Montaigne's Journal , p. 289 et seq.)
“ At Loretto. I spent Monday, Tuesday and Wednesday morning, and
left after mass. To mention one experience of this place which interested me
very much ; I met Michel Marteau, Seigneur de la Chapelle, a Parisian, a very
rich young man, with a numerous train. I got a very particular and curious
account both from him and from some of his suite, of how his leg was cured
as he said at this place ; it is not possible to see better or more exactly the
effect of a miracle. All the Surgeons of Paris and Italy had failed in his case.
He had spent more than three thousand crown-pieces upon it: whilst his knee,
swollen, useless and very painful three years ago, more sore, more red, inflamed
and swollen so as to give him fever; in this one moment, after all other
medicines and relief had been abandoned some days before ; whilst asleep,
suddenly he dreams that he is cured, and he seems to see a flash of lightning ;
he awakes, cries out that he is cured, calls his people, gets up, walks about,
which he had not done since his trouble; the swelling of the knee subsides,
the skin all round the knee is shrivelled and seems dead, he still continues
to improve without any other sort of help. And then he was in this state
of perfect cure when he returned to Lortftto; for it was after another
voyage one or two months before that he was cured, and had since been
at Rome with us. From his own mouth and from all his people, this is
all that one can gather for certain.”
{Montaigne's Journal , p. 307.)
11 Plan della Fonte , twelve miles. Rather a bad inn, where is a fountain
just above the town of Anchisa, in the Arno valley, which Petrarch talks
of and where he is supposed to have been born at a house of which only
scant ruins can be found. Anyhow they mark the spot. They were then
sowing melons amongst others already sown, and hoped to gather them in
August.
11 During the morning I had a heaviness of the head and troubled vision like
my ancient migraines which I had not felt for ten years. This valley which
we passed, was formerly all full of marshes, and Livius maintains that
Hannibal was forced to cross it on an Elephant (the only one he had
remaining) and on account of the bad season of the year, lost an eye. It is
54
Mark : The Medical Aspects of Montaigne
truly a very flat and low district, and is liable to be overrun by the Arno.
Here I would not have any dinner, and repented afterwards; as it would have
helped me to vomit, which is my most prompt cure : otherwise I continue with
this heaviness of the head for one or two days, as it now happened to me.
“We readied Florence (twelve miles) by one of the four stone bridges which
cross the Arno.”
A First Season at the Baths of La Villa.
His first season at the baths of La Villa lasted until June 21. He
had comfortable quarters with a pleasant outlook Over the surrounding
hills. Unfortunately he met with little congenial society and few
“ distractions ” except the baths. This makes him give more attention
to his journal, and he regrets not to have described his past ailments
with more detail, so as to be able to take more care of himself in
future. He now starts writing his journal in Italian, by way of
improving his knowledge of that language. His observations about
the baths are most copious. Each day he records exactly the number
of glasses of water which he drinks, the baths and the douches which
he takes and the effect derived from them. He goes in for his cure
heart and soul, but he treats himself according to his own fashion
“ against the rules of his country ” and to the great scandal of the
doctors.
On many days he drinks seven glasses of the water, then he takes
as much as 6J lb. of water in thirteen glasses for three days running.
He scrupulously measures the amount of urine passed and is sometimes
puzzled when perhaps he notices that its volume is only equal to one-
fifth of the quantity of water taken by the mouth. He spends an
hour and a half to two hours in the bath. He goes on to take as
much as 8 lb. of water. No doubt he overdid things. After a while
he takes to complaining of migraine and weakness of the eyes every
day after he had had his head douched, so he stops the treatment
for a few days. He also complains of sharp pains and cramp which
come on in his leg at night, but this happens soon after he had
received a present of some choice wines, and one wonders if they
were the cause of it. He concludes that the effects of the waters
in his own case prove that they do not produce the gravel.
He has already made the observation that his brother, who never
before had passed any gravel passed some in his urine one day after
drinking the water. So he goes on to wonder what is the real action
of those waters and where the sand comes from.
Section of the History of Medicine
55
An interesting episode of hi3 stay there was the occasion on which
the doctors found themselves obliged to invite Montaigne to be present
at one of their consultations and to beg him “ to hear their opinions
and their controversies” because their patient, a young Italian nobleman,
nephew of a cardinal “ had decided to abide by his judgment. ’ This
made him laugh in his sleeve.
His experiences of these baths are so interesting that you must have
a translation of some of his own words :—
Montaigne's Voyage (Translation of p. 353.)*
“ On Wednesday I went to the bath. I felt greater heat in the body and
had more sweating than usual, also some weakness, and dryness and bitterness
in the mouth and I know not what sort of giddiness such as the heat of the
waters had brought on me at all the other baths: Plombteres, Bagn^res,
Preissac. This never happened at the baths of Barbotan nor at this bath,
except on this Wednesday, either because I went there much earlier than on
other days, before my bowels had acted, or because I found the waters much
hotter than usual. I was there one hour and a half and I douched my head
for about a quarter of an hour.
“ I used to do many things against the common rule. I took the douche
whilst in the bath, whereas it is the custom to have first one arid then the
other. I was douched by this same water, whereas there are few persons who
do not go to the douches, of the other bath, and there try such and such a
spring, the first, the second or the third according to the prescription of the
doctors. I drank the water, then bathed, then drank again, thus mixing up
all the days together, whereas others drink the waters on a certain number of
days and then go to the baths for several days following. I did not take note
of the length of time, because others drink the water on ten days at most, and
bathe on twenty-five days at least with no interruption. I bathed once a day
instead of always twice a day. I took the douche for a very short time whilst
the custom is to stop there always for at least an hour in the morning and the
same in the evening. As to having my head shaved, as they all do, and
covering my scalp with a small piece of satin held in its place on the head
with a net, my shiny head did not require it.”
{Translation, p. 358.) a
“ On Thursday, the feast of Corpus Domini, for an hour and more I was
in a bath of moderate heat; I sweated very little and I came out without
feeling any change. I douched my head for half a quarter of an hour, and
1 “Montaigne: Journal de Voyage,” edited by ^ouis Lautrey, 2nd ed., 1909, Hachette
et Cie, p. 353.
2 Loc. cit., p. 358.
4
56
Mark: The Medical Aspects of Montaigne
when I got back to bed, I slept for some time. With this bath and douche I
was unusually pleased. I felt on my hands and other parts of the body some
slight eruption, and I observed that amongst the inhabitants of the district
many of them were scabby, and many children suffered from lactation-crusts.
It happens here as elsewhere that what we ourselves, with so much trouble
go in search of, is treated by the inhabitants of the locality with contempt.
I met many who had never tasted these waters and considered them bad,
withall, there are few old people to be met with here.
44 With the mucus which I threw off in the urine (which happened to me
continually) one could see a lot of sand suspended and enveloped in it. I
seemed to feel this effect of the bath, when I held the jet of water applied to
the pubes that the wind was driven out of my body. And in truth, I felt
suddenly, and clearly, that the testicle on my right side diminished in size, if
by chance I sometimes had it puffed up, as happens to me often enough.
From this I almost conclude, that such puffiness takes place by means of the
wind which becomes pent up in it.
44 On Friday I bathed as usual, and douched my head a little more. The
extraordinary quantity of sand which I passed continually, made me doubt
whether it could have been shut up in the kidneys, for if it had been
squeezed together, quite a large ball might have been made out of it; and
I supposed that most likely the water had conceived it and brought it
forth little by little.
44 On Saturday I bathed for two hours and had the douche for more than a
quarter of an hour. Sunday I remained quiet.”
#
( Translation , p. 438.)*
“ When talking to the country folk, I asked one very old man if they used
the baths and he answered that the same thing happened to them that
happened to the people who live near the Madonna of Loretto, that they
rarely make a pilgrimage there, and the effect of the waters is only seen
to favour strangers and those who come from distant countries. Anyhow
one thing troubled him very much, which was that for some years past
he noticed that the baths did more harm than good to those who used them.
He said that the cause of this was that, although in former times there was
not a single apothecary on the spot, and that a doctor was rarely seen, now
one found quite the contrary; these fellows who looked to their profit, spread
the opinion that the baths were of no good to those who did not take
medicines, not only both after and before, but also mixed with the water of
the bath; which water they would not easily allow to be taken pure. Hence
he said that the result which followed was very clear, more people died from
these baths than went away cured. And he looked upon it as certain that in
a short time they would be in bad repute and get despised by the world.”
1 Loc. cit., p. 438.
Section of the History of Medicine
57
Excursion in Tuscany.
He spends most of the next two months on a tour through the
country and visits to Florence and Pisa. It is midsummer, and he
suffers a good deal from the heat. The diary contains complaints of
his dry mouth, his giddiness, the pains in his side, the incredible
amount of sand he passes. He fancies that the light sparkling
wines cause his migraine. He talks of quenching his thirst with
large quantities of Trebesian wine. He receives presents of wines
from friends, which seems to be the usual complimentary offering to
a visitor. One day he will not put 'snow in his wine as he does not
feel well. Another day he feels overheated, and has such a dry mouth
that he eats nothing but fruit and sugared salads. One rather
puzzling entry in the diary is when he talks of having colic on the
right side, but eats melon, cucumbers and almonds. One wonders'
which was the cause, and which the effect. He does not think much
of the baths of Pisa, and says the waters, which looked turbid, must
have acquired their smell and impurity from the outside. He passes
more stones, one which from its shape was evidently “ detached from a
much larger body; God knows ! ”
Returning to Lucca he begins his second season at the baths of
La Villa.
A Second Season at La Villa.
He returns to La Villa and is much gratified at the ovation which
he receives from all his friends there. He begins another course of
baths, and for the first day is troubled because he passes red urine and
blood. Then he has violent toothache. One morning a stone gets
lodged in the canal, and he describes how he went till dinner time
without passing any urine, to be able to expel it with a great gush,
so that he got rid of the stone quite easily. It was the size of a
pine nut.
The journal at this time gives a better insight into his state of mind,
and he writes one day :—
“ The only rule and the unique soienee for avoiding the ills whioh beset
a man on every side, at every hour, whatever they be, is to resolve to suffer
them humanly and to end them courageously and promptly.”
This passage has been much criticized. Did Montaigne want to
approve of suicide, or did he wish to condemn it according to some of
his more zealous friends ? It is difficult to tell,
58 Mark: The Medical Aspects of Montaigne
He now gets more anxious to know what becomes of all the
water which he drinks, how, when he has absorbed nine glasses
during the day, he only evacuates half of it by the time he sits
down to dinner. He is continually occupied in making up the
balance between the quantity of water drunk and the amount of
urine.
It ends by this very meticulous man taking a dislike to the Baths
of La Villa. He talks of going farther south, to Naples, to try some
other famous baths in the way. But his plans are altered by the receipt
of good news from France, luckily for him, as it puts an end to his
experiments in thermal waters which, at the rate he was going, would
soon have been the cause of his leaving his bones in Italy. The news
was that he had been named Mayor of Bordeaux, and it was accom¬
panied by a flattering letter from the King of France, Henry III,
“ commanding him and enjoining him very especially and without
delay or excuse to return from Italy and as soon as possible to under¬
take the charge.”
Fabewell to Home.
He leaves La Villa on September 15. At Lucca he is much troubled
by noticing that the amount of urine passed is this time double the
amount of the water which he has drunk, and concludes that some of
the waters of the baths must have remained inside him.
After passing Sienna he sees the Baths of Viterbo, which had a
great reputation. He describes how the waters form a foam and a
crust which is deposited, and he questions whether these w’aters when
drunk are not likely to become petrified in one’s kidneys.
For several days after getting back to Rome he complains of fatigue
of the stomach, so he takes his meals apart, in order to eat less. He
also has a good deal of headache. When he leaves Rome, on Sunday
morning, October 15, he is accompanied as far as the firs$ post by some
dozen of his friends and “ if I had not started before the hour, to avoid
giving this trouble to these gentlemen, there were many others about
to come, who had hired horses to do it.” Montaigne has now increased
in importance, for he has had conferred upon him the title of “ Citizen
of Rome,” to his intense satisfaction.
Section of the History of Medicine
59
The Journey Home by the Mont Cenis.
He makes use of post horses on the journey home, as he is only
accompanied by his own domestics, after leaving his brother and friends,
who remain on in Home. His route takes him again through Viterbo,
Lucca and Sienna, to Pavia. He avoids going by sea to Genoa, as he
fears to get his stomach upset. The road by the coast is unsafe for
travellers, so he makes for Milan and crosses the Alps again, this time
by Suza and the Mont Cenis. On this journey home, his attacks con¬
tinue, and as Sainte-Beuve says of him in “ Les Causeries du Lundi,”
“ he goes on scattering his stones and his gravel on the highroads of
Italy.” One day by way of testing the strength of his kidneys, he rides
at full gallop for two whole posts. He found no harm or lassitude as a
result, and the urine was natural.
He rests for a week at Lyons. On November 20 he starts from
Clermont for a day’s excursion, and ascends the Puy de Dome, and on
reaching the summit he “ passed a fairly big stone, large and flat, which
was in the passage since the morning and which he had felt the day
before. It w r as neither hard nor soft.”
We are now well on into the winter, frequent storms are met with
on the way to Limoges. * Travelling is unpleasant in the poor, hilly
districts of the centre of France. The roadside inns are miserable,
there is a want of good wines, Montaigne’s headaches are aggravated by
the winds and storms. The entries in the diary become more scanty,
some days a mere record of the number of leagues ridden and of the
villages where he puts up for the night.
The journal comes to an end with the words :—
“On Thursday, feast of St. Andrew, the last day of November, after
riding seven leagues, I came to sleep at Montaigne, whence I had started
on the 22nd of June, 1580. Thus my voyage had lasted 17 months and
8 days.”
We have thus accompanied this interesting man on his travels, one
whom Sainte-Beuve calls the wisest Frenchman that ever existed. We
have looked into the journal which he kept all the time and forms a
most entertaining book. If it has been our lot to draw attention to so
many passages which perhaps would be expurgated if the work were
Bowdlerized, the excuse is that it is given to interest a special audience.
It would perhaps have been easier and more pleasant to entertain you
with an account of the other important parts of the book, where
60
Mark : The Medical Aspects of Montaigne
Montaigne deals with the doings of other men, their beliefs, customs
and laws, for he is one of those for whom the proper study of
mankind is man. Yet of all men, the one he knows best and studies
most is Montaigne himself, so it cannot have been waste of time to
listen to some of his own observations about his own body.
Such is the journal, written in order to aid his memory, also to
provide him with the very precise observations which he made use of
later on, to enrich some of the chapters of his Essays, such as those on
the eulogium of the bath, on drinking waters, the diversity of customs
followed at the baths of France, Germany and Italy, from which he con¬
cludes is derived “ the confusion and incertitude of medicine. 0 To his
chapter on “ Experiences ° he is enabled to add details about his own
health, and about his particular tastes when he is at table or elsewhere.
One admires his scrupulous anxiety to lend himself to the customs of
other countries, his desire to understand everything, for he “ took all
knowledge as his portion, 0 like his great contemporary Bacon, who
must have written these words at the time that Montaigne was on his
journey.
One would like to have had him with us here to-day, knowing the
keen desire expressed in his Essays, “ to bring round those that he
confers with to talk of those things that they know best. 0
Dr. F. PARKES Weber : A volume could easily be filled with comments on
the medical aspects of Montaigne’s journal, as so admirably sketched out in Dr.
Leonard Mark’s interesting paper. ‘Montaigne suffered from “ showers ” of
urinary gravel, and he shrewdly suggested that some of the gravel might be
formed in the urine itself, when it had left the kidneys. After his return from
Italy he lived for many years and did much conscientious and public-spirited
work as Mayor of Bordeaux. Montaigne’s remarks as to the kindly or bene¬
volent appearance of Pope Gregory XIII are somewhat remarkable, when we
remember the part played by this pope in regard to one of the most dreadful
religious and political crimes recorded in history—the massacre of St. Bartholo¬
mew’s Eve, in 1572; but he may have been bigoted enough to think it was for
the best. An Italian medal commemorating this event has the bust of Pope
Gregory XIII on the obverse, with the signature of the medallist Federigo
Bonzagna, called 41 Parmigiano.” On the reverse the Protestants are repre¬
sented being slaughtered by the destroying angel, and the legend is: “ Ugonot-
torum strages, 1572.” Many re-struck examples and later copies of this medal
exist, but the originals are scarce. The massacre of the Huguenots is com¬
memorated also in the same spirit by Vasari s fresco in the Sala Regia of the
Section of the Histonj of Medicine
61
Vatican at Rome, though the inscription under the painting has been obliterated.
In spite of sceptics as to the efficiency of treatment by mineral waters and
baths, the health resorts visited by Montaigne still flourish. In recent years
Plombteres in France (Vosges) has become still better known in England by
the use at Harrogate and elsewhere of what is known as the “Plombi&res
treatment” (including the Plombi6res ** douche horizontale ” for lavage of the
large intestine). The Bagni-di-Lucca_ (of which Villa forms part), which had
been resorted to in 1245 by the enlightened Emperor Frederick II, and long
after Montaigne’s time were visited by Byrorf, Shelley and Heine, are still well
known, though possibly many visitors from Florence and other parts of Italy
come chiefly for recreation and “ change of air.” Baden in Switzerland is
frequented in the season, though not still famous for the particular kind of
“ gaiety ” of life described in 1416 by the great Italian scholar and Papal
Secretary, Poggio Bracciolini, in a letter to his friend, Nicolo Nicoli.
Section of tbe Ibtetorp of flDeincine.
President—Sir D’Arcy Power, K.B.E., F.R.C.S.
Note on Celsus’s Operation of Lithotomy . 1
By Charles Greene Cumston, M.D.
[Geneva, Switzerland.)
“ Cum jam eo venit (the calculus), et super vesicae cervicem sit, juxta
anum incidi cutis plaga lunata usque ad cervicem vesicae dehet, cornibus ad
coxas spectantibus paululum : deinde ea parte, qua strictior ima plaga est,
etiamnum sub cute, altera transversa ])laga facienda est, qua cervix aperiatur,
donee urinae iter pateat sic, ut plaga paulo major quam calculus sit.”—ArREL.
Corn. CELSrs, lib. vii, edit. Almeloveen.
“ Quum jam eo venit, incidi juxtu anum cutis plaga lunata usque ad
cervicem vesicae debet, cornibus ad coxas spectantibus paulum ; deinde ea
parte qua resima plaga est, etiamnum sub cute altera transversa plaga facienda
est, qua cervix aperiatur, donee urinae iter pateat sic, ut plaga paulo major,
quam calculus sit.”—A urel. Corn. CELSUS, lib. vii, cap. xxvi, edit.
Daremberg, Leipzig, L859.
This passage of Celsus has been translated and commented upon in
the most varied ways for the past two centuries, and still none of the
translations satisfy me, neither can I offer a suitable one. In all, it is
assumed that Celsus intends to convey the idea of an oblique or curved
incision, but whose horns and concavity are directed towards the same
side, but in all the Latin texts with which I am familiar there is
ad coxas , that is to say, the thigh bones on the ischii, which form part
of this portion of the skeleton, and which Celsus nowhere designates
by a particular definition.
Of course the incision is cresentic in shape, and made above the
anus with the horns directed upwards or doicnwards , and this is the
At a meeting of the Section, held November *20, 1918.
Section of the History of Medicine
63
point which I maintain is impossible to interpret correctly from the
various Latin texts.
Vedrenes, in his French version of Celsus (Paris, 1876), says:
“ Cornibus ad coxas spectayitibus paulum means directed towards the
coxal bones, towards the groins, therefore upwards ” (note 7, p. 679), but
I am not prepared to accept this version as final. That in all probability
the upward direction of the horns of the incision is the correct one I
am bound to admit, but the downward direction appears to me as not
improbable. However, in favour of the upward direction of the horns
of the incision, it must be recalled that the crescent-shaped incision of
the perineal integuments is followed by a transversal one, as is indi¬
cated by the text qua strictior ima plaga est, which indicates that this
second incision should be made in the deepest part of the first or
crescentic-shaped incision, rather than at its lower portion, as some
have inferred.
In Daremberg’s text the exact position of the second incision is
indicated, qua resima plaga est, in the concavity of the first incision.
Whether or not the concavity of the perineal incision be directed
upwards or downwards, it is logical to assume that, according to the
Latin texts, the incision is a crescentic one in front of the anus, and
that the second incision is transversal and made in the middle portion
of the crescentic incision down to the vesical neck.
The transversal incision is unquestionably bilateral, and not a
lateral or median vertical incision of the urethra as some have
maintained.
A Contribution to the History of the Surgical Treatment of
Aneurysm, from the Notes of Dr. Charles T. Maunoir,
of Geneva, made during the year 1802. 1
By Charles Greene Cumston, M.D.
( Geneva , Switzerland.)
At the commencement of the nineteenth century, surgeons had
practically given up all the ancient therapeutic measures for controlling
haemorrhage, and resorted almost entirely to ligature of the bleeding
1 At a meeting of the Section, held January 15, 1919.
64 Cumston : Surgical Treatment of Aneurysm
vessel. The vessel was freed from all surrounding tissues before the
ligature was applied, because it had been proved both by animal
experiments and also, unfortunately, in man, that if some of the sur¬
rounding structures were comprised in the ligature with the artery,
secondary haemorrhage was very prone to occur.
Direct ligature, although efficacious when the vessel was completely
divided, was found ineffective when the solution of continuity did not
involve the entire circumference of the vessel, and serious secondary
haemorrhage was the result.
The means of preventing this accident was to ligate above and
below the opening in the vessel and then to divide it completely between
the ligatures. This method is unquestionably due to Dr. Jean Pierre
Maunoir (1768-1861), a famous Geneva surgeon, who first referred to it
in his work entitled: “ Memoires physiologiques et pratiques sur
l'andvrisme et la ligature des arteres,” Gen&ve, l’an 10 (1801). This
work was one of his earliest contributions to surgery. His brother,
Charles T. Maunoir (1775-1830), 1 whose notes form the substance of
this short contribution, says that no matter what reasons he might have
had for adopting his elder brother’s method, he nevertheless remained
in doubt as to the advantages that it offered, and when he compared it
with John Hunter’s technique, he found it difficult to pass judgment
and to give his preference to either one or the other procedure. How¬
ever, after an experience of a few years, Charles Maunoir became a firm
believer in the teachings of his brother Jean.
On April 12, 1802, Mr. Young introduced young Maunoir to
Mr., afterwards Sir Astley Cooper, who was about to operate for an
aneurysm of the popliteal according to the elder Maunoir’s method.
The patient was a sailor, aged 32. The tumour was in the right
! Charles Th6ophile Maunoir was born at Geneva March 13, 1775 (Choisy says May 13).
He was Doctor of Surgery (Paris,' 1804) and Adjunct Professor of Anatomy and Chemistry
at Geneva in 1810. He was nominated Surgeon-in-Chief of the Geneva Hospital in 1817,
which post he was compelled to resign on account of ill-health in 1825 (Choisy says in
1826). In 1817 he was made Honorary Professor of Anatomy. Socn after his retiiement
from hospital practice Maunoir was obliged to give up his private practice, retiling to the
little village of Mornex, where he died on February 23, 1830. Maunoir's principal contri¬
butions to surgical science are :—
(1) “Sur la section de l’artere entre deux ligatures dans l’operation de l'aneurisme,”
Dissertation, Paris, 1804.
(2) “Observations sur une plaie p6netrante de l’artfcrc axillaire gauche gu^rie par la
ligature et la section de l’artere,” Ann. de la Soc. de mtd. prat. de Montpellier , 1808.
(3) “ Une plaie penetrante de Tabdomeu compliquOe de Tissue d’une portion considerable
de l’estomac,” Idem , 1809,
(4) “ Nouvelle methode de trailer la sarcocele,” Geneve, 1820.
Section of the History of Medicine
65
popliteal region, and the size of a duck’s egg, blue in colour, but gave
rise only to weak pulsations. Mr. Cooper made an incision about
3 in. long over the internal aspect of the thigh at its middle, following
the direction of the posterior border of the sartorius muscle. The
dissection was long, but finally the femoral artery was exposed, and
after considerable difficulty (because the incision was too short) it was
dissected from the surrounding structures. He used both a sharp knife
and a dull one made of silver, the latter when not too near the vessel.
After a grooved director had been passed under the artery, it was freed
from the vein, after which a blunt needle with two waxed ligatures was
passed under the artery along the grooved director. The ligatures
were tied about \ in. apart, and the vessel was divided with the scalpel,
cutting down on the director. As the dressings were about to be
applied it was found that the distal ligature had slipped, and a haemor¬
rhage ensued. With some difficulty the vessel was caught in strong
dissecting forceps and ligated. Just as the dressings were to be applied,
it was found that the proximal ligature had given way. Compression
was made in the groin and a ligature applied. The incision was closed
by strips of adhesive plaster.
On May 7, the aneurysm was smaller and softer, and a few days later
some blackish pus was given exit with a lancet. The patient left the
hospital on June 7 in good condition, although Maunoir says that he
still limped a little.
Maunoir points out that the reason of the haemorrhages after
completion of the operation was due to the fact that the skin incision
was not long enough, which made proper exposure of the artery
difficult, and that the ligatures were placed too near together.
In the early part of May, 1802, Mr. Cooper operated on a cab-
driver for a popliteal aneurysm, but he placed his ligatures farther apart
than in the preceding case, and before cutting the artery he pierced the
vessel below the proximal and above the distal ligature with threaded
needles, and tied them together with a double knot. This was done to
prevent slipping of the ligatures, but Maunoir points out that this
procedure is quite useless if the ligatures are properly tied and
sufficiently far apart. He further says that should the ligatures slip,
the thread transpiercing the vessel would retain them in place, but
would not prevent haemorrhage from occurring. This patient left the
hospital on June 7 without a limp, although the wound was not
completely cicatrized.
Maunoir mentions a third case of aneurysm, this time of the
66
Cumston: Surgical Treatment of Aneurysm
brachial artery, in which Mr. Cooper divided the vessels above
the aneurysm between two ligatures. The operation was perfectly
successful, the patient recovering more rapidly than the two previous
ones.
Under the date of June 16, 1802, Maunoir mentions a case that
Mr. Abernethv showed him of a female, aged 55, with a large aneurysm
of the peroneal artery. Two days later the popliteal artery was cut
between two ligatures, but as Maunoir says, “ the wound promptly
suppurated, and although there were no pulsations in the aneurysm, it
had increased greatly in size. At autopsy, an aneurysm of the posterior
tibial was found in a state of suppuration, and the tibia was extensively
necrosed.
Maunoir accompanied Mr. Cooper on a visit to Paris, and on his
way back to London the young Geneva surgeon passed ten days at
Antwerp. He explained to the medical men of that city the reasons
why he considered his brother’s operation for aneurysm superior to that
of Mr. Hunter, but they were sceptical. Maunoir then proposed to
make some comparative experiments on the ligature of arteries, which
was accepted. A large dog was procured, and both femoral arteries
were ligated ; on one side two ligatures were applied and the vessels
divided between them, on the other a single ligature was applied. The
distance between the two ligatures was 1 in. The side on which the
single ligature was applied was operated on by M. Somme, one of
Desault’s students. A few days later Maunoir left for London without
knowing what the outcome of his experimental work might be, but a
few days after his arrival in town he received the following letter :—
“ Monsieur,
“ Anvers, le 15 aoilt, 1802.
“ Yous avez desire connaltre Tissue de nos operations sur le chien, ot nous
nous empressons de vous satisfaire.
“ 11 a et6 assez bien portant pendant les cinq premiers jours, il faisait
parfaitement ses fonctions, mangeant et buvant bien, meme un peu trop pour
son etat qui aurait demande une di£te plus severe. On a cherche a voir les
plaies pour couper les fils des sutures, si elles eussent occasionne trop de
tiraillement, mais Tanimal grondait des qu’on Tapprochait, et nous n’avons
pas juge a propos de satisfaire notre curiosite. lie matin du sixieme jour on
alia le visiter comme de coutume, il etait mort et baigne dans son sang.
“ Nous proceditmes de suite a Texamen des parties. Le plaie du cote droit,
ou la section de l artere avait ete i'aite entre deux ligatures, suppurait dans une
assez grande etendue ; ses bords etaient ecartes, les tils ayant coupes la peau
Section of the History of Medicine
67
vers le milieu de Tincision. Les ligatures se sont d6tach6es facilement; la
retraction de Tartere, ou l’intervalle qui existait entre les deux extremity
coupees, etait d’un pouce ou quatorze lignes; le canal n’etait pas encore
oblitere a l’endroit des ligatures, nous y avons passe un stylet, et apres avoir
dissequo et enleve Tartere, nous l’avons conserveo. L’hemorrhagie n’a pas
en lieu de co cote.
“ Nous avons examine plaie du cote gauche, ou la ligature a etc faite sans
section de Tartere; les bords en ytaient rapproches et recoll^s dans presque
toute l’etendue de l’incision ; un ecartement d’un demi pouce environ donnait
issue a un caillot de sang ; l’ouverture etant agrandie, il s’est presents un
caillot fort epais, qui ne nous a plus laiss6 de doute que c’etait de ce cot6 que
Themorrhagie avait en lieu. Nous presumames que la ligature trop serree
avait coupe Tartere, et nous cherchames a verifies nos conjectures: le vaisseau
fut mis a decouvert avec precaution ; nous vlmes que la ligature entourait
encore Tartere qui etait entiere a cet endroit, la ligature etant relachee bien
loin d’avoir coupe Tartyre ; mais il y avait, un demi pouce environ au-dessous
de la ligature, une ouverture ou crevasse au vaisseau, qui comprenait au moins
les deux tiers de son diametre. Les tuniques, en se retirant, avaient forme un
trou ovalaire plus etroit que le diametre de l’artere. Nous avions commence
a introduire un stylet du memo diametre que celui de Tartere; il etait parvenu,
en passant sous la ligature, jusqu’a ce trou, ou il fut arrete. Pour conserver
cette piece en ontier, il a fallu employer un stylet plus mince, qui a penetre
ensuite a la partie inferieure du vaisseau dont Touverture m’etait pas retrecie.
“ Comment expliquer cette rupture ? Est-il presumable que la ligature
s’etant relachee, le sang ait voulu reprendre son cours naturel, et que Tartere
se trouvant deja retrecie, les tuniques ayant perdus leur elasticity elles se soient
rompus: ou d’apres l’opinion de M. Maunoir, y aura-t-il eu retraction a Tartere
a cause de la ligature, et cette retraction aura-t-elle cause une crevasse par ou
le sang sera sorti ? Ce qui pourrait en quelque sorte confirme cette hypothese
dans le cas present, c’est que cette crevasse 6tait dispos£e de maniere a indiquer
l’effet d’une cause qui aurait agi en meme temps sur les parties superieure et
inferieure a l’ouverture ou crevasse du corps de Tartere, de fa 5 on qu'on pourrait
soupconner que la permanence de cette cause aurait infailliblement opere la
division de la totality du vaisseau; ou enfin aurait-on blesse Tartere pendant
Toperation ? Mais il eut ete facile de s’en apercevoir. Au reste, quelle qu’en
soit la cause, il y avait un retraction bien sensible dans les parties divisees de
Tartere, quoiqu’elle ne fAt point en entier.
“Nous nous proposons do r6pyter l’expyrience en faisant seulement la
ligature sans section, et nous vous rendrons compte du rysultat.
“ Agreez nos salutations amicales,
{Signed) Somme, chirurgien-major de la 76® demi brigade.
P. Vandenzande, Prof, de chimie et de physique.
A. Dekin, Prof, d’histoire naturelle.”
68 Cumston: Surgical Treatment of Aneurysm
The day following his return to London, August 25, 1802, we find
Maunoir with Mr. Cooper, who was to perform an operation on the
left popliteal at Guy’s, on a patient aged 40, of strong constitution.
The artery was compressed at the groin, and an incision, this time 5 in.
long, was made above the middle of the thigh, over its internal aspect.
The vessel was promptly exposed and separated from the vein and nerve
by blunt dissection. Two ligatures, 1 in. apart, were applied and tied,
but Mr. Cooper again resorted to transpiercing the vessel with silk, as
in the operation already referred to. The vessel was then divided.
Although the wound still suppurated a little at the beginning of October,
the patient walked without a limp.
It would seem that Mr. Cooper had followed Maunoir’s advice in
this operation, since he made a long incision and applied the ligatures
much farther apart.
On September 3, Mr. Lucas invited Maunoir to be present at Guy’s
Hospital at an operation on a patient aged 36, for “a tumour occupy¬
ing and extending beyond the right popliteal cavity,” with swelling of
the surrounding parts. Pulsation was very evident in the tumour.
The incision was begun above the lower third of the thigh, on the
anterior border of the sartorius muscle, and measured 3 in. in length.
Mr. Lucas applied two ligatures to the vessel, but as they were too near
together it was decided not to divide the artery between them. The
ligatures were tied with such force that Maunoir was fearful that
the vessel would be cut through, but this did not happen. The result
of the operation was that the leg became gangrenous, and the patient
died on September 12 from sepsis.
Returning from Tottenham with Mr. Cooper, on September 21,
1802, Maunoir went to Guy’s Hospital to witness an operation for
aneurysm that the London surgeon was to perform. A young man,
aged about 26, had cut his thigh with a wood-knife, which resulted in
a fearful haemorrhage on the day before. When he was brought to
hospital Mr. Lucas wished to amputate at the thigh, which apparently
the patient refused. That evening the patient had a very considerable
haemorrhage, and Mr. Cooper had been sent for and decided to ligate
the artery at once. The wound, which was parallel to the vessel, was
enlarged, and, it should be remarked, was at the point of election
indicated by Jean Maunoir for the ligation of the vessel in cases of
aneurysm. Mr. Cooper exposed a vast clot which he removed, and
then found that the artery had been dissected by the blood to the
extent of some 2 in. or more. Another smaller clot was found
Section of the History of Medicine
69
occluding the solution of continuity in the vessel walls. A ligature was
placed above and below this and the vessel divided between them. The
patient progressed favourably until October 1, when a free haemorrhage
obliged Mr. Cooper to open up the wound. He found both ligatures
loosened, both arterial ends contracted, and giving issue to the blood.
The artery was more freely exposed by enlarging the incision in
order to ligate and cut both ends of the vessel in healthy tissue.
After this had been accomplished, another haemorrhage occurred in the
space between the two cut and ligated ends of the artery, coming from
a collateral given off by the femoral above the proximal ligature. This
vessel was ligated.
Maunoir remarks that the good effects of complete division of the
artery between two ligatures were “ impaired from the inflammation of
the wound, which prevented the divided vessel from retracting, as is
the case when it is divided in healthy tissues, and the haemorrhage
would probably not have occurred if the artery had been ligated some
distance from the ravage occasioned by the wound and by the blood
which accumulated around it.”
After this the patient improved and “ regained a little colour,” and
appeared to be on the road to recovery.
Maunoir expresses regret at not having been able to follow the
case to the end. The last time he saw the patient was on October 9,
1802.
If I have brought to your notice the notes and reflections of the
young Geneva surgeon made during his stay in London in the year
1802, it is merely because it occurred to me that they might be of
some interest from the fact that they show the work of two great
men, Cooper and Abernethy, as seen through other eyes, and also give
us an insight into practice in the days when English surgery was
developing into the great school it represents at the close of the year
1918.
Section of the IMatorp of flDefcidne.
President—Sir D’Arcy Power, K.B.E., F.R.C.S.
St. Isidore of Seville and his Book on Medicine 1
By G. R. J. Fletcher, M.R.C.S.
St. Isidore was a compiler of the general knowledge of his time
and his encyclopaedia contains among other subjects those of medicine
and the physical sciences. The Etymologicie, with its fourth book on
medicine, enjoyed a great popularity for so many centuries that the
medical portion may well claim some share of our attention. One
might suspect that his “ De Medicina ” only survived because it formed
part of the Etymologiae, were it not a fact that as late as the sixteenth
century it was the subject of separate commentary. The British
Museum possesses a copy in black letter, Liber Quartus Etymologiarum
Sancti Isidori Hispalensis, qui est de Medicina. Cum interpretatione
seu commentario Domini Simphoriani Champerii, Lugdun. [1508].
Isidore was born at Carthagena in Spain about the year 560.
Severinus his father had been banished from Carthage, when that
country was ravished by Agila, king of the Goths, in 552. Severinus,
his wife and son, Leander, came to Carthagena; there Isidore was born.
Another tradition makes the family Hispano-Roman. Isidore’s parents
died while he was yet young and his education was undertaken by his
brother Leander, now Bishop of Seville, who had established in that
town a cathedral school, the first of its kind in Spain. At this school,
according to his biographers, Isidore acquired a knowledge of Latin,
Greek and Hebrew. Whether he ever had more than a smattering of
Greek is doubted by his modern critics.
1 At a meeting of the Section, held March 19, 1919.
Section of the History of Medicine 71
Spain, whose population was orthodox in religion, had suffered
persecution at the hands of its Arian Gothic rulers for nearly two
hundred years. Leander, a man of force and the chief of the orthodox
party against the Arians, undertook a journey to Constantinople to
seek the aid of the Emperor. There he became the friend of Gregory
the Great and translated that Father’s “ Morals ” into Latin for the
use of the Spanish clergy. At Constantinople Leander came in contact
with the relics of the old classical culture and, determined that what
was good in it should be available for the education of his priests, on
his return established the cathedral school at Seville.
In 586 King Reccared came to the throne, was converted by
Leander to the orthodox faith and in 587 religious peace was secured
for Spain. Leander died in 599 and Isidore succeeded him as Bishop
of Seville.
To put briefly the historical setting of Isidore. With the extinction
of the Roman Empire by the Goths in 476, the ancient institutions
and classical learning were fast disappearing. Classical paganism was
extinct, its last traces above ground belong to the age of Theoderic,
493-526. Philosophical paganism lingered on until Justitian in 529
suppressed the schools at Athens, the chief “ university ” of classical
antiquity and the last refuge of philosophical paganism. A year earlier,
528, St. Benedict had founded the monastery of Monte Cassino which
was to have so large a share in the preservation and diffusion of the
monuments of ancient culture, including those of medicine. In 538
Cassiodorus, to improve the education of the clergy in South Italy,
founded his monastery at Viviers (Vivarium) and according to its rule
the transcription of ancient MSS. was to be a particular care of the
monks. About 560 Isidore was born. Three years later St. Columba
was crossing from Ireland, the first of that succession of Irish
missionaries who for the next hundred years carried not only Christi¬
anity but a highly developed indigenous culture to Western Europe.
It appeared at one time as if Celtic culture would hold permanent
sway over the whole of Northern Europe, in fact its intellectual and
artistic influence was in full activity until the eleventh century.
In Spain a new civilization was being evolved from the blending of
the racial elements which made up its population. In the earlier years
of the Empire, Spain had been thoroughly Romanized and in its
culture was little inferior to Italy. Its language and literature were
Latin. Many of its sons had won distinction, the two Senecas, Lucan
Quintilian, Martial, Hyginus, Pomponius Mela, Columella, Orosius,
5
72
Fletcher: St. Isidore of Seville
and the Emperors Trajan and Hadrian. For nearly two hundred years,
however, the Goths had been in supreme control and their contempt
for learning had brought destruction to the old civilization. Isidore
realized that the spiritual and material welfare of the nation depended
on the full assimilation of the foreign elements and for this purpose he
employed all the resources of religion and education. He made Seville
an educational centre and encouraged the establishment of cathedral
schools elsewhere. In 633 the Fourth National Council of Toledo, at
which Isidore presided, passed a decree ordering these schools to be
organized in every Spanish diocese. At his own school in Seville, the
study of the Seven Liberal Arts and Greek and Hebrew were prescribed
while interest in the study of medicine and law was encouraged. Long
before the Arabs had awakened to an appreciation of Greek philosophy,
Isidore had introduced Aristotle to his countrymen. He was the first
Christian writer to attempt the task of compiling a “ summa ” of
universal knowledge. This, the Etymologiae, is an encyclopaedia
epitomizing all ancient learning as well as that of his own time. Many
fragments of classical culture which would otherwise have been lost
are enshrined in its pages. The work sprang into immediate popu¬
larity and gave a new impetus to encyclopaedic writing which bore
abundant fruit in the Middle Ages. The influence of Isidore on the
educational life of the Middle Ages was immense. The eighth Council
of Toledo, held in 653, seventeen years after his death, calls him “ the
extraordinary doctor, the most learned man of the latter ages: ”
Montalambert describes him as “ le dernier savant du monde ancien.”
Braulio, Bishop of Saragossa, his friend and contemporary, at whose
request Isidore compiled the Etymologiae, says in his preface to that
work, “ Isidore a man of great distinction ... in him antiquity
reasserted itself, or rather our time had in him a picture of the wisdom
of antiquity . . . God raised him in recent times, after the many
reverses of Spain, I suppose to revive the works of the ancients that
we might not always grow duller from boorish rusticity.”
Isidore, the last of the Latin Fathers of the Church, died a.d. 636.
The Church canonized him as a Saint, and Dante admitted him into the
select company of the “ Paradiso.”
The literary output of Isidore was enormous. To the student of the
Natural Sciences and Medicine the interest lies in certain books of the
Etymologiae —Book IV, on Medicine ; Book XI, on Man and his Parts ;
part of Book III, on Astronomy; Book XIII, Meteorology and the
Elements, Healing Springs; Book V, The Seasons; and Book XXII,
Section of tlie History of Medicine
73
on Diet. In his work “De Natura Rerum,” he gives his view of the
physical universe: in “ De Ordine Creaturarum ” we find the same
subject treated. In the “ Libri duo Differentiarum ” we have the
constitution of man, similar to and supplementing Book XI of the
Etymologiae. In the “ Sententiarum ” we have the microcosm
explained by the macrocosm.
One word with regard to “ De Natura Rerum,” a very popular work
in the Middle Ages. This is a manual of elementary physics, com¬
posed at the request of King Sisebert, to whom it is dedicated. In the
preface Isidore says that he has consulted not only Christian but pagan
writers. There has been much misunderstanding by many modern
writers regarding the condemnation of pagan philosophy by some of the
Fathers of the Church. One cannot tell here in full how some of the
early Fathers in an attempt to further their apologetic work among
the pagans tried to set forth Christian teaching in the terms of
Greek thought: how at Alexandria, the heart of the movement, specu¬
lative thought passed all bounds and became the mother of serious
heresies: how in consequence the Eastern Fathers viewed the study
of pagan literature with grave suspicion, and the Western Fathers in
fright banned it absolutely. The ban was never strictly observed, and
in time, when paganism was a dead force and only a memory, the
restriction was practically disregarded. As far as Isidore was con¬
cerned he adopted the opinion of St. Augustine, whose words he quotes
(Etymologiae I, 43, i). “ The histories of the pagans do no harm when
they speak of what is profitable,” and no Christian writer either before
or after him showed a more liberal mind in this respect: in fact the
essentials of the Etymologiae are derived from the pagan and not the
Christian side of Latin tradition. “ De Natura Rerum ” is the only
work in which Isidore regularly notifies in the text the sources of his
information. His principal authorities are St. Ambrose, St.
Augustine, St. Jerome, the Pseudo-Clementine Recognitions, Sue¬
tonius, Solinus, Hyginus, Macrobius, Aratus, Cicero, Pliny, Lucretius,
and of course the Servian Commentary on Vergil. Ptolemy he knew
at least by reputation through Cassiodorus, whom he quotes in
Etymologiae, lib. III.
The main thesis of this work is the Kosmos, as seen in the first
chapter of Genesis, interpreted through an adaptation of Hellenic
thought. Isidore draws largely on the Hexameron of St. Ambrose,
who in turn was dependent on the Hexameron of St. Basil, and Basil
again owed much to the views of his teacher Origen. It may be
74
Fletcher: St. Isidore of Seville
noted in passing that Basil, according to the testimony of his friend
and admirer St. Gregory Nanzianzen, possessed a knowledge of
medicine among his many accomplishments.
The Etymologiae or Origines takes its name from the subject matter
of one of its books. These, twenty in number, comprise an encyclo¬
paedia or dictionary of all knowledge: “ about all that ought to be
known,” says Braulio, their editor. The work is a compilation from a
large number of authorities, many of them centuries old ; Isidore’s own
personal view is not given, he is content to give the views of
others, sometimes, but rarely, naming the sources of his information.
The object of the Etymologiae apparently is to give by way of a
vocabulary the definitions of the technical terms employed in the arts
and sciences. It follows the traditional principle of classical education
that the stepping stone to knowledge is by way of words explained by
reference to their origin. Isidore’s literary style is simple and easy to
read, but not classical; he writes in the ordinary language of his day,
and shows the imperfections inherent in an age of transition. It
shows an increasing Gothic influence, many Spanish words, over 1,600
being found in his works. The Etymologiae is without doubt a vast store¬
house in which is gathered, systematized, and condensed all the learning
current in Isidore’s day, and the proof of its utility and popularity is
that during the greater part of the Middle Ages it was the text-book
most in use in educational establishments. The number of MS. copies
of the work must have been enormous, and many remain. Even the
Benaissance did not diminish its esteem, for ten editions were printed
between 1470 and 1529. I can make no attempt to give an account of
the authors whom Isidore laid under contribution for the whole work;
150 Christian and pagan have been identified.
This work was written at the request of Bishop Braulio not long
before Isidore’s death, and from their correspondence we learn that the
entire work had not been received by him in 630. St. Ildephonsus
says that Isidore was engaged upon it until his last day, and left it
incomplete and uncorrected. The want of any opportunity to correct
and to revise may explain the difficulty experienced in the interpreta¬
tion of certain passages. Braulio, who edited the work, divided it into
twenty books: (1) Grammar, including Metre based on Cassiodorus
and Boetius; (2) Bhetoric and Dialectic, from Boetius’ translation of
Aristotle; (3) Arithmetic, Music, Geometry and Astronomy; (4)
Medicine ; (5) Law and Chronology.; (6) Ecclesiastic Books and Offices;
(7) God and the Heavenly and Earthly Hierarchies; (8) The Church
Section of the History of Medicine
75
and the Sects; (9) Language, Peoples, Kingdoms and Official Titles;
(10) Etymology based on the lost Pratum of Suetonius; (11) Man and
his Parts (mostly from Lactantius “ De Opificio Dei ”); (12) Beasts and
Birds; (13) The World and its Parts; (14) Physical Geography (13
and 14 based largely on Pliny and Solinus) ; (15) Public Buildings and
Koad Making; (16) Stones and Metals; (17) Agriculture, Plants;
(18) Terminology of War and Jurisprudence, Public Games; (19)
Ships, Houses, Clothes; (20) Diet, Domestic and Agricultural Tools,
Furniture.
Books I to III are of interest to us because they are taken up with
what, from the end of the fourth century, was known as the Trivium
and Quadrivium, or the Seven Liberal Arts, and Isidore, who believed in
a liberal education as essential to a physician, devotes Chapter XIII of
his book on medicine to the demonstration that the Seven Liberal Arts
are the necessary preliminary training of the doctor. 1 The Trivium
comprised grammar, rhetoric and dialectic, i.e., the science of language,
oratory and logic. It was known also as the Artes Sermocinales or
language studies. The group was considered elementary and called
trivium, a well beaten ground, like the junction of three roads. The
quadrivium consisted of arithmetic, geometry (including geography),
astronomy and music, or the mathematico-physical discipline: known
also as the Artes Reales vel Physicae, and called quadrivium, or road
with four branches. The term “ liberal ” as applied to the arts denoted
the education of a Freeman ( liber free), but by the time of Cassiodorus
the derivation was drawn from liber, a book, and the “ liberal ” denoted
book learning.
This system did not receive its full development until the Middle
Ages but in t*he history of education it extends backwards and forwards,
to the Greeks and Bomans on the one hand, and beyond the Middle
Ages on the other. It is beside our purpose to-day to trace its
development and to show the influence which Pythagoras, Plato and
St. Augustine had in the making of the system.
There were two books which undoubtedly had an influence on
Isidore: (1) The Satyricon of Martianus Capella, written at Carthage
at the beginning of the fifth century. Books I-III, Nuptiae Philo-
logiae et Mercurii contain an allegory in which Phoebus presents
the Seven Liberal Arts as maids to the bride Philology. In the
1 Philosophy was ever considered as the culmination of these studies and “ medicine, as
they say, is the sister of philosophy “ (Tertullian, “De Amina”). Galen had insisted in a
special treatise “ Quod optimus medicus sit quoque philosoplius.”
76
Fletcher : St. Isidore of Seville
remaining seven books each of the Liberal Arts presents the sum of
her teaching. (2) De Artibus ac Disciplines Liberalium Litterarum,
by Marcus Aurelius Cassiodorus, a little book of simple treatment on
the Seven Liberal Arts intended for the use of clerics. Cassiodorus,
the skilful minister of the Ostrogothic dynasty, when seventy years of
age (c. a.d. 538), gave up public life and retired to his estate in the South
of Italy. There he founded the Monastery of Vivarium (Viviers) and
passed the remaining years of his life. His great object in founding
the monastery was to elevate the standard of education among
ecclesiastics, inducing them to study the models of classical antiquity
and to extend their general knowledge by research. For this purpose
he formed a library, spent large sums of money in the purchase of
manuscripts, and established a scriptorium for their careful reproduction.
To him we owe indirectly the preservation of many precious relics of
ancient genius. We know nothing of the later history of this monastery,
but its library, or a considerable portion of it, is believed to have found
its way to Bobbio, and since the destruction of Bobbio some of the MSS.
have been preserved at Verona.
I am convinced that Isidore wished to do for the Spanish clergy
what Cassiodorus attempted to do for those in Italy. He certainly
imitated the De Artibus in his Etymologiae, I-III, and that Book IV
on medicine follows was probably due to the encouragement which
Cassiodorus gave to his monks to study this science. In De Institutione
Divinarum Litterarum, cap. 31, Cassiodorus explains to his monks that
a knowledge of medicine is very necessary for those who have care of
the sick and, as he commands that no monk is to accept any earthly
reward for such labour, it is evident that their ministration to the sick
extended beyond the walls of the monastery. For those who cannot
read Greek, he recommends first the Herbarium of Dioscorides, in
which the plants are shown (? dried) and their .properties described:
then the works of Hippocrates (probably the Aphorisms) and the
Therapeutica Galeni ad Philosophum Glauconem; all of which, he says,
we have translated into Latin. Also for their study is an anonymous
author “ who has collected his material from various authorities ”:
possibly this may be Cassius Felix or the Synopsis of Oribasius. Then
he recommends Aurelius Coelius’ de Medicina and Hippocrates' De
herbis et curis, and “ many other works on the art of healing which
through God’s help I have stored away in our library ” (in sinibus
bibliothecae reconditos ). Reconditos suggests MSS. on special subjects
stored away as not for general reading. An interesting question arises,
Section of the History of Medicine
77
whether “Aurelius Coelius” is Aurelius Celsus or Coelius Aurelianus.
The title of the work of Celsus is De Medicina, and no work of
Aurelianus is known under that designation. At Vivarium therefore
in the sixth century there was a fair collection of books on medicine by
both Greek and Latin authors. Isidore had an extensive library of
general literature and, as we shall see presently, one of the chests was
reserved for works on medical subjects.
In presenting his information in encyclopaedic form, Isidore was
following a literary tradition which had its origin under the Empire.
Roman culture in its decline sought to generalize rather than to
specialize and hence arose the tendency to epitomize knowledge.
In this way originated the works of Varro, Verrius Flaccus, the elder
Pliny, and Suetonius. Varro and Verrius set themselves to reduce the
mass of accumulated knowledge to order. Their compendia included
grammar, word deriviation, philology, antiquarian history, &c.
• Varro (b.c. 116 a.d. 28) wrote Antiquitatum Berum Humanarum
et Berum Divinarum in twenty-five and sixteen books respectively.
Books II-IV were “ on Man.” The whole of the original work has been
lost but much of the second section is contained in St. Augustine’s
De Civitate Dei and fragments of other parts are found in the works
of later writers, many of them in those of Isidore. Varro also wrote
Disciplinarum, lib. xi, a treatise on the Seven Liberal Arts, &c.; the
eighth book on medicine. This work is said to have been lost before
the time of Isidore.
Verrius Flaccus (latter half of first century a.d.) wrote De
Verborum Significatu, a work of pure Latinity much quoted by later
authors. The original has been lost, but not I think before the time of
Isidore. Our present knowledge of the work is mainly through the
epitomes of Pompeius Festus and Paulus Diaconus. Festus, whose
date is uncertain (after Martial and before Macrobius) made an
abridgement of Verrius, cutting out all archaic words and anything
which he thought superfluous. He copied obvious clerical blunders and
had apparently little scholarship. These epitomes, from the greater
ease with which they could be reproduced, are probably responsible for
the loss of the larger works. Paulus in the eight century made a
similar abridgement of Festus. Pliny the Elder (a.d. 23-79) arid
Suetonius (a.d. 75-160) were also compilers, but in their case natural
science was brought into the foreground. Unfortunately it was merely
extracts from numerous authors, reproduced and arranged without any
critical judgment. Isidore was much indebted to both of these authors.
78
Fletcher: St. Isidore of Seville
The Natural History of Pliny is extant and well known to you all:
the principal work of Suetonius, an encyclopaedia in at least ten books,
is lost, only some fragments remaining. Isidore drew much of his
information from the Prata, another lost work of Suetonius. It is said
that the Prata inspired the general plan of the Etymologiae as well as
many of its details.
At the beginning of the fourth century Nonius Marcellus of
Thubursicum, in Numidia, compiled for the use of his son an
encyclopaedia in twenty books entitled De Compendiosa Doctrina.
It is not a literary production and critics accuse Nonius of either
ignorance or carelessness in the compilation. The value of the work
lies in the fact that Nonius was of the conservative school and used
no post-Augustan authorities, in consequence he has preserved many
fragments of the early Latin literature, including numerous quotations
from Yerrius Flaccus.
It is beside my purpose to discuss the indebtedness of Isidore to
each of these authors. In fact the question of the exact source is a
complicated one, and classical students are not of one mind on the
relation of these authors to one another, or of Isidore to them. For
instance Isidore draws largely, one would say, from the Vergilian
Commentary of Servius. In Etymologiae Book IV, on medicine, and
Book XI, on man, I have collected thirty-three apparent references.
Professor Nettleship, however, is of the opinion that Servius and
Isidore were indebted to a common source, probably Verrius Flaccus.
Other scholars think differently and it is not for me to decide between
them. That the Servian Commentary was known to Isidore I do not
doubt, considering the extraordinary position of eminence which Vergil
held in the schools. The children in the Roman schools were taught by
reading standard authors, the teacher providing a running commentary
on the text. The scholars committed to memory a store of quotations
from the early poets and historians, and it was largely owing to this
influence that Vergil came to occupy and retain so large a place in the
intellectual and moral life of the Romans. From the second century
the jEneid was regarded as a great compendium of learning, a history
of gods and men. In the Christian schools Vergil was the one pagan
author never forbidden : with its full commentaries like that of Servius
there was no more useful text-book and it kept its popularity through
the Middle Ages. Dante, you may remember, much as he would have
liked to have canonized Vergil, was unable for chronological reasons to
make him a Christian and so had to place him in limbo: but if he
Section of the History of Medicine
79
cannot place Vergil in Paradise, he does the next best thing, he converts
Statius to Christianity by means of the Sybylline strains of the poet’s
“ Pollio.”
We will turn now to Isidore’s presentment of science and commence
with his view of the Kosmos. All his work is a mosaic of borrowings
and as may readily happen in the case where the compiler has no special
scientific knowledge, inconsistencies occasionally creep in.
The Constitutiofi of Matter. —The origin of the visible universe had
long perplexed the philosophers. As their knowledge was confined to
the observation of the more obvious phenomena they were unable to do
more than hazard conjectures respecting their probable causes. The
result was a number of fanciful hypotheses sanctioned by the names of
the leading Greek philosophers. Hence arose the eternal chaos of the
Stoics, the shapeless mass of Aristotle, the self-existing atoms of
Democritus, &c. In Isidore’s day the Four Elements postulated by
Empedocles (or rather by Athamas the Pythagorean) held sway. Plato
had given them the name o-To^eta, which Latin writers translated
elementa. Isidore admits, as the primary constitution of matter, the
four elements: of fire from which the heavenly bodies derive their
light; of air destined for the support of animal existence; of water
which surrounds and binds together the globe on which we live; and of
earth, the heavy inert matter of which the globe is mainly composed.
To the different combinations of these elements with the additional aid
of the Four Primary Qualities, heat, cold, moisture, and dryness he
attributed the various properties of bodies and the exhaustless fecundity
of nature. These four elements were not simple but the visible
manifestations of one underlying matter : this primary matter was a
substance devoid of all qualities but susceptible of all forms and qualities.
The elements were not mutually exclusive but all elements exist in all
and therefore it was possible for one element to be transmuted into
another (“ all things are convertible into all things ”—Aristotle) (see
fig. 1). “ For water is formed from earth and air from water: ether
from air : and then inversely from ether air, from air water, and from
water earth which is the lowest in the scale ” (Cic., De Nat. Deor., II, 33).
The elementary qualities are not invariable but, as a rule, fire is hot and
dry; air, hot and wet; water, wet and cold ; earth, cold and dry. Each
successive pair has a common quality and by means of this common
quality one element can pass into another. In all this Isidore follows
Plato and Aristotle through St. Ambrose and St. Augustine. The
peripatetic theory of the fifth essence, “ Quintessence,” as distinct
80
Fletcher : St. Isidore of Seville
from the four elements, finds no place here. St. Basil had noticed the
theory not without scepticism, and the Fathers of the Church generally
did not adopt it.
Isidore follows the usual arrangement of the cosmographical works
of his time, based on Aristotle’s four books “ On Meteors ” and four
books “ On the Heavens,” but his spirit is quite different from similar
Greek and Latin works. While he gives a summary of astronomy,
meteorology and geography his principle is to cite all allusions to them
in Scripture and in the writings of the Fathers, also in passages from
the poets and pagan literature, but little or no consideration is given to
their scientific elucidation. With Isidore, or with Ambrose from whom
he quotes largely, science is only useful to them to explain the first
chapter of Genesis.
In the Universe, according to Isidore, the elements arrange them¬
selves in strata according to weight—fire uppermost and in succession,
air, water, earth (fig. 2).
In the constitution of man the elements have their part. Man is
explained by the universe. Man’s body therefore .contains the four
elements. He has in him something of fire, air, water and earth.
There is the quality of earth in the flesh, of moisture in the blood, of
air in the breath, and of fire in the vital heat. This recalls Cicero in
De N. D., II, 18. “ If anyone should ask the source from which we
have the moisture and heat which are diffused throughout the body, the
earthly firmness of the flesh and the air we breathe, it is clear that we
have taken the one from the earth, another from liquid, another from
fire, and another from the air which we inhale.” So also as the elements
in the universe are arranged in strata the human body must correspond.
The head - corresponds to the heavens, the eyes, as two luminaries, to
the sun and moon. The chest corresponds to the atmosphere and
the breath to the winds. The belly corresponds to the sea because
all the humours are collected there, and the feet correspond to
the earth because like it they are dry (fig. 3). The mind of man is
placed in the citadel of his head, like God in the heavens, to rule and
govern. In a passage in the Differ. II, 16, 17, fire has its seat in the
liver, thence it flies to the head as to the heavens of the body. From
this fire come the rays which flash from the eyes, and from the middle
of this fire narrow passages lead not only to the eyes but also to the
other senses.
Before leaving the elements let me remark in passing a tit-bit
contained in the Greek original from which the Pseudo - Clementine
COLO
82
Fletcher: St. Isidore of Seville
Recognitions was derived (it is not in Isidore). Bufus who made the
translation from the Greek tells us of several parts which he omitted,
one was that the devil was the result of an accidental mixture of the
elements.
Belated to the four elements and the four elementary qualities were
the Four Humours. Each humour had its corresponding element
and shared the qualities of that element (see fig. 1). Blood like air,
was hot and moist: phlegm, like water, cold and moist: yellow bile,
like fire, hot and dry: and black bile like earth, cold and dry. In youth,
blood abounds; in early manhood yellow bile; in middle age, black
bile ; and in old age, phlegm. The bodily constitution varied according
to the proportion in which these qualities were mixed, and the particular
constitution was accordingly called the “ mixture ” (icpao-i?) or its
Latin equivalent temperamentum, hence our word temperament. In
the state of health there was a harmony between, or a temperies of the
elementary contraries, hot, cold, moist and dry. Disease was due to
an excess or a defect, intemperies, of one or more of these qualities
so that Hippocrates described the art of medicine as “addition and
subtraction; the addition of that which is deficient, and the with*
drawal of what is in excess.” Acute diseases were produced by an
excess of the two hot humours, blood and. yellow bile ; chronic diseases
by an excess of the cold humours, phlegm and black bile.
The Four Elements, Four Qualities and Four Humours formed the
basis of Classical and Mediaeval Physiology and Pathology. They have
been aptly described by Dr. Singer as “ The Physical and Physio¬
logical Fours.” We have often laughed at this “humoral theory”
which held its own for so many centuries, but has it not struck you
in the last year or two that the ancients are finding some justification
for their humoral theory in the light of biochemical research, particu¬
larly in that part dealing with the internal secretions, and some
justification for their belief in the transmutation of the elements in the
light of research into the nature of radium ?
I must notice very briefly some other points in Isidore’s general
view of the universe.
The phenomena of meteorology are explained largely by the
elements. The upper air is akin to the fire above it and therefore
calm and cloudless; the lower air akin to the water in its proximity
and therefore cloudy, and disturbed ( Etymologiae , XIII, 7, 1). The
clouds are formed of condensed air which on further condensation
is converted into water as rain (Ibid., caps. 3 and 7). In the explanation
84
Fletcher: St. Isidore of Seville
of the seasons the qualities of the elements are used. Spring is
composed of moisture and heat; summer of heat and dryness ; autumn
of dryness and cold; winter of cold and moisture ( De Nat. Rer., 7, 4 ;
Etymologiae,N, 35, 1). To complete the cycle of “Fours” the four
quarters of the compass are connected with the seasons and the
elements (figs. 4 and 5), and the winds also have their separate relation
to the four elements and through them to the four humours. Thus
serving to explain the influence which the seasons, winds, &c., were
thought to exercise upon the human body, a point made prominent in
the aphorisms of Hipprocrates and noted by Isidore ( Etymologiae,
IV, 4).
Isidore holds with Hyginus that the earth is spherical, but in his
diagram (fig. 6) of the five zones into which the Greek philosophers
divided the earth, he treats it as a flat surface. I place beside it for
comparison a diagram from Macrobius. 1
The Heavens are plural ( De Nat. R., XII). Coeli enarrant
gloriam Dei ” sang David, therefore it must be so. Therefore in
addition to the solid and mobile heaven known to pagan astronomers
and called the firmament, there was above it a heaven of waters,
according to the words of the Psalmist “ et aquae quae super coelos
su 7 it, laudent nomen Domini." Above this again was a third heaven,
the abode of spirits ( De Nat. R., cap. 13 and 14). This curious
hypothesis was adopted by most of the early Christian cosmographers
and had an important influence on mediaeval astronomy (fig. 7).
Like all of his time Isidore believed that the heaven i6 a sphere,
rotating round an axis, having the earth in the centre {Etymologiae,
XIII, 5; III, 31-32). Philolaus, a follower of Pythagoras (not Pythagoras
himself as so often stated), had suggested that the centre of the
universe was occupied by the sun, round which the heavenly bodies
revolved. His conclusion was formed not from the observation of
phenomena, but from the principles of a fantastic geometry, the
the mysteries of the Pythagorean system of numbers requiring that the
sun should be so placed {see Arist. I, p. 363; Laert. I, viii, 85). His
opinion, however, was so repugnant to the daily illusion of the senses
that his theory was rejected, and for centuries before Isidore the
philosophers had taught that the earth is suspended in the centre and
equally poised on all sides by the pressure of the revolving universe.
They adopted the system of Ptolemaeus Claudius and from them it
1 I think this is only a case of copying a diagram, for in Etymologiae , XIV, 5, 17,
in speaking of Africa, Isidore refers again to the spherical shape of the earth.
Section of the History of Medicine
85
was received by the Fathers of the Church and adjusted with a few
modifications to Christian use. This Ptolemaean system held sway
without opposition until scientifically disproved by Nichole Oresme,
Bishop of Lisieux, mathematician and physicist, in his treatise TraiU
du del et du monde ” written in 1377. Oresme is one of the principal
founders of modern science; in astronomy he forestalled Copernicus,
as in the invention of analytical geometry he forestalled Descartes.
Isidore borrows from Ambrose (echo of Basil) the flux and reflux of
the sun and its effect upon the moon ( De N. B., 16). He takes from
Augustine, who had it from Pliny or Chalcidius, the hypothesis of the
attraction exercised by the solar rays causing retrograde movement of
Venus and Mercury (. Etymologiae III, 66). From Ambrose he takes
his view of the nature of the sun and the suggestion that it is
replenished by water, supplied by exhalations from the ocean situated
in the torrid zone ( Etymologiae III, 49). Thales was originator of this
theory which we find in Aristotle ( Meteor . I, 3), Cicero (D. N.D. I, 10)
and Basil ( Hexam .). Isidore held that man is a microcosm or parallel
on a small scale of the universe or macrocosm. Man contained the
same four elements, distributed in much the same way, and all things
are contained in man and in him exists the nature of all things. In
short that man could be explained by the universe and the universe be
explained by man.
We pass now to the fourth book of the Etymologiae, the De
Medicma.
With regard to the text. Of printed editions there have been many,
the best of the Omnia Opera is, I believe, that of Arevali, printed at
Rome, 1797, annotated by Grial and Arevali: this has been reprinted
in Migne’s Latin Fathers, vols. LXXXI-LXXXIV. The best text of the
Etymologiae is undoubtedly the recension of Professor W. M. Lindsay,
Clarendon Press, 1911. Lindsay gives particulars of thirty-six MSS.,
containing all or part of the Etymologiae. Of these four are in
England : Harleianus lat. 3034, lib. I-XX, eighth century ; Harleianus
lat. 2686 extracts lib. XV-XX, ninth century (both in the British
Museum); Colleg. Begin® Oxonii 320 ninth century; Colleg. S. Trinit.
Cantab. 368 ninth century, lib. V, 31-IX, 7, 28. There are also at
Oxford portions of the Etymologiae in a twelfth century MS. at Oriel,
a thirteenth century MS. at Balliol, and an eleventh century MS. at
Trinity. I have not been able to examine any of these MSS., but
hope to do so later—at least those which contain Books IV and XI.
From whom did Isidore obtain his medical information ? In
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Fletcher: St. Isidore of Seville
tracing the sources of Isidore, as with other writers of his time and of
those before him, the initial difficulty is that although all his information
is borrowed, it is seldom that any acknowledgement is made of the
indebtedness. In early days little heed was paid to such formalities,
and the old authors, like the primitive Christians, seem to have had all
things in common. In the whole of Book IV the only names men¬
tioned are those of Varro, twice for the derivation of words, Ezechiel
and St. Paul approving medicines, Vergil with quotations, Horace and
Julius Caesar in connexion with drugs, David and Asclepiades as ex¬
ponents of the influence of melody on malady. Of these Asclepiades
is the only one with any special knowledge of medicine. The library
of Isidore was contained in fourteen armaria (presses) adorned with
the portraits of twenty-two authors. From the elegiac verses which
Isidore wrote to commemorate these authors, we learn that over the
press containing the medical MSS. were the portraits of SS. Cosmas
and Damian, Hippocrates and Galen. The SS. were patrons of the
art of medicine, not authors, as far as we know, but the choice of
Hippocrates and Galen show a critical discernment. Isidore unfortu¬
nately gives us no list of his medical books, but shall we be far wrong in
thinking that, following Cassiodorus in many things, he had among
others collected the works recommended by that Father to his monks.
Dioscorides, Hippocrates, Galen, Ad Glauconem, all of which were
to be had in Latin translations, Caelius Aurelianus or possibly
Celsus. Who was the anonymous author possessed by Cassi¬
odorus? Possibly the Compendium of Oribasius or that of Cassius
Felix. Isidore certainly possessed a copy of Cassius, but I am
doubtful about Oribasius, and think that Isidore’s source of Galen was
an epitome of that author corresponding to those found in the Middle
Ages. There is one passage in Etymologiae, Book TV, which bears a
striking identity with a passage in the De Medicina of Celsus. In
Book XVII, 1, Isidore cites Cornelius Celsus by name as one of his
authorities, De rebus rusticis, from which it would appear that he
knew the lost De re rustica of Celsus; unfortunately the whole list
of authorities has been borrowed from Columella, and Columella’s own
name added to the list.
It has been often stated that Isidore was indebted to Cselius Aure¬
lianus De morbis acutis et de morbis tardis for nearly all of his book
on medicine. This is too wide an estimate. As far as medical authors
are concerned Book IV has been compiled from the works of two
opposite schools: the Methodist, represented by Aurelianus, who
Section of the History of Medicine
87
supplies the material for nearly all Chapter VI on acute diseases, and
Chapter VII on chronic diseases ; the second the Logical (or Bational
or Dogmatic) school, represented by Hippocrates, Galen and Cassius
Felix, supply material for most of the other chapters. The chapter on
drugs is from Scribonius Largus, Pliny, Theophrastus and Dioscorides.
With the exception of one or two passages, the sources of which I have
not yet identified, the following is a list of authorities used by Isidore
in Book IV de Medicina.
Fathers of the
Church.
Lactantius.
St. Ambrose.
St. Augustine.
Tertullian.
Cassiodorus.
Papias.
Pseudo-Clementine
Recognitions.
Physicians.
Prose Writers .
Hippocrates, fifth century b.c.
Galen, second century a.d.
Scribonius Largus, first century
A.D.
Soranus, second century a.d.
Serenus Sammonicus, third
century, a.d.
Theodorus Priscianus (?), fourth
century a.d.
Cassius Felix, fifth century a.d.
Crolius Aurelianus, fifth century
Cicero.
Seneca.
Plato.
Aristotle.
Varro, Verrius,
&c.
Lucilius.
Aulu8 Gellius.
a.d.
Theophrastus.
Dioscorides.
Poets.
Lucretius,
j Vergil.
Servian Com¬
mentary.
Ovid.
1 Horace.
Of the medical authors, there is no need to make any comment on
Hippocrates and Galen, and, with the exception of Aurelianus and
Cassius, the remainder have but a small share in the book. Of Caelius
Aurelianus one must say a few words. There is no definite knowledge
regarding the date at which he flourished, but by a process of deduction
it is believed that he lived in the fifth century a.d. Nothing is known
of his life, but from the description Siccensis applied to him in manu¬
scripts he is thought to have been a native of Sicca Veneria, in
Numidia. His only work which has survived is the De morbis acutis
et de morbis tardis, a fragment of his work on diseases of women, and
probably a fragment of his book on fevers. From the preface to his
book on acute disease we learn that he had written a work on surgery
(Xeipovpyovfieva), Besponsionum libri (a general work on medicine),
Muliebrium passionum, Graecorum epistolarum ad Praextatum, Ad-
jutoriorum sive Medicaminum. It is also known that he wrote a
book on fevers, and one on the preservation of health. Some of his
works were in Greek, for he says that he dedicated the Besponsionum
libri to Lucretius, who was an adept in that language, and that he
wrote De acutis morbis in Latin for the use of his pupil Bellicus, who
knew not Greek. His Latin is barbarous, as judged by classical
6
88
Fletcher: St. Isidore of Seville
standards, and his Greek not much better. One does not expect purity
of style or diction from a Punic author, but Aurelianus certainly makes
hard reading. The subject matter of his book on acute and chronic
disease is full of valuable information. It is usually stated that this
book is a work of Soranus, which Aurelianus translated into Latin.
This may be correct, but I have doubts about it; the impression which
a perusal of the preface and certain remarks in the text have left upon
my mind, is that the book is an abbreviated edition in Latin of his
Responsionum libri. Aurelianus was a devoted disciple of Soranus, and
loves to quote him as his authority : it is certain also that the book is
essentially the teaching of Soranus, but I should hesitate to accept the
view that it is a mere translation. Aurelianus does not hesitate to
criticize his beloved master when he thinks it necessary.
Aurelianus was a zealous member of the Methodici, and it is
principally from his work that we are able to obtain a correct view of
the principles and practices of this medical sect. The book on “ Acute
and Chronic Diseases ” is a compendium of medicine, uniform in design,
the arrangement being’much more like our present system of describing
disease than is found in any other medical author of antiquity known
to us. Aurelianus commences with the definition of the disease, its
Greek and Latin names: then the technicalities of the disease are
clearly and shortly described, the material being arranged upon the
usual plan of the time caput ad calcem. He gives the aetiology,
symptomatology, pathology (frequently with anatomical additions),
diagnosis and treatment. One great feature is that Aurelianus makes
use of all preceding medical literature from Hippocrates to Soranus:
he mentions eighty-nine physicians and authorities: the opinions of
some are quoted frequently, Hippocrates twenty-four times, Asclepiades
forty-seven, Themison thirty-nine, &c. Despite the want of style the
symptoms of disease are depicted in living colours : differential diagnosis
is developed with an accuracy not found before him and physical
examination is not neglected. To give an example of his method
take the first disease mentioned, Phrenitis : (1) Definition; (2) Dif¬
ferent views on causation; (3) Prodromata; (4) Symptoms; (5) Dif¬
ferential Diagnosis from furor, melancholia, pleuritis, peripneumonia,
and certain poisons. (6) Treatment: (a) Soranus-Methodist; ( b )
Diodes and Erasistratus-Dogmatic; (c) Asclepiades; (d) Themison-
Methodist; (e) Heraclides-Empiric.
It was probably on account of the clear description of disease
and the fullness and simplicity of the directions for treatment that
Section of the History of Medicine
89
Cassidorus * recommended the work of Aurelianus to his monks and
Isidore made use of it. The book was popular in the early years
of the middle ages and found among the Salernitan collections.
As it is impossible to consider in detail the description of diseases
in Isidore’s book, let me put before you a short general statement of the
Methodist standpoint in regard to medicine. Asclepiades adopted the
doctrine of Atomism and applied it to medicine. He conceived the
human body as built of pores (07*04) on the movement of which
life depended. Combinations of these atoms formed innumerable tubular
spaces—the pores of the body—endowed with sensation. In the tubular
spaces atoms of different sizes were in constant movement, and along
them flowed the stream of body juices. All the physiological processes
were considered as purely mechanical. Health was dependent on the
proper proportion of atoms (o-opperpia) to pores, so that free move¬
ment could take place. Disease was primarily referred to a disturbed
movement of the atoms (everracns, (miens) . Themison, the successor
of Asclepiades, held that by a comparison of one disease with another
certain common characteristics were evident. That all diseases, acute
or chronic, could be classified into genera, and these again into two
fundamental varieties ( KoivorrjTes , communicates) —viz., the condition of
tension (o-Teyvaxris, status strictus), or the condition of relaxation
(pxxns, status laxus), both dependent on the condition of the pores.
A further step was to classify all acute diseases as due to a status
strictus and chronic to a status laxus. This simplified, at least in
theory, the question of treatment which was to consist in counteracting
the constriction or relaxation of the pores by therapeutical measures
acting upon the whole body. From the adoption of this cut and dried
theory his followers were called Methodici. According to them “ medi-
cina est methodus inveniendi morborum KoiveoTijras quae simulper se sit
evidens.” The later disciples, like Aurelianus, though adopting the
theory in general, were much more rational in their practice. Aure¬
lianus treats the body as a whole, but his attention is also directed to
the part affected. Holding a pathology of “ solidism,” the Methodists
paid little consideration to the humours or the pneuma.
Their line of treatment was that of safety, using general remedies
and never resorting to heroic measures. All specifics were rejected and
Aurelianus poked fun at those who used them. The treatment for the
first three days was expectant—fasting, massage, warmth and friction.
Much care was bestowed on the environment of the patient, the
ventilation and lighting of the sick room, the patient’s position in
90
Fletcher: St. Isidore of Seville
bed and his diet. During the second triduum, unless'the disease
was very acute, the treatment might include venesection or wet
cupping, sometimes leeches, sometimes dry cupping. Among the
general remedies for solution of tension were hot air, soft clothing,
rinsing out the mouth with hot water or sweet oil, fasting, unctions,
warm baths, poultices, venesection, wet cupping, gestatio, mild clysters
or emetics.
Those for a relaxed condition were, astringent and tonic measures,
cold affusions, poultices and baths; mouth rinsed out with cold water
and vinegar ; body sponged with posca (vinegar and water); wine ; local
application of alum to the skin; sleep, rest, narcotics, &c. Purgatives
were seldom used except in hydrops. Diuretics and sudorifics only in
a few cases. Convalescence, “ curatio recorporativa,” was very fully
considered. Cure was divided into five stages: (1) Primo —mild
astringents ; (2) In augmento —soothing and relaxing; (3) In statu —
soothing and relaxing ; (4) In declinatione —emollient; (5) In recoipo-
rativa —fortifying and building up.
The text of Aurelianus is, I feel certain, very corrupt. Unfortunately
the MS. from which the first edition of his “ Chronic Diseases ” was
printed in 1529, and that from which the “ Acute ” was printed in 1533
have been lost. In 1567 the two works were printed in one volume
and another edition appeared in 1569. Amman’s edition of 1708 is the
best and has been many times reprinted; the ninth edition, the one
I have had in use, is dated 1755.
Daremberg, in the preface to the first volume of his “ Oribasius,”
says that in the “ Collectio Salernitana ” of Renzi (Naples, 1857) is
a work of Gariopontus the Salernitan writer of the eleventh century,
and that this work includes two treatises, both very ancient, the one
attributed to /Esculapius and the other to Aurelius. In 1847 Daremberg
had published a MS. preserved at Brussels entitled “ Aurelius De Morbis
acutis ” which on examination was found to be an epitome of the
De morbis acutis of Aurelianus, and some observations on fever (possibly
part of the lost work of Aurelianus). iEsculapius is found to have a
great analogy with Aurelianus, and Daremberg was of opinion that from
a collation of these MSS. it would be possible to correct the text of his
De morbis acutis. Daremberg hoped to give us this amended text, but
even if he had time to complete it I do not think that it has been
published.
The work of Cassius Felix is a compendium, an epitome of the
theoretical and practical teaching of the dogmatic school. Written in
Section of the History of Medicine
91
a.d. 447 it has for title De medicina ex graecis logicae sectae auctoribus
liber translatus sub Artabure et Calepio consulibus. From the uncouth
Latin and the Punic expressions it is concluded that Cassius hailed
from North Africa. The works of Galen, especially Ad Glau-
conem, and the pseudo-Galenic Euphoriston are mostly drawn upon.
Nothing is known of Cassius. His work was first printed by Valentine
Rose in 1879, the text being a collation of three MSS., St. Gall 105,
eleventh century; Cambridge G. g. 32 chart, fifteenth century, and
Paris, lat. 6114, thirteenth century. Cassius, as well as Aurelianus,
was known to the Salernitan compilers of ancient medical authors.
The “ Medical Lexicon ” of Simon Januensis (c. a.d. 1300) has some
200 entries under his name, and the preface of this dictionary speaks of
the frequent use of his two works De practica. From that time until
our own day Cassius appears to have been unknown. Simon says that
Cassius borrowed much from Cornelio (Celsus) but I do not think this
statement is correct.
To these two writers, Aurelianus and Cassius, Isidore was most
indebted,—Aurelianus the mouthpiece of Soranus, and Cassius the
mouthpiece of Galen. “ Thus it came to pass that at the close of this
period of antiquity, Soranus the medicorum princeps and Galen the
physician of Pergamos found expression through the medium of Latin
translations ” (Neuburger) and were united by the hands of Isidore.
Isidore’s book on medicine is divided into thirteen chapters:—
Chapter I tells us that medicine is that which preserves or restores
the health of the body. To it belong, beside the usual medical subjects,
the questions of food, drink and clothing, and everything which protects
the body.
Chapter II: Medicine is derived from modus, i.e., moderation.
Nature is injured by any excess. This is the doctrine of the old
Greek philosophy, the application in the physical order of the “ Be
moderate ” of the Seven Sages. To the Greek moderation was the
virtue par excellence. Hippocrates, or the “ Timaeus” of Plato may
be the source of this chapter.
Chapter III: The Founders of Medicine. Its discovery by Apollo,
its development by iEsculapius his son ; the death of iEsculapius and
the eclipse of Medicine until the advent of Hippocrates. Isidore’s
sources are Pliny, Plato’s Republic, and Soranus.
Chapter IV : The Three Medical Sects. The Methodica, founded by
Apollo, depends on remedies and incantations and takes note of nothing
but the disease. The Empirica, founded by iEsculapius, depends upon
92
Fletcher: St. Isidore of Seville
experiment and not on the interpretation of symptoms. The Logica or
Rationalis, founded by Hippocrates, takes into consideration the age,
diseases, locality, climate, &c. I cannot find the source of this chapter,
it is not from Galen De sectis, nor from Celsus who has written the best
critical examination of the pretensions of the three sects. ThemisoD,
and not Apollo, was the founder of the Methodists. The Empirics and
not the Methodists used charms and incantations, the works of the
latter being as free from superstitious practices as those of the former
are full of them. If carmina may stand for musical therapeutics the
source was probably Methodist, and the reference to Apollo an impudent
claim to seniority.
Chapter V: The Four Humours. Sanitas is derived from sanguinis
status because the state of health depends on the proper composition of
heat and' moisture, i.e., blood. Morbus is derived from mors because
disease has something of death in it. Then follows the enumeration
of the four humours and their corresponding elements. Cholera (yellow
bile), so-called “ because it is terminated in the space of a day”; this
from /Esclepiades. Melancholia is the admixture of bile with the dregs
of black blood, i.e., the black residue of the hepatic digestion strained
off and carried to the spleen. Galen, who is followed in these early
chapters, held that a concoction took place in the liver and that 1 from
the crude blood of the venae portae was separated the yellow bile, which
passed to the gall bladder, then to the duodenum, and a heavy impurity,
the black bile, which passed to the spleen. Phlegm also was a waste
product from the blood, cold in nature, and served to temper the heat
of the choler and of the blood. Health depends on the mixture in
proper proportions of the qualities of the humours. In this chapter
Isidore’s source is Galen’s Med. Dejin. Following the same author,
acute disease is due to blood and yellow bile, chronic disease to phlegm
and black bile.
Chapter VI: On Acute Diseases.—The entry under each disease. is
quite short, merely a derivation of its name to show what it is. The
whole of the book in fact is merely a syllabus of diseases which Isidore
intended his students to investigate in detail in the medical MSS. in
the library. Perhaps intended as a syllabus for lectures. Phrenesis,
Cardiaca, Lethargia, Synanche, Pleuresis, Peripneumonia, Apoplexy,
Spasmus, Tetanus, Ileos, Hydrophobia, Phlegm one Stomachi, are
mainly or wholly from Aurelianus. Telum from Serenus Sammonicus;
Carbunculus from Cassius ; Febris from Varro. Pestis and Inguinaria
from Lucretius and the Clementine Recognitions.
Section of the History of Medicine 93
Chapter YII: On Chronic Diseases.—Cephalea, Epilepsia, Vertigo,
Mania, Melancholia, Catarrhus, Coryza, Brancho.s, Raucedo, Hsemo-
ptois, Phthisis, Empye, Hepaticus morbus, Lienosis, Hydrops,
Nephritis, Paralysis, Cachexia, Atrophia, Sarcia, Podagra, Arthritis,
Calculus, Stranguria, Dysenteria, Colica, Haemorroides, are from
Aurelianus. Tussis, Lienteria, Apostema, Ischias from Cassius. Part
of Epilepsia from Sammonicus and Apuleius. Mania from Cicero or
Plato. Rhagades possibly from Celsus. A humoral explanation is
attached to Vertigo. The arteries and the veins produce in the head a
windiness from the resolving of moisture and make a whirling in the
eyes. This would be a transmutation of the element of water into that
of air, whether from the phlegm in the ventricle or from the water of
the “almost fluid” brain (Aristotle and Galen) is not said. An
interesting statement concerning cerebral localization is attached to
melancholia. Epilepsy arises in phantasy, melancholia in reason and
mania in memory. Isidore was acquainted with the three ventricles of
the brain through St. Augustine (see Differ., II, 51). It was Poseidonios,
of the fourth century, who located imagination in the anterior ventricle
of the brain, reason in the middle and memory in the posterior
ventricles. Paralysis is said to be due to great cooling of the body.
Satyriasis and diarrhoea which Aurelianus includes among the acute
diseases, Isidore places among the chronic.
Chapter VIII: Diseases of the Surface of the Body.—From
Aurelianus none except part of Icteris and possibly Elephantiasis.
From Cassius Felix—Alopecia, Parotides, Erysipelas, Serpedo, Impetigo,
Prurigo (?), Scabies, Lepra and Frenusculi. Part of Icteris from
Pliny and Varro. Cancer from St. Augustine. Lentigo, Oscedo and
Furunculus from Sammonicus. Papula and Sanies from Servius Vergil.
Nyctalmus and Cicatrix from Plinjr (and Theodorus Priscianus). Of
Syringio (Fistula) we have only the name. Ordeolus, Ulcus, Vulnus,
Pustula I have not yet traced, but expect they may be from an Epitome
of Galen.
Chapter IX: Benefit of Drugs from Tertullian. Division of
remedial measures into Pharmacia, Chirurgia, Diaeta — great verbal
resemblance to preface of Celsus lib. I. Use of herbs as the start of
medicine from St. Ambrose. “Ex contrariis” and “ex similibus.”
Antidotes from Galen or possibly Hippocrates. Drugs with special
names derived from their properties. Hiera, Arteriaca, Theriaca, Cathar-
tica, Catapotia, Diamoron,Diacodion,Diaspermaton, Electaria, Trochisci,
Collyria, Epithemata, Emplastra, Catasplasmata, Malagmata, Enemata,
94 Fletcher : St. Isidore of Seville
Pessaria. From Pliny, Scribonius Largus, Cassius and Galen. Critical
days from Galen or Cassius. Chiron from Pliny and Servius Vergil.
Chapter X: Medical Books.—Aphorisms, Prognostica, Dynamidia,
Botanicum Herbarium. From Galen, Hippocrates, Servius Vergil and
Cassiodorus.
Chapter XI: Surgical Instruments.—Enchiridion, Bleeding lancet,
Scalpel, Sharphook, Probe and Spatula, Cupping instruments, Clyster,
Pestle and Mortar, Coticula. From St. Augustine, Aurelianus,
Cassius, Theodorus Priscia'nus, Varro, Servius, Nonius Marcellus.
Chapter XII: Perfumes and Ointments.—Thymiama, Incensum,
Stacte, Myrobalanum. Simple ointments, Telinum, Amaracinum,
Rosaceum, Cyprinum and Anethinum. Compound ointments, Cerotum
Chalasticum, Martiatnm. From Pliny, Columella, Theophrastus,
Dioscorides, Servius Vergil.
Chapter XIII: On the Preliminary Education of the Physician.—
From Galen, Hippocrates, St. Augustine, Cassiodorus, Aristotle.
Isidore says that some persons ask why medicine is not included
among the Liberal Arts. The reason is because each art deals with its
own particular subject but medicine embraces all of them. For the
physician must know Grammar that he may be able to understand and
explain what he reads; Rhetoric that he may be able to discuss his
subject; Dialectic (Logic) that he may rationally investigate the cause
and cure of disease: Arithmetic that he may be able to reckon the
intervals of periodic fevers; Music for its curative value; Astronomy
that he may be able to calculate the course of the stars and the change
of seasons. That is to say that the physician must have a knowledge
of the Seven Liberal Arts. Hence Medicine is called Philosophia
Secunda for philosophy and medicine both lay claim to man. By the
one the mind, by the other the body is cured. So said Aristotle.
I should like in conclusion to thank Dr. Singer for the help he has
given me in this study. Without his advice and suggestions it would
have been impossible for a beginner like myself to have attempted it.
Postscript. —Since this paper was written I have had the opportu¬
nity of reading De Vlcole de Salerne in La Mldecine, Histoire et Doctrines
by C. Daremberg. The author notes the strange mixture of the
teaching of the two opposite schools, Methodist and Galenic, in the
Salernitan MSS. prior to a.d. 1050. In Isidore, as I have shown, we
find the same curious feature some 400 years earlier. Daremberg says
that the early Salernitan MSS. present more of Methodism in their
details than in the general propositions. We find the same holds good
for the fourth book of the Etymologiae.
Section of the History of Medicine
95
SOME OP THE BOOKS CONSULTED.
Abevali. “ Isidori Omnia Opera/* edit, in Migne, lxxxi-lxxxiv,
Lindsay, W. M. “Isidori Etymologiarum,” lib. xx, Clarendon Press, 1911.
44 Liber Quartus Etymol.,” Ac., Commentario Simphoriani (1509).
Brehaut, E., Ph.D. 44 An Encyclopaedist of the Dark Ages: St. Isidore.*’
D’Ault-Dumesnil, E. “ Etude sur la vie, les oeuvres, et les temps de St. Isidore de Seville,”
L'TJniversitt Catholique , xvi.
Sandys, J. E. 44 A History of Classical Scholarship,” 1906.
Nettleship, Henry. “ Lectures and Essays,” 1885.
Graves, Professor. 44 History of Education before the Middle Ages,” 1911.
Laurie, Professor S. 8. 44 Lectures in History of Education, a.d. 200-1350,” 1886.
Duhsm, Pierre. 44 Le Syst£me du Monde,” 1915.
Dreyer, J. L. E. 44 Planetary Systems,” 1906.
C A3lius Aurelianus. 44 De MorbiB Acutis ” and 44 De Morbis Tardia,” Amsterdam, 1755.
The works of Verrius Flaccus, Festus, Paulus, Nonius, in the Teubener series.
The usual texts of the old medical writers.
Neuburger. History of Medicine.
WrtHiNGTON. Medical History.
Section of the 1>i0ton> of fl&efcidne.
President—Sir D’Arcy Power, K.B.E., F.R.C.S.
Survey of Medical Manuscripts in the British Isles dating
from before the Sixteenth Century . 1
Dorothea Waley Singer.
The medical MSS. form the largest group in the Catalogue of MSS.
of Scientific Material in the British Isles dating from before the
sixteenth century, on which I have been working for some years.
The formulation of this work has not been the result of an
abstract theory that it might prove a useful instrument of research.
In attempting to trace the rise and development of scientific thought
Dr. Singer and I were soon confronted by the paucity of available
mediaeval material.
From the ancient classical period we have abundant survival, printed
and thoroughly edited. We really can picture to ourselves something of
the outlook and practice of the great minds of science and of medicine—
both in Greece and throughout the Roman Empire, where ideas on
such subjects were carried from Greece. Again from the early begin¬
nings of modern interest in the material world, say from the time of
Fracastor, or from Yesalius onwards, we have a mass of printed books,
through which we can trace the evolution of medical theory and
practice right up to our own times. Even for a generation before these
pioneers we can study in a series of incunabula and early printed books
the last stages of mediaeval medicine beginning to crumble under the
influence of Renaissance ideas. But for the period intervening from
the fall of Greek science to the rise of the more modern work, roughly
for the 1,000 years from 500 a.d. to 1500, printed material is extra-
At a meeting of the Section, held February 19, 1919.
Section of the History of Medicine
97
ordinarily scarce. The ideas of our mediaeval forefathers on science
and on medicine are at present largely hidden from us.
They are not, however, irretrievably lost. All that is needed is an
enthusiasm and an expenditure of time and labour on our part com¬
parable to the merest fraction of that displayed by the scholars of the
Renaissance who rescued the thought of antiquity for us. I would
plead seriously for the extreme interest and value to the human race
of the sense of continuity. Perhaps every generation has to relearn in
in a new aspect the great lesson of the solidarity of the human race in
time and in space. Certainly in many respects that fact was appre¬
hended far more vividly and practically by our mediaeval ancestors than
by ourselves. Perhaps in spite of knowing less astronomy, they were
more conscious than ourselves of citizenship of the whole universe
rather than merely of this earthly sphere, still less of a single political
state. But whatever be the disintegrating forces that have led to the
exaggerated modern sense of race—usually as our anthropological friends
assure us, based on sad misinformation as to fact—it will not be denied
that the study of the growth of thought in the long line of our human
ancestors stimulates us to a wider outlook. It is not necessary, how¬
ever, to plead before this Section the claims of historical study. In
surveying the foreigner of another age we are all less anxious than
in the presence of a contemporary stranger. We are not startled by
the dusky complexion of St. Augustine. We do not consider the
nationality of Dante. Similarly it is not difficult to gain enjoyment
and even inspiration from mediaeval writers without committing our¬
selves by any means to their general outlook.
It may be objected that mediaeval science is worthless. The
answer to this criticism is really complete and brief. All science is
superseded and cast aside as soon as it becomes old enough, but in order
to produce a history of scientific thought, and especially in order to
understand those beginnings of modern science that are not yet quite
old enough to be regarded as pure rubbish, it is absolutely necessary to
give a clear and accurate picture of the derelict systems out of which our
scientific thought has grown. We cannot fully understand an idea until
we know its history, and to gain a complete understanding of what
science is we must have an adequate account of how it arose. No such
account exists, and it is the rough material for such a work that
we have endeavoured to collect. The first need has been a classified
list of the MSS., and this we now have in working order. It has
been compiled mainly from published catalogues of MSS., but where
98 Singer: Medical Manuscripts in the British Isles
these have been found very meagre, the MSS. themselves have been
handled and dated, a work in which we have received much kind help,
especially from Mr. J. P. Gilson of the British Museum, Mr. Robert
R. Steele, who has specially helped us over Bacon, and Miss M. V.
Taylor.
In compiling our hand-list we have had the great encouragement of
grants from both the Royal Society and the British Academy. The
help from these two bodies symbolizes that co-operation of scientific
method with humanism and scholarship that has, I think, characterized
medicine, and that we hope will be fostered by the growing study of the
history of science and of medicine.
But this hand-list is of course merely a tool, or rather a finger-post.
Already we have begun the examination of manuscripts to convert our
bald list into a catalogue raisonnA But a great deal remains to be
done. Just as the Renaissance writers eagerly transcribed and printed
the classical MSS. as they were successively rediscovered, so I would
plead for volunteers who will transcribe and edit our mediaeval medical
MSS. In one important respect our task is far easier than that which
confronted the Renaissance enthusiasts. It is no longer necessary to
examine the MSS. themselves in the libraries where they repose. The
modern method of rotography, the fixing of negative photographs,
enables us to obtain at a cost of but a few pence per page copies of the
MSS., which except for colour are exact facsimiles of the originals.
Thus we can study these documents at leisure in our own homes,
and I would appeal for volunteers for this work, and would even
venture to suggest that it may command from future generations of
our countrymen no less gratitude than other more immediately tangible
forms of national service.
We can provide for the most various and the most specific taste
in research. We have purposely provided our catalogue with detailed
indices enabling us to turn up at once material for those who are inter¬
ested in any scientific or medical subject, using the terms in their
widest sense, in any language, in any period, in any man or woman—
for we must not forget Dame Trot of Salerno. The scholar who will
generously give his time or even a little of his time to a careful
examination of the MSS. in any one subject and will write a mono¬
graph upon them, will be laying the foundation for the catalogue
raisonnd which we hope ultimately to produce with the help of many
co-editors; and this catalogue raiBonne comprising many careful
monographs will we hope, in its turn, form the basis of the mediaeval
Section of the History of Medicine 99
section of a complete history of science somewhat on the lines of
such a work §« the Cambridge Modern History.
The following are the headings of our catalogue :—
HEADINGS OK THE CATALOGUE.
Alchemy and Chemistry.
Anatomy.
Aristotle.
Abts and Crafts.
Astrology and Menolpgy.
Astronomy.
Bestiares, Monstrosities and Fables.
Calendar.
Computus.
Charms and Magic.
Children.
Cosmology (De Rerum Natura, De Elementis,
&c.).
Diet.
Fermentation and Generation.
Fevers.
Geography and Travel.
Gnomic.
Gynecology.
H^ematoscopy.
Herbaria.
Hospitals.
Husbandry.
| Lapidaries.
Marvels.
Mathematics.
Measures and Weights.
Medicine (General).
Melothesia.
Music (Harmony, Scientific aspects).
Ophthalmology.
Pestilence, Contagion, Epidemic, Plague
and Infection.
Phlebotomy.
Physics.
Physiognomy and Cheiromancy.
Physiology (Four Complexions, Ac.).
Prognostics.
Pulses.
; Recipes (Medical) and Drugs.
1 Regimen.
1 Science, General, and Encyclopaedias.
! Surgery.
| Urine.
I Veterinary.
Throughout our Catalogue we are confronted by thD difficulty of
classification. What is Science ? What is Medicine ? My point is,
not that there is no answer to these questions, but that the mediaeval
answer was not that of to-day. Last week, for example, I was
handling in our History of Science Room at the Bodleian a fifteenth
century general handbook of medicine, 1 in which several times a herbal
salve is followed by the description of a cure by incantation. To the
writer there was no important dividing line between the two therapeutic
methods. But soon after the work was written we find that an annotator
went through the volume, marking valuable recipes in red but sternly
crossing through all the charms!
Since the fringes of our subject are often entertaining and even
illuminating, I hope you will forgive my adopting the mediaeval
rather—shall I say broad view of the curative art in considering
these survivals from the writings of that age.
So I shall ask you to allow me to include not only recipes but also
charms and magic in our survey. I propose to give first a very few
Bodley Add., A X06,
100 Singer: Medical Manuscripts in the British Isles
statistics which will indicate the broad outline of the subject, and then
to illustrate the various categories by pictures and quotations from the
MSS. themselves.
Our Catalogue contains some 30,000 manuscripts of which
some 15,000 fall in the medical or quasi-medical categories. The
15,000 MSS. cover, of course, but a few thousand texts, as there
will be many duplicates. The figures of texts which follow are
tentative, as the final allocation of the MSS. into separate texts
is only possible after they have all been examined. Especially many
of the apparently distinct anonymous texts will probably be found to
have a common basis and these anonymous texts are a large proportion
of the whole. Their examination and allocation form in fact the main
part of just that complex task in which I have ventured to plead for
your co-operation. 1 And the fruit of this work will probably, in this as
in other lines of science, lead to a simplification of the whole problem.
There survive in this country some
1,900 texts on general medicine within our date. Many of
these are of course wholly or partly copied from one
another with accretions and variations from hand to
hand.
We find 225 passages or treatises on anatomy.
194 surgical texts.
42 on the pulse.
274 on diagnosis by urine.
63 dealing with the eye (often merely recipes).
10 on diagnosis by blood inspection.
600 on herbals and simples, classified according to the herbs.
2,500 recipe entries, some collections and some single, apart
from those in the general works and some curious
recipes in the bestiaries.
669 bestiaries.
600 magical texts and charms apart from those scattered in
general works.
953 works on alchemy and alchemical medicine.
183 lapidaries.
114 works on physiognomy and cheiromancy.
41 melothesia.
1 Since this paper was read in February, 1919, considerable additions have been made
to the Cabal igue. These, however, will not materially alter the proportions shown in the
following diagrams.
Section of the History of Medicine
101
624 texts on the four complexions.
234 on phlebotomy, in many of which astrology, menology
and the unlucky days play a main part.
168 on fevers, in a number of which the conception of
complexions is predominant.
144 on diet.
90 on pestilence, in many of which astrology is reckoned
as an important factor.
176 on gynaecology.
106 on fermentation and generation.
72 devoted to the regimen and health of children.
214 other regimens, and perhaps I should mention
220 texts, chiefly charters, throwing light on the early
history of hospitals,
and 144 veterinary.
The great mass of the MSS. were written between the years 1200
and 1500, especially in the fourteenth and fifteenth centuries.
A very few of the most ancient works, such as Greek papyri, are
included in our work. Practically, however, we have little before the
eighth century. The distribution in time of our surviving medical
material is roughly shown in the following tables :—
no. of
MSS.
Pio. l.
102 Singer: Medical Manuscripts in the British Isles
Fio. 2.
N? OF MEDICAL MSS.
IN WESTERN LANGUAGES.
<
$
VI
|
Greek
Others
Tota/s
VIII
5
1
6
IX
17
2
19
X
23
12
2
i
38
XI
73
20
5
0
98
XII
158
6
4
7
175
XIII
974
20
5
59
1058
XIV
1940
140
40
123
2251
c
XV
3729
872
144
106
4931
Fia. 3.
Section of the History of Medicine
103
We will now turn to a few slides illustrating the MSS. in our
Catalogue. I beg you to regard the slides as something in the nature
of bait. Of course, I have had to choose them almost at random from
some 15,000 MSS., so if any one feels that some other sort of MS.
might interest him more than these here shown, I hope he will still
give us a chance of providing him with material that may interest him.
If anybody will undertake a whole section of the Catalogue we shall
be delighted, or if any one cares to transcribe or translate only one
manuscript of a few pages we shall no less welcome his help.
(1) British Museum. Royal 2 B V folio 189 recto. Ninth century. Anglo-
Saxon work. Page of general information as to the Ages of Man (the
Hippocratic division as continued by Galen), the size of the world and the
following brief anatomy : “ De ossibus, uenis et dentibus. In perfecta etato,
ossa hominis sunt numero CCXYIIII. Numerus uenarum CCCLXV, dentium
numerus in perfecta etate XXXI1.” These few sentences constantly recur in
MSS. of all periods. Something very like them is to be found in the Talmud,
and they occur, for example, in a fourteenth century MS. at Jesus College,
Cambridge ; and in a fifteenth century MS. at Trinity College, Cambridge. No
doubt examples could also be cited for the intervening centuries.
(2) Bodleian Library. Bodley 579, folios 50 verso, 51 recto. Tenth
century. Anglo-Saxon work. (Published by E. F. Warren, “ Leofric Missal,”
Oxford, 1883.) Sphere of Apuleius Platonicus (here compressed into a
rectangle) from the Leofric Missal. The name of Apuleius Platonicus is
associated with a herbal that was translated into Anglo-Saxon, and with
many magical devices, perhaps on account of the Apuleius, author of the
“Golden Ass,” and of the “Florida” who successfully defended himself
from the charge of magic in the second century A.D. The Sphere of
Apuleius is designed to prognosticate life or death by means of calculations
based on the numerical value of the patient’s name and the day of the month
on which he fell sick. It appears frequently in early mediaeval MSS.
(3) British Museum. Cotton Cleopatra A iii folio 78 recto. Late ninth
century. Anglo-Saxon script. (Published T. Wright’s “ Anglo-Saxon Voca¬
bularies,” edited by R. P. Wiilker, London, 1884.) A page of anatomical
terms from a Latin and Anglo-Saxon vocabulary. “ Incipit de homine et de
partibus eius.” These vocabularies often throw interesting light on contem¬
porary ideas as to anatomy and other subjects.
(4) British Museum. Harley 585, folio 160 recto. Eleventh century.
(Published by O. Cockayne, “ Anglo-Saxon Leechdoms,” London, 1864-1866,
vol. III.) From a collection of Anglo-Saxon remedies known as the “ Lac
nunga.” The passage shown is the “ Song of the nine healing herbs ” and is
of much greater antiquity than the manuscript. It is a pagan composition
which invokes the aid of Woden.
7
104 Singer: Medical Manuscripts in the British Isles
(5) Lord Clifden (Lanhydrock) B. 12.16, folio 144. Eleventh century.
(Published by H. Napier in Herrig’s “ Archiv fiir das Studium der neueren
Sprachen,” vol. LXXXIV, Kleinere Mitheilungen P. 325, Brunswick, 1890.)
Anglo-Saxon recipes. Herbs for “ Heort aech,” etc.
(6) British Museum. Cotton Faustina A X, folios 115 verso and 116
recto. Eleventh century. (Published by O. Cockayne, “ Anglo-Saxon Leech-
doms,” London, 1864-1866, vol. Ill, pp. 292-294.) Some recipes and medical
charms used by the Anglo-Saxons. The ingredients of an all powerful eye
salve, ecclesiastical charms against feverish chills (frigora) at every hour #
against fevers, kc.
(7) British Museum. Cotton Vitellius C III frontispiece. First half
2 eleventh century. From Anglo-Saxon Herbal. Figures of “ Esculapius, Plato,
^ Centaurus.” Two other copies of the Anglo-Saxon Herbal have survived, the
British Museum Harleian 585 and the Bodleian Hatton 76. The text is in
each case the same, each volume containing three works to which are attached
the names of Apuleius, Dioscorides and Sextus respectively.
(8) From the same MS., folios 79 recto and 81 verso. Figures of beasts:
the lion, the bull, the goat and the serpent. The Anglo-Saxon herbals, like
their Latin prototypes, discuss beasts as well as plants.
(9) British Museum. Arundel 60, folio 1 r. Late eleventh century. “ Ad
Sanguinem Minuendum.” A table of the lucky and unlucky days of the month
for phlebotomy attached to a beautiful volume of the Psalter. This table is
usually attributed to Bede, but does not here bear his name. Mr. J. P. Gilson
considers that the handwriting indicates Winchester origin.
(10) St. John’s College, Oxford. MS. 17, folio 175 recto. Eleventh century.
(Published by Charles Singer in 44 Annals of Medical History,” Philadelphia,
New York, 1918.) Charm against nose bleeding used by Anglo-Saxons,
wi blod rine of nosu wriht on his forheafod in Xristis mel
oo
e*-
O
3
«>
3
3
Stomen <t> calcos -f
«-►
9
o
cT
+
The mystic words may be recognized as forming the central phrase of the
Liturgy of Chrysostom, <rr&fjL€v /caXcSv (TT&fiev fiera <f>o/3ov. The Byzan¬
tine pronunciation of <f>o/3ov would be correctly transcribed “ fofu ” while the
<o of Ka\S) 9 was mistaken by the Anglo-Saxon scribe for CO. The liturgy of
Chrysostom presumably reached this country with Archbishop Theodore of
Tarsus in the seventh century.
Section of the Histonj of Medicine
105
(11) British Museum. Cotton Caligula A XV, folio 125 verso. Twelfth
century. English work. The Sphere of Apuleius again, this time in its more
usual and complete form. The legends are in Greek, and partly in Greek
script, by an English hand.
(12) Gonville and Caius College, Cambridge. jfus folio 6. First half
twelfth century. A scheme to illustrate the junctions of the brain. It is
divided into geometrical figures, and shows their supposed relationship to the
senses of sight, smell and hearing. The idea of the triangles of the brain is
derived from the Timaeus of Plato.
(13) Bodleian Library, Bodley 130, folio 16 recto. Twelfth century. The 1/
Vetch. One of the most beautiful of the early English naturalistic drawings.
(14) Bodleian Library, Ashmole 1462, folio 20 recto. Twelfth century.
From a herbal of late Anglo-Saxon workmanship of the conventional school.
(15) Bodleian Library. Ashmole 399, folio 13 recto. Twelfth century and
fifteenth century. An example of an early manuscript with the blank spaces
utilized by a later hand. The beautifully clear twelfth century hand closes a
work on Physiognomy and this is one of the rarer cases when the date is
given : “ Explicit phisonomi a anno iesus Christi milesimo centesimo. lij.” The
remainder of the page has been utilized by a fifteenth century writer to note
down some recipes—such as are constantly found on the spare spaces of pages
of MSS. up to at least the sixteenth century.
(16) British Museum. Sloane 1975, folio 91 verso. Thirteenth century.
Cutting the scalp for epilepsy. 1 This procedure was recommended by
Hippocrates. The illustration is one of the latest of the English pictures
that show no Norman influence.
(17) Bodleian Library. Ashmole 399, folio 34 verso. Thirteenth century.
[Published by Charles Singer, Proceedings of the Eoyal Society of Medicine
(Sect. Hist.), ix, p. 42, 1915.] Two pictures under Norman influence of lady
apparently suffering from the vapours. She is being treated by the usual
mediaeval restoratives, a feather dipped in vinegar applied to the nostrils, and
a fire in the room in which presumably aromatic herbs are being burnt. The
queer little puppy may represent some of the more repulsive of the mediaeval
prescriptions.
(18) British Museum. Harley 4751, folio 6 verso. Thirteenth century.
The Unicorn, from a bestiary. These Bestiaries ” discuss the moral,
medical, marvellous and every other aspect of the beasts considered. The
miniature illustrates the fable of the unicorn mentioned in Aelian, second and
third centuries A.D., “ De Natura Animalium,” XVI, cap. 20, and popularized
by Isidore of Seville (sixth century). This most savage animal, it appears, was
gentle and affectionate to young maidens, who therefore acted as decoys for
the huntsmen We see here the unicorn laying its head against the maiden s
breast while two huntsmen with spear and sword are simultaneously stabbing
it from behind. A third huntsman in the rear bears an axe.
la
10G Singer : Medical Manuscripts in the British Isles
(19) From the same MS. Thirteenth century. The Caladrius. The
sick monarch is shown lying on a couch, not daring to look for the verdict of
the large white bird whose gaze, however, is turned full on him, thus showing
that he will recover.
(20) Bodleian Library. Ash mole 391, folio G recto. Thirteenth century.
(Published by Charles Singer, Johns Hopkins Hospital Bulletin , vol. xxx,
No. 340, June, 1919.) Manus meditationis. No doubt it was the popular
science of cheiromancy that suggested the form in which these rather beautiful
little verses have been set forth on the page.
(21) British Museum. Arundel 295, folio 25 verso. Fourteenth century.
Our modern hand of fate. Seated physician feels the pulse of seated female
patient.
(22) British Museum. Arundel 251, folio 46 recto. Fourteenth century.
Zodiacal man, with key. The twelve signs of the zodiac are placed on the
parts of the body that they are believed to influence. The key on left shows
that if the signs are written under one another in their usual order, beginning
with the ram, and lines are drawn from them to a human figure, these lines
will in fact link each organ of the body to the zodiacal sign connected
with it by the astrologers. It is thus easy to see how the connexion was
evolved.
(23) British Museum. Egerton 2572, folio 51 verso. Late fourteenth
century. From the Guild Book of the Barber Surgeons of York, figures
representing the Four Humours grouped round the head of Jesus. Scroll
work issuing from the hands of the figures towards the centre of the
picture bears legends in English setting forth the connexion between the
four elements and the four humours, “ otherwysse calde the four
complexions.”
(24) Same MS., folio 51 recto. Volvelle for prognostics, supported by
John the Baptist and John the Evangelist (above) and the medical saints
Cosmas and Damian (below.) The volvelle consists of a movable pointer and
circle of the days of the months, set on elaborately drawn concentric circles
showing the signs of the zodiac, the names and symbols of the twelve months,
and the days of the lunar and solar years.
(25) British Museum. Sloane 965, folio 107 recto. Early fifteepth
century. Following on an English translation of Guy de Chauliac we
have here an English treatise on the four complexions, setting forth at
length the “ physiology ” of the four humours and the organs especially
connected with each.
(26) British Museum. Arundel 251, folio 37 recto. Fourteenth century.
Disease mannikin, or human figure with the various diseases written on the
parts liable to be attacked by them. Each foot, for example, is labelled
“ podagra.”
Section of the History of Medicine
107
»
(27) British Museum. Additional 17987, folio 101 recto. Fifteenth
century. German work. Haematoscopy. On a table stand a number of
vessels, containing specimens of blood. The physician has picked up one and
discourses on it to a female patient. Pictures of haematoscopy are rare, though
mediaeval texts on the subject abound.
(28) Brit^h Museum. Additional 5467, folio 72 recto. Fifteenth century.
English text on blood-letting, attributed to “ Saynte Beede,” This is not a
translation of the text usually bearing the name of Bede, nor do the lucky
and unlucky days cited correspond entirely to Bede’s instructions on the
subject.
(29) Bodleian Library. March 54, folio 25 verso. Fifteenth century.
Arabic text of Albucasis, with very rough drawings of instruments for opening
the artery behind the ears.
(30) Above: Bodleian Library. Rawlinson C 328, folio 110 recto.
Fifteenth century. Below : Bodleian Library. E Museo 19, folio 162 recto.
Fifteenth century. Illustrations to Latin translations of Albucasis. The
upper drawing would be hard to understand by itself, but the lower figure
makes it plain that each drawing is intended to represent the instrument for
straightening the back described by Albucasis.
yj (31) British Museum. Royal 15 E II, folio 77 verso. Fifteenth century.
From a beautifully illustrated MS. of the De Proprietatibus Rerum of Bartholo-
maeus Anglicus. Physician’s shop. The patient is nude but for a waistcloth.
The physicians, in doctor’s academic robes, stand on each side of him, one
bearing ointment and the other a drug. In the front is the deerhound
characteristic of this type of Renaissance work.
(32) From the same MS., folio 165 recto. Surgeon’s shop. A surgeon,
in the master’s academic robes, is performing phlebotomy on a patient’s arm.
Another similarly robed surgeon is examining the urine bottle of his patient.
On the left Qf the picture we see cripples with crutches making their way to
the shop.
(33) Windsor Castle. Drawings of Leonardo da Vinci. Late fifteenth or
early sixteenth century. (Published by Fonahm, Hopstock and Vangensten,
“ Quaderni d’Anatomia,” vol. II, folio 3 verso, Christiania, 1911.) A beautiful
and accurate drawing of the heart, showing the coronary vessels.
(34) Windsor Castle. Drawings of Leonardo da Vinci. Late fifteenth or
early sixteenth century. (Published by Fonahm, Hopstock and Vangensten,
“ Quaderni d’Anatomia,” vol. Ill, folio 8 recto, Christiania, 1911.) Folded
babe in an opened uterus. An exquisite work of art, perhaps the masterpiece
of all these drawings. Leonardo has enshrined for us thought and feeling in
every accurate line, and the folded figure seems to embody in itself the mystery
of man’s destiny.
Sectton of tbe UMatorp of flftebidne.
President—Sir D’Arcy Power, K.B.E., F.R.C.S.
Dies Aegyptiaci . 1
By Robert Steele.
On many mediaeval calendars certain days are marked Dies
Aegyptiacus, D.E., or very rarely, Dies Aeger: more often a verse
such as “ Prima dies mensis et septima truncat ut ensis ” is placed at
the head of each month. These days are the “ dies maledicti ” or
Egyptian days.
Three sets of them are known. The oldest set is of two days in
each month, a second is found in the pseudo-Bede and comprises three
Mondays in the year, and the third gives certain days in each lunar
month. They were held to be unlucky for beginning any enterprise,
and especially for bleeding.
The earliest reference to their existence is found in the Fasti of
Furiu8 Dionysius Philocalus, dating from a.d. 325-354, which have
been published several times, last of all in the Corpus Inscriptionum
Latinarum I, pt. 1.2,256. In the Calendar twenty-five days aYe marked
“ Dies Egyptiacus.” No clue is given to their meaning, but as they
immediately succeed the “ dies senatus legitimi ” established by Con¬
stantine, it is suggested by Mommsen that their origin is later than the
foundation of the Byzantine empire. 8 They are not marked on a some¬
what similar calendar, the Fasti of Polemius Silvius (c. a.d. 449).
They are:—
Jan. 2, 6, 16. Feb. 7, 25. Mar. 3, 24. Ap. 3, 21. May 3, 21. June 7, 20.
July 6, 18. Aug. 6, 21. Sep. 2, 19. Oct. 3, 20. Nov. 2, 24. Dec. 4, 14.
1 At a meeting of the Section, held December 18, 1918.
- The fact that St. Ambrose and St. Augustine both refer to them as “ diei posteri ”
would seem to support the connexion suggested. In Non. Marccllus a verse is quoted giving
the further equivalent, “dies ater.” “ Septembris heri callendas hodie ater dies.” Non.
Marcellus proceeds “ Atri dies dicuntur quos nunc nefastos vel posteros vocant.”
/
Section of the History of Medicine
109
Traces of this list appear on early mediaeval calendars up to the
tenth century. Harl. 3017, marks on its calendar:—
Jan. 2, 6. Feb. 2. Mar. 27.
We next hear of them from St. Ambrose (who wrote c. 383) in his
Epistles I, 23 : “ Vel cavere quosdam dies, quemadmodum plerique
posteros dies vel Aegyptiacos declinare consuerunt,” when, writing to
the bishops on the observation of Easter, he rebukes a number of
superstitious observances.
St. Augustine, writing early in the fifth century, has a similar
denunciation of their observance among Christians “ Non observers
dies qui dicuntur Aegyptiaci.” And again “ Jam vero ne aliquid
inchoetur, aut aedificiorum aut hujusmodi quorum libet operum.
Diebus quos Aegyptiacos vocant, saepe enim nos monere non dubitant
. . .” Ep. ad Gal. c. 4. “ Non proficiscar hodie quia posterus dies
est aut quia luna sic fertur.” Ep. 55, c. vii (13).
The observation of these days by the Neo-Platonist plilosopher
Proclus (412-485 a.d.) is recorded by his biographer Marinus, who
succeeded him in his chair. Kai ra<? trap' ’ AiyvirTtois d.iro<f>pd8a<;
e^vAar Te paXAov t) avrol exetvoi. “ Dies Aegyptiis infaustos diligentius
observabat quam ipsi Aegyptii ” (c. 19).
Salmasius (De annis climactericis, p. 816) quotes from two Greek
manuscripts (unidentified, as his manner is), lists of dies Aegyptiaci.
One of them is said to have been revealed to Esdras, and hence may
perhaps belong to the sixth or seventh century, but is more probably
much later. I quote the original and Salmasius’s translation, which
does not coincide with it:—
’Ev TavTdK yap t ais r/ptpais odaOevtov 6 vk dviaTarai 6 ydpovt ttoimv
ov %aipei, 6 et? iroXepov iirdywv ovk dvaarpefyeTat, 6 vpayparevopevo 1 ;
diroXXei rj tut pdirohov rj SovXov, rj op/cov ttoiw v, 6 Kii^wv ov arijtcei, o
ei? KptTijptov ttLtttwv pera vfSpeox; xai al<T%vvr)<; arpe(f)eTat.
“ Alias alibi inveni . . . quas auctor dicit a Deo monstratas esse
Esdrae sacerdoti et prophetae, ut per eum populo Israelis declararentur, et
scirent quibus diebus in unoquoque mense abstinere deberent a coitu cum
uxore, a plantarum insitione, sanguinis missione, et ab aliis multis operibus.”
The dates are as follows. They are given in Greek numerals, but
use the Roman months. 1
Jan. 2, 4. Feb. 16, 21. Mar. 4, 20. April 3, 20. May 6, 20. June 3, 18.
July 6, 20. Aug. 1, 5. Sep. 3, 21. Oct. 3, 20. Nov. 8, 11. Dec. 3, 24.
The dates in heavier type correspond with those of the normal mediaeval list.
110
Steele : Dies Aegyptiaci
The second list is different:—
Jan. 2, 4. Feb. 2, 26. Mar. 4, 20. April 3, 20. May 7, 22. June 3, 12.
July 6, 22. Aug. 4, 15. Sept. 3, 14. Oct. 3, 21. Nov. 5, 11. Dec. 8, 14.
From the eighth century on we find lists of the Egyptian days,
separated from the calendar. As might be expected these lists show
much variation. Only a few use the Roman method of dating, and
these are presumably copies of earlier date. We know of MSS.
Einsiedler 319, Titus D, XXVI, and SI. 475, all of the tenth or eleventh
centuries, and the dates are given as alternatives to the common verses
“ Si Tenebrae ” (p. 7). They are :
Einsiedler, 319 (tenth century).
Jan. 3, 26.
July 13, 23.
Feb. 8, 25.
Aug. 7, 24.
Mar. 12, 23.
Sept. 6, 30.
April 3, 20. May 7, 22.
Oct. 10, 29. Nov. 6, 23.
June 9, 25.
Dec. 8, 24.
SI. 475 (late eleventh century).
Jan. 2, 25.
July — , 22.
Feb. -, 26.
Aug. —, 30.
Mar. — , 28.
Sept. 5, 21.
April 10, 20. May 1, 28.
Oct. 4, 22. Nov. 5, 28.
June 10, 16.
Dec. —, 15.
Titus B, XXVI (late tenth century).
Jan. 2, 24.
July 7, 22.
Feb. 8, 24.
Aug. 7, 20.
Mar. 3, 27.
Sept. 2, 25.
April 3, 23. May 6, 17.
Oct. 3, 26. Nov. — , — .
June 9, 16.
Dec. —, — .
The more usual method of dating in such lists is the Bononian
method, in which the days of the latter half of any month are reckoned
from its last day. This method is also used in the verses concerning
the Egyptian days which will be given later. The earliest dated
manuscript in which its use is found is of a.d. 785, but if the verses
attributed to Bede in the Hymns are his, it must have been in use
before a.d. 731.
Berne 318 (ninth century) gives an alternative list in this form,
“ Januarius die II et antequam exeat die III.”
Jan. 2, 29. Feb. 3, 26. Mar. 3, 25. April 3, 20. May 7, 29. June 8, 19.
July 18, 20. Aug. 6, 20. Sept. 8, 24. Oct. 8,20. Nov. 12, 24. Dec. 12, 24.
A MS. in Tironian notes at Wolfenbiittel, of a different tradition,
reckons similarly
Jan. 2, 18. Feb. —, 20. Mar. 4, 23. April 3, 20. May 6, 20. June 3, 18.
July 6, 21. Aug. 6, 21. Sept. 8 , 16. Oct. 8 , 21. Nov. 6, —. Dec. 3, 23.
Reichenau 172 (ninth to tenth century), has.the-following list:—
Jan. 3, 24. Feb. 8, 24. Mar. 3, 19. April 3, 18. May 6, 17. June 9, 16.
July 9, 22. Aug. 6, 20. Sept. 8, 25. Oct. 8, 17. Nov. 9, 26. Dec. 12, 22.
The lists yet given do not correspond with that commonly received
in the Middle Ages in more than two or three days. That in Reichejau
Section of the History of Medicine 111
229 (a.d. 785) beginning “ Hi sunt dies egyptiaci apud dominum male-
dicti ” is
Jan. [1], 29. Feb. 8, 22. Mar. 3, 25. April 10, 20. May 3, 27. June 10, 16.
'July 14, 22. Aug. 6, 20. Sept. 3, 21. Oct. 9, 22. Nov. 3, 28. Dee. 13, 15.
So Harl. 3017, f. 59, and Add. 22398, f. 104.
Reichenau 167 (ninth century) has this list:—
Jan. 1, 25. Feb. 4, 26. Mar. 1, 28. April 10, 20. May 3, 25. June 10, 16.
July 13, 22. Aug. 1, 30. Sept. 3, 21. Oct. 3, 31. Nov. 5, 28. Dec. 12, 15.
The pseudo-Bede “ de minutione sanguinis ” has
Jan. 1, 25. Feb. 8, 22. Mar. 3, 25. April 10, 20. May 4, 24. June 8, 26.
July 17, 22. Aug. 5, 17. Sept. 9, 22. Oct. 9, 22. Nov. 5, 25. Dec. 15, 24.
Paris, cod. lat. 1338 (tenth century) has :—
Jan. 1, 26. Feb. 4, 26. Mar. 1, 28. April 10, 20. May 3, 25. June 10, 16.
July 13, 22. Aug. 1, 30. Sept. 3, 21. Oct. 3,31. Nov. 5, 28. Dec. 12, 15.
The commonly accepted days are :—
Jan. 1, 29. Feb. 4, 26. Mar. 1, 28. April 10, 20. May 3, 29. June 10, 16.
July 13, 22. Aug. 1, 30. Sept. 3, 21. Oct. 3, 22. Nov. 5, 28. Dec. 7, 22.
Before passing on to the verses in which these Egyptian days were
enumerated, we must turn to the rubrics of the foregoing lists. Many
of them have two differing statements, collected from different sources
and.preserved by the scribe with little care to harmonize them. The
earliest rubrics resemble in some ways the passage of the Greek MS.
quoted by Saumaise, and seem to indicate a Greek origin, while their
differences mark an independent translation :—
“ Hi dies observandi sunt, ne in itinere exeas, non vindemia colligas, non
plantetur, non vendatur, nec animalia domitetur, nec quod volueris in profectum
venire in suprascriptos dies nullatenus incipiatur, quia hi dies a domino male-
dicti sunt.” (Berne 318.)
“ Hi sunt dies egiptiaci qui in anno observandi sunt per unumquemque
mensem. In diebus istis non iteratur homo, non vinea plantatur, non causa
sequatur, non messis trituretur, nec ullum opus quod ad profectum esse debet
faciatur, quia hi dies a domino maledicti sunt.” (Reichenau, 172.)
“ Incipiunt dies aegyptiaci qui in anno observandi sunt per unumquemque
mensem, ii. duo, non iteratur homo, non vinea plantatur, non messis trituretur,
non causa sequatur, non opus quod ad profectum esse debet facere, quia male¬
dicti sunt.” (Titus D. XXYI.)
Another form of this rubric is found :—
“ Observandi sunt in his diebus si quis in lectum ceciderit non cito evadet,
nullum genus peccoris in his diebus dometur aut aliquis a parentibus separetur,
quoniam sic factum fuerit, non proderit. Nulla opera tunc incipiantur.”
(Reichenau 120.)
112
Steele : Dies Aegyptiaci
This follows a list of unlucky days of the moon, first, fifth, ninth,
fifteenth, and the three days before and after new moon, but in
Eeichenau 167, it is applied to the Egyptian days, perhaps in error:—
“ In istis diebus si quis in lectum ceciderit, non cito evadit; nullum genus
pecoris his diebus domatur, aut aliquis a parentibus separatur, ea causa quod
si increpaveris nihil proficiet; nulla opora tunc incipientur.”
The probability that the source of these days was Greek is increased
by finding them in Budge’s “ Syriac Book of Medicine ” II, 557, a
collection of recipes and treatises, many of them of Byzantine origin.
The dates and rubric are: “ The evil days of the months—
Jan. 2, 3, 11, 14. • Feb. 7, 11, 20, 21. Mar. 4, 5, 20, 21. April 3.
May 6, 20. June 3, 18. July 6, 20. Aug. 1, 4, 15.
Sept. 3, 10, 20. Oct. 3, 6, 20. Nov. 3, 5,11. Dec. 3, 20.
“ If a man falleth sick on any one of these days he will not live. And if a
man be born on any one of them, he will not live. And if he make a feast on
any one of them, he will have no pleasure therein. And if he setteth out on a
journey on any one of them, or if he goeth forth to war, he will be conquered by
his enemies. And if he planteth a vineyard on any one of them, it will not thrive.
And if he goeth on a journey, evil will befall him. And if he getteth married,
he will be destroyed, for these days are evil and are lacking (in good), even as
the Living God commanded the children of Israel by the hands of Moses. . .”
It will be seen that up to the end of the tenth century the twenty-
four Egyptian days had no special medical signification, the prognosti¬
cation as to sickness being attached to the evil days of the moon, and
the prohibition of blood-letting being originally attached, as will be
shown later, to the three Mondays.
At a comparatively early date the Egyptian dates were enumerated
in the form of verse. The earliest and rudest of these are found in the
Hymns of Bede, first printed from an unknown manuscript by Hervagius,
at Basle, in 1563. The editor seems to have been J. Pamelius. They
are accepted as genuine and are therefore prior to a.d. 731. They run
as follows:—
Prima necat Jani, nocet astans septima fini.
Quarta necat Februi, nocet astans tertia fini.
Mars tua frons cuspis, prope finem quarta fit aspis
Aprilis decimam, notat undecimam prope caudam.
Tertia mors Maii, sed septima proxima fini
Junius in decimo ferit et quindenus ab imo.
Alter ab undecimo, nepa Juli nonus ab illo
Augusti primus ferit et de fine secundus.
Stat Septembris acus hinc tertius inde decenus
Octobris stat acus, hinc tertius inde decenus.
Quinta necat capitis sed tertia fine Novembris
Frontis septenam notat ultimus ordo decenam.
Section of the History of Medicine
113
The only variation from the accepted list is July 23 for 22.
Early in the niilth century an improved set of verses, printed by
Riese in the “ Anthologia Latina” I, 2-156 (680a olim 736), became
popular. The six introductory and four concluding lines seem to be of
later date than the month verses.
Si Tenebrae Aegyptus Graio sermone vocantur
Inde dies mortis tenebrosos jure vocamus.
Bis deni binique dies scribuntur in anno,
In quibus una solet mortalibus hora timeri
Mensis quisque duos captivos possidet horum
Nec simul hos junctos homines ne peste trucident.
Jani prima dies et septima fine timetur
Ast Februi quarta est, praecidit tertia finem.
Martis prima necat, cujus sub cuspide quarta est.
Aprilis decima est, undeno et fine minatur.
Tertius in Maio lupus est et septimus anguis,
Junius in decimo quindenum a fine salutat.
Tredecimus Juli decimo innuit ante Kalendas
Augusti nepa prima fugat de fine secundam.
Tertia Septembris vulpis ferit a pede denam
Tertius Octobris pullus, decern in ordine nectit.
Quinta Novembris acus, vix tertia mansit in uma
Dat duodena cohors septem inde decemque Decembris.
His caveas, ne quid proprio de sanguine demas
Nullum opus inoipias, nisi forte ad gaudia tendat.
Et caput et finem mensis in corde teneto
Ne in medio ima ruas, sed clara per ethera vivas.
It will be observed that the preface limits the evil effect of the day
to one particular hour in it, which is not indicated, while the end verses
bring in the prohibition of blood-letting.
From this time on there is little or no variation (except by scribal
error) in the dates given by the verses. A variant for January is
sometimes found (e.g., Berne 260, fourteenth century):—
“ Jani prima dies et tercia fine timetur.”
and St. Johns MS. 18, agreeing with another list, for February:—
“ Ast Februi quarta est, sed septima serviet umbris.”
Most MSS. of the ninth, tenth, and eleventh centuries have these
verses, and they appear in a printed Ambrosian Missal of 1522.
A variant is found in Sloane 475, an English MS. of the late
eleventh century, which may be the original form :—
114
Steele: Dies Aegyjptiaci
Jani prima dies et septima fine timetur.
Principio Februi quarta est et terfcia fine
Martis prima necat cujus sic cuspide quarta est.
Aprilis luctus ina x. est undenaque finem.
Mail tertia fit mors et grave septima letum
Junii bis quina est necnon quindena periculum.
Julii tredecimam fugias decimamque sequentem,
Augusti mala prima, cave de fine secundum.
Tertia Septemberis caveatur denaque finis
Octobris paribus sit, tertia denaque lege.
Quinta Novembris in hac et tertia lege tenentur
Septima fit pestis, idens et dena Decembris.
A list of hours was soon discovered and incorporated with the
verses. One of the earliest forms is printed by Muratori (Ber. Ital.
Script. II, 2, 1035) from a tenth century calendar. It is also found in
Eg. 1139, a manuscript executed for Melissenda, Queen of Jerusalem,
in the first half of the twelfth century.
1 Prima dies nona sit Jani scorpius hora
Vulnera seva nimis fert horis septima quinis.
3 Quartus in octonis Februi manet ut lupus horis
In denis ternis est horis fine timendus.
5 Dando diem primam dabit horam Marcius ipsam
Quarta nec est munda cui nocet hora secunda.
7 Horis in primis decimus suffocat Aprilis.
Undecimus nonas ferit inde diesque per horas.
9 Interimit terna Mai lux horaque sexta
Estque mali moris in denis septimi horis.
11 Quinta nocet deni Junii satis hora diei
Horis quartanis quindenus mordet ut anguis.
13 Dampnat tredecima Julius vorat hora secunda
Hujus et in nonis decimus quaque sauciat horis.
15 Horas dat primas Augustus datque kalendas
Inde secunda dies septenas turbidat horas.
17 Horis September perimit lux tercia ternis
Ejusdem mensis necat horis decima quaternis.
19 Sauciat Octobris in quinis tercius horis
Inde die dena hujus fert hora novena.
21 Pungit in octonis horis lux quinta Novembris
Cujus terna nigram facit horam confore quintam.
23 Vulnerat in primis horis (septena) Decembris
Septimus in senis decimus sit causa doloris.
The list of hours varies from manuscript to manuscript. Some
variants are 1. 4, Undecimus ternus est. Eg. 1. 14, Tredecimus
Section of the History of Medicine
115
mactat Julius decimus labefactat. Eg. 1. 18, decima M. 1. 20,
Hincque dies dena ferit hujus hora octava. Eg. 1. 23, Yulnerat in
quinis horis duodena Decembrem M. 1. 24, Hincque senis horis
decimus fit causa doloris. Eg. The days and hours are :—
Jan. 1 (9), 25 (5). Feb. 4 (8), 26 (10). Mar. 1 (1), 28 (2). Ap. 10 (1), 20 (9).
May 3 (6), 25 (10). . June 10 (5), 16 (4). July 13 (2), 22 (9). Aug. 1 (1), 30 (7).
Sept. 3 (3), 21 (4). Oct. 3 (5), 22 (9). Nov. 5 (8), 28 (5). Dec. 7 (1), 21 (7).
Another set of verses is quoted by Muratori from an Ambrosian
MS. of the eleventh century:—
1 Nona prote Jani vae sibilat hora diei
Septima fine dies in quinta parvulus est serps.
3 In quarto Februi fas est octava timeri
Tertia lux decima de cuspide laedit in hora.
5 Prima notat primam lux Martis mordicus horam,
Quarta dies nequam damnat de fine secundam.
7 Lux parit Aprilis decimam primam velut anguis,
Clamat in undecimo de cuspide nona nociva.
9 Tertius est Judas in Maio, sextaque Elisas,
Septimus in decima serpens est lividus hora.
11 Juni dena dies in quinta constat Ofites,
Quindenus quarta vocat horam fine sagitta.
13 Terdecimo Juli stat linea dena timeri,
In nona decimus de cuspide fit basiliscus.
15 Cernitur Augustus primae nepa prima diei,
Est in septena lux noxia fine secunda.
17 Tertia Septembris in quinta quaeritur hostis,
Et pede dena dies in quarta funeris hospes.
19 Tertius Octubris in quinta quaeritur hostis,
Nititur undecimo fore pestis linea nona.
21 Est acus octava lux quinta Novembris in hora,
A pede terna manet cui pessima quinque cohaeret.
23 In prima Cancri lux est septena Decembris,
Sic nocet undecimus, septaque mortalibus hora.
Jan. 1 (9), 25 (5). Feb. 4 (8), 26 (10). Mar. 1 (1), 28 (2). Ap. 10 (1), 20 (9).
May 3 (6), 25 (10). June 10 (5), 16 (4). July 13 (10), 22 (9). Aug. 1 (1), 30 (7).
Sept. 3 (5), 21 (4). Oct. 3 (5), 21 (9). Nov. 5 (8), 28 (5). Dec. 7 (1), 21 (7).
the dates being wrong for October 21 and December 21.
A calendar is printed in the first edition of Bede (I, 242) which,
besides the verses beginning “ Jani prima dies et septima fine timetur ”
has the following hour indications, in a separate line :—
116
Steele: Dies Aegyytiaci
Jan. 1 (1), 25 (5). Feb. 4 (8), 26 (5). Mar. 1 (1), 28 (2). Ap. 10 (1), 20 (9).
May 10 (7), 25 (10). June 10 (5), 16 (4). July 13 (11), 25 (9). Aug. 1 (1), 30 (7).
Sept. 13 (11), 21 (9). Oct. 3 (5), 22 (9). . Nov. 5 (8), 30 (4). Dec. 7 (1), 22 (8).
varying in dates on May 10, July 25, September 13, November 30.
A very common set of verses is found as early as the eleventh
century (Zurich C., 58, f. 28), though the hour verses, being separable
from the day verses, may be of later date.
1 Prima dies Jani, timor est et septima vani:
Nona parit bellum sed quinta dat hora flagellum.
3 Alterius mensis, post quartum tertius ensis:
Nullus ut octave, vel dene dixerit ave.
5 Martius in prima, cum quarta ducit ad ima:
Prima nocet multum, nullum dabit altera cultum.
7 Cum decimus cedit, undenis Aprilis obedit:
Prima petit telis, quem nona requirit Aprilis.
9 Tertius hie captat, Maii quod septimus aptat:
Sexta minus sordet, cum vulnera dena remordet.
11 Cui nil dena dabit, Junii quindena negabit:
Ledit quinta cutem, nulli dat quarta salutem.
13 Terdecimus fortis, Julii decimus via mortis:
Est lupus undena, pariter quoque nona leaena.
15 Sexti prima furit, a fine secunda perurit:
Cuspide prima ferit, quae septima perdere querit.
17 Tertia turbatur, Septembris dena minatur :
Tertia Septembris et quarta dabunt mala membris
19 Tertius Octubris, nulli decimusque salubris :
Quinta dat Octubris, cui nona venena colubris.
21 Quinta Novembris obest, nulli lux tertia prodest:
Est octava canis, fore quarta videtur inanis.
23 Hoc dat bissena, decimique, septima dena:
Prima parat luctum, nullum dat septima fructum.
This works out thus:—
Jan. 1 (9), 25 (5). Feb. 4 (8), 26 (10). Mar. 1 (1), 28 (2). Ap. 10 (1), 20 (9).
May 3 (6), 25 (10). June 10 (5), 16 (4). July 13 (11), 22 (9). Aug. 1 (1), 30 (7).
Sept. 3 (3), 21 (4). Oct. 3 (5), 22 (9). Nov. 5 (8), 28 (4). Dec. 7 (1), 22 (7).
The Zurich MS. adds to 1. 23 ‘'Septima cum dena decimi dat
vulnera plena.”
When the fashion of leonine verse became widespread, early in the
twelfth century, the following set was composed, probably in England,
as it is found in Sarum, York, and Hereford calendars. The earliest
English MS. (early twelfth century) is l.D.x. Others are Ar. 157,
2.B.VI., Tit. B. Ill, Harl. 3601 (a.d. 1295), Queen Mary's Psalter, the
Gorleston Psalter, and others similar to it.
Section of the History of Medicine
117
1 Prima dies mensis et septima truncat ut ensis.
Quarta subifc mortem prosfcemit tertia fortem.
3 Primus mandentem, dirumpifc quarta bibentem.
Denus et undenus est mortis vulnere plenus.
5 Tertius occidit et septimus ora relidit.
Denus pallescit quindenus federa nescit.
7 Terdenus mactat Julii denus labefactat.
Prima necat fortem, perditque secunda cohortem.
9 Tertia Septembris et denus fert mala membris.
Ternus et denus est sicut mors alienus.
11 Scorpius est quintus, et tertius est nece cinctus.
Septimus exsanguis, rivosus denus ut anguis.
Later variants are 1.8 Percutit ut funda, lux prima diesque secunda
(late fourteenth century) 1.11 Quinta Novembris, vix tertia manet in
urnis (York Missal). In 1.8 “ Sternitque ” is sometimes found for
“ perditque.”
A thirteenth century variant of the “ Si tenebrae,” published by
Gotz and Lowe from Laurentian St. Mark 249, without hours, is:—
1 O miserum mortale genus, quis noscere possit
Que fugienda tibi, que tuto rite sequenda.
3 Dum res nulla manet sub (tempore) tu quoque semper
Volueris et multa rerum de morte laboras.
5 Hoc vere vivis sed multa morte fatiscis
At qui d iff err is quedam nocitara cavere.
7 Cogeris in quantum tua se vigilantia tollit
Que geminos in mense dies quocunque timendos.
9 Corporis in cura tradit ne fundere cautus
Quisquam praesumat certa de luce cruorem.
11 Solvere, vel venerem salubrem aut temptare regestum,
Jani prima dies et septima fine minatur.
13 Principio Februi quarta est et tercia fine.
Martis prima necat cujus sub cuspide quarta est.
15 Aprilis decima est undenaque fine timetur.
Maii tercia lux et septima fine cavetur.
17 In decima simul et quindena Junius obstat.
Ternam post decimam Julii fuge fineque denam.
19 Prima sub Augusto nocet et de fine secunda.
Septembris ternam primo fuge cuspide denam.
21 Creditur October nocuisse diebus eisdem.
Novembris quintam caveas et cuspide ternam.
23 Undena est capitis in fineque dena Decembris.
Has Egiptiacis antiquo nomine lucis
25 Dicunt quod celi cura studiosior orbis
Egipti nocuas ex re persenserit illas.
118
Steele : Dies Aegyptiaci
Another set of verses is reprinted from Loiseleur : Mem. Soc. Ant.
Fr. 33 (1872), p. 248, from an Orleans Missal
1 Dat prima undenam Jani pede septima sextam,
Februarii octavam quartam pede tertia denam.
3 Mars primam prima finalis quarta secundam,
In decimo prima est undeno undenaque Aprilis.
5 Tertius in Maio sextam pede septima denam,
In decimo sextam Junii, quindenaque quartam.
7 Tridecimo undenam Julius pede denus eandem,
Augusti in prima est pars septima sive secunda.
9
Tertius Octobris quinta decimus pede novam.
11 Octavam quinti Novi pede tertia sextam,
Septima dat prima, sextam pede dena Decembris.
The hours being :—
Jan. 1 (11), 25 (6). Feb. 4 (8), 26 (10).
May 3 (6), 25 (10). June 10 (6), 16 (4).
Sept. 3 (4), 21 (4). Oct. 3 (5), 22 (9).
Mar. 1 (1), 28 (3). Ap. 10 (1), 20 (11).
July 13 (11), 22 (11). Aug. 1 (7), 30 (7).
Nov. 5 (8), 28 (6). Dec. 7 (1), 22 (6).
To conclude, the following set of hour verses is found in a St.
Mark’s MS. 173 of the fifteenth century (Valent. 3.117):—
1 Est Janus in nona et quarta scorpius hora,
Inficit octavam Februi lupus et leaena denam.
3 Mars habet infestam dubius primam atque secundam,
Est acus Aprilis in primis atque novenis.
5 Maius habet sextam, decimam quoque febre perustam,
Est Junii quinta serpens et quarta sagitta.
7 Julius undecimam nonam simul igne perurit.
Augusti serpens prima est et septima vulpis.
9 Tercia Septembris vulpis ferit a pede dena.
Octobris quintam, nonam simul aspis oberrat.
11 Languet in octava et quarta sub peste Novembris,
Oondempnat primam et sextam quoque clade perustam.
Jan. 1 (9), 25 (4). Feb. 4 (8), 26 (10). Mar. 1 (1), 28 (2). Ap. 10 (1), 20 (9).
May 3 (6), 25 (10). June 10 (5), 16 (4). July 13 (11), 22 (9). Aug. 1 (1), 30 (7).
Sept. 3 (3), 21 (10). Oct. 3 (5), 22 (9). Nov. 5 (8), 28 (4). Dec. 7 (1), 22 (6).
During the revival of the twelfth century the Egyptian days come
into literature. Honorius, Bishop of Autun, who died in a.d. 1130,
mentions them in his compendium “De Imago Mundi,” ii, 109.
“ Dies Aegyptiaci ideo dicuntur quia ab Aegyptis sunt inventi. Et quia
Aegyptus dicitur tenebrae, ipsi tenebrosae inde nominantur, eo quod incautos
ad tenebras mortis perducere affirmantur.”
Peter Comestor in his “ Historia Scholastica,” c. 24, lib. Exod.,
written c. 1150, says :—
Section of the History of Medicine
119
“ Unde quidem dies Aegyptiaci dicuntur, quia in his passa est Aegyptus,
quorum duos tamen in singulis mensibus notamus ad memoriam, cum plures forte
fuerint. Nee est credendum quod Aegyptii, licet astrorum periti, deprehenderint
dies hos infaustos in inchoatione operis, vel itineris, vel minutionis.”
Ivo of Chartres in his “Panormia” (1096) and subsequently Gratian
in his “ Decretum ” (1148), caus. 26, q. 7, c. 16, quote St. Augustine,
whose prohibition thus becomes part of Canon Law. The Egyptian
days are not mentioned by Burchard, or by the German penitentials.
Uguccio, Bishop of Ferrara, is quoted as writing :—
“In quolibet mense dicuntur duo dies mali Aegyptiaci, quia ab Aegyptiis
fuerunt inventi. Aegyptii enim comporientes quod in aliqua hora dierum
illarum non erat bonum sanguinare, id est sanguinem minuere, ne aliquid opus
inciperetur, illios dies vocaverunt.”
There are many references in thirteenth century writers, and among
them we find two sets of verses for remembering the days. One is
found in the “ Rationale ” of Durandus, lib. 8, c. 4, n. 20.
“ Augurior decios audito lumine clangor,
Liquit olens abies, coluit colos, excute gallum.”
In this the first letter of the first syllable gives the number of the
day of the month from the beginning, the first letter of the second
syllable that from the end; e.g., “ a ” is the first letter and “ g ” the
seventh—i.e., the first of January and the twenty-fifth (the seventh
from the end) are the Egyptian days. Similarly in liquit “ 1 ” is
the tenth letter and “ q ” the fifteenth (h is not counted), therefore the
10th and 16th of June are the Egyptian days.
Vincent of Beauvais in his “ Speculum Naturale,” lib. 15, c. 83,
gives a different form, probably earlier :
“ Argue discernens ad lucem coge loquelas,
Ollas abbatum cole calibus excute gallum.”
An imperfect set of day and hour verses is given by Hampson as
from Harl. 863.
1
2 Quarta dat octavam (tertia) dat denam prenomen
3
4 Dene prima premit, undone undena pereant.
5
6 Dene sexta minans undone quarta suspirans
7
8
9 Tertia lux terna nocet hora dena quaterna
10
11 Octavum quinta noni pede tercia quintain
12
120
Steele: Dies Aegyptiaei
The earliest documents connecting blood-letting with the days of
peril are two tracts included in the first complete edition (Basle, 1563)
of the works of Bede. One is attached to the “ Horologium,” and
consists of a paragraph, “ De tribus diebus periculosis,” followed by
the verses “ Si Tenebrae ” (p. 113) : the second is attached to the “ De
minutione sanguinis,” and consists (1) of a similar paragraph, (2) a prose
list of the Egyptian days and of the days of the moon in each month
unfavourable for bleeding and purging, (3) a presage of the days of the
lunar month, followed by a note as to the danger of the dog-days,
and other periods in which bleeding and purging are desirable. The
passages relating to the three Mondays are here given as printed :—
De tribus diebus periculosis.
“ Sunt tres dies in anno, qui per
omnia observandi sunt. 8 idus
Aprilis, ille dies lunis, intrante
Augusto, ille dies lunis, exeunte
Decembre, ille dies lunis obser-
vandus est, in quibus omnes venae
in homine et in pecude plenae sunt.
Qui in his hominem aut pecus per-
cusserit, aut statim, aut 3 die
morietur, aut 7 die periclitabitur.
Et si potionem acceperit, intra 15
dies' morietur. Et si masculus aut
foemina in his diebus nascuntur,
mala morte morientur. Et si de
auca in his diebus aliquis mandu-
caverit, intra 15 vel 40 dies
morietur” (p. 467).
De minutione sanguinis.
“ Plurcs sunt die s aegyptiaei , in
quibus nullo modo nee per ultam
necessitatem licet homini vel pccori
sanquincm minuere , nee potionem im¬
pend ere sed ex his tribus maxime
observandi, octavo idus Aprilis, illo
die lunis, intrante Augusto: illo die
lunis, exeunte Decembri: illo die
lunis, cum multa diligentia obser-
vandum est, quia omnes venal tunc
plenae sunt.
“ Qui in istis diebus hominem aut
pecus incident, aut statim aut in ipso
die vel in tertio morietur, aut ad
septimum diem non perveniet: et si
potionem quis acceperit. quindecimo
die morietur: et si masculus sive
mulier in his diebus nati fuerint,
mala morte morientur: et si quis de
auca in ipsis diebus manducaverit,
quindecimo die morietur” (p. 473).
Setting aside the introductory remarks in the second passage, it
seems obvious that we have here such differences as would point to
separate translations of a common original at present unknown, most
probably Greek. The MS. from which these tracts were printed
has not yet been identified, but the identification should be simple
since all known manuscripts make the first Monday that following
8 kal. Ap., not 8 id. It was probably an English one, as it is only in
Section of the History of Medicine 121
English forms that the prohibition of eating goose is found : though
it is inserted in the “ Schola Salernitana” and may possibly have been
connected with it.
The “ Horologium ” form has not been found elsewhere, but we
find the other in a group of MSS. associated with works of Bede, and
written, in districts evangelized by British influence, during the ninth
and tenth centuries. Thus Reichenau 120, f. 211 vo., contains (1) a prose
list of the Egyptian days and of the unfavourable days of the moon,
(2) the paragraph “ Si quis in lectum,” (3) the three Mondays, as in
Reichenau 120, (4) the unfavourable days of the moon. The Moustier
Missal (early eleventh century) has the three Mondays as in
Reichenau 167. Harl. 1772 has the three Mondays and goose
prohibition in a late ninth or tenth century hand on the margin
of f. 112 vo. Titus D. XXVI, the Newminster book, of late tenth
century, has (1) the three Mondays, as in the “de minutione,” (2) a note
of Hebrew origin as to three other days, and, later on in the book,
(3) the presage for each day of the lunar month. In Titus D. XXVII,
we have the presage for each day, and later on, (1) the month verses
of “ Si tenebrae ” with their conversion into the Roman calendar,
(2) a shortened form of the three Mondays, and (3) in a note two other
prohibitions from the end of the “de minutione’’—as to the dog-days
and days of the lunar month.
BIBLIOGRAPHY.
Du Cange. “ Glossarium,” sub voce.
Schmitz, Wilhelm. “ Beitrage zur lateiniscben Sprach und Literaturkunde,” Leipzig,
1877.
Goetz, G., und Loewe, G. “ Leipziger Studien,” Leipzig, 1878.
Loiseleur, Jules. “Mem. de la Soc. Nat. des Antiq. de France,” 1872, xxxiii.
Ranzovius, H. “ Diarium,” Witerbergae, 1593, p. 120.
Salmasius, Cl. “ De annis climacteribus,” Leyden, 1648.
Birch, W. de G. “ Trans. Roy. Soc. of Literature,” 2nd ser., 1878, xi.
Sinner, J. R. “ Catalogus Codicum, MSS. Bibl. Bernensis,” 1760*72.
Senebier, Jean. “Cat. des MSS. de Geneve,” 1779.
Valentinelli, G. “ Bibl. MS. ad S. Marci Venetiarum,” 1868-73.
Piper, F. “ Die Kalendarien u. Martyrologien der Angelsacbsen,” Berlin, 1862.
Hampson, R. T. “ Medii Aevi Kalendarium,” 1841.
Thompson: Some Old Pewter Bowls
'
122
Note on Some Old Pewter Bowls in the Royal Mineral
Water Hospital at Bath.'
By C. •). S. TuoMf-sox.
On vj,
months a<
me- had been in th£* hbHptial since- foakdation in 171-., Frdin the
time gf QueenTuh^abetfav.by Art # Barhaiueul, the poor had a nghi to
tiw .!:?•? oi thy Both Waters, and this institution Was established
so that the tfeservin? poor who■ really' needed treatment, might sure the
expense attending 3 long reydehee. in Bath, atld at the same tini*
receive the advantages >d 0 eeurse. of the waters Nash and
Su Hipbard Steele. of SpatMor thine, were among - .its .chief promoters,
Local opinions vary as to the magma! use of these bow is'., lie some
they are (lmughi :.<> be oh! bleeding. basmy formerly mod rathe hospital,
and it has been suggested by others that they are bowls that were vised
for adimmsterijig the'' 0 at.fr. waters to patients The Committee- have
•kindly lent me two speenueos. which 1 have broughtfor your inspection
> -AX a xri^twg <ut ii>ea%'bvetoTer iftf, UH6,
Section of the History of Medicine
123
I may say, on examination, I find from the mark or “ touch ” on
the bottom of each vessel, that they were made by Edgar and Son,
pewterers, of Edinburgh, who flourished in the eighteenth century.
The graduations marked on the inside measure 4, 8, 12, 16 and 20 oz.
to the brim. Bleeding bowls of the same period are usually graduated
either from 2 to 16 oz., or from 4 to 24 oz. The shape of the handles
supports the theory that they were used as drinking vessels.
Beferring to some of the early books on the Bath waters, to
ascertain the quantities given for internal use, I find Dr. Wilkinson,
in his “Researches on the Bath Waters” in 1811, states that the
“ quantities to be taken should be from four to eight ounces twice
a day,” which corresponds to the graduated marks on these bowls.
Joseph H. Spry, in his treatise on the Bath waters, published in 1822,
recommends the fourth of a pint. After two days this is to be increased
to one-third of a pint, and then gradually increased at intervals to
one pint.
In the discussion that followed, in which Sir D’Arcy Power and
Dr. Raymond Crawfurd joined, it was the general opinion that the
bowls were originally used for administering the waters to hospital
patients in the latter part of the eighteenth century.
8
Section of tbe t>iston> of flfoebictne.
President—Sir D’Arcy Power, K.B.E., F.R.C.S.
The Lorica of Gildas the Briton (? 547). A Magico-medical
Text containing an Anatomical Vocabulary. 1 2
By Charles Singer.
Chapter page
I.—Introduction ... ... ... ... ... ... ... 124
II.—Title, Author and Date... ... ... ... ... ... 126
III. —Language ... ... ... ... ... ... ... 131
IV. —Manuscripts ... ... ... ... ... ... ... 135
V. —Text and Translation ... ... ... ... ... ... 136
VI.—Obscure and Difficult Words ... ... ... ... ... 141
(I) Introduction.
In dealing with the medicine of the Dark Ages, that is the period
from the fifth to the eleventh century, we are faced with a very different
task to that presented to the investigator of the Middle Ages proper.
The material for setting forth the science of the Middle Ages is
embarrassing by reason of its vast bulk; for the Dark Ages we have
to deplore the scarcity of our records and in order to fill in the details of
the picture have frequently to resort to works not intended exclusively
for medical use. In what follows we shall discuss a Dark Age
document of this non-medical type of British origin.
The very little known of the practice of medicine in England during
the Roman occupation has been collected. 3 But the Romans abandoned
this country in the early years of the fifth century, and from then
until the appearance of Anglo-Saxon medical documents, the earliest
manuscript of which can hardly be dated before the tenth century, first
hand evidence is practically non-existent. Of the medicine of the Celtic
speaking inhabitants of these islands during the first millennium nothing
is now recoverable by the direct method, though a small amount of
1 At a meeting of the Section, held May 15, 1918.
2 Henry Barnes, “ On Roman Medicine and Roman Medical Inscriptions found in
Britain,” Proc. Roy. Soc. Med., vii, Lond., 1911 (Sect. History of Medicine), pp. 71-88.
Section of the History of Medicine
125
botanical folk-lore, such as they may be supposed to have shared with
their brethren of Gaul, has been laboriously put together, while some
yet remains to be gathered from folk custom. 1 The surviving earliest
writings—British, as we had best call them to avoid the ambiguous
word Celtic and to distinguish them from Anglo-Saxon material,—are
either a mixture of folklore, magic, romance and fable, or are of a
devotional character. 2 Some knowledge of the medical system that had
been developed by the British people may yet be gleaned from the
literature of prayers and invocations and lives of saints. The Lorica
falls into this liturgical category. It is a document that has reached us
from perhaps as early as the sixth century, and may be valued not only
for the insight it gives into the magic of the Christianized British people
but also as displaying, as well as such material could, the character and
limits of the slight anatomical knowledge that the Celtic tribes of
Britain had succeeded in gathering from their Boman conquerors.
Now the early devotional literature of the Celtic speaking peoples
has certain characteristics into the details of which it is not our purpose
to enter, 3 but it is sharply contrasted with liturgical material emanating
more directly from Rome by its highly emotional character and the
extraordinary love of minutely detailed invocation. The Romans were
a working people whose interests were exclusively practical. This
feature displays itself to the full in the Roman liturgy when compared
with compositions of native British origin. The prayer here discussed
is very different from the Roman type and in close accord with the
surviving fragments of the Celtic hymnology. It opens with an
invocation to the heavenly powers couched in a tone of unrestrained
and, as we may now consider, of unbalanced emotion. After an
1 M. Hofler, “ Volksmedicinische Botanik der Kelten,” Archiv /. Gesch. d. Med., Leipz.,
1912, pp. 1 and 241. The investigations of Whitley Stokes (“ Materia Medica of the Mediaeval
Irish,” Revue Celtique , Paris, 1888, ix, p. 224) shows that in the true mediaeval period the
Celtic-speaking Irish had absorbed the Arabian medical system and that the ancient herb
lore had, even at that date, ceased to be customary. See also P. Pansier, “La Medecine
des Gaulois au Temps des Druides,” Janus , Haarlem, 1907, xii, pp. 436 and 525.
7 A fragment of a Celtic leech book, perhaps dating from the tenth century, was described
by Stokes in vol. i of the Archiv f. celtische Philologie. This fragment is Celtic only in the
use of a few vernacular words. In other respects it is a typical specimen of Dark Age medicine.
3 Some have thought that the basis of these characteristics was a fundamental heresy in
the Celtic Church involving a confusion of the second and third pfersons of the Trinity
bringing the Celtic Church in close relation to Gnostic and Neoplatonic views.
F. C. Conybeare, “The Character of the Heresy of the Early Biitish Church,” Trans.
Hon. Soc. of Cymmrodorion , Lond., 1898. This view is opposed by the liturgiologist,
F. E. Warren, “ Liturgy and Ritual of the Celtic Church,” Oxford, 1881, and “ Conversion
of the Kelts ”—“ Cambridge Mediaeval History,’’ ii, p. 498, Cambridge, 1913.
8«
126
Singer: The Lorica of Gildas the Briton
introduction of fourteen stanzas of this character the Lorica proceeds,
in a series of thirty-three stanzas, to beseech God’s aid against the
assaults of demons on the body of the suppliant. In the course of
this prayer, every organ of which the author could possibly think is
mentioned and exorcised. The names of the members are set down
in detail, and the divine guardianship is asked for each in turn.
In spite of its Celtic setting the Lorica is a piece of pure Eastern
demonism which has somehow fascinated the English speaking people
and become absorbed into the Anglo-Saxon magico-medical system.
(II) The Title, Author and Date.
The word Lorica meant primarily a leather coat or cuirass and was
used in this sense as early as Plautus (died 184 b.c.). In later classical
writings the term came to describe a hauberk or byrnie of linked mail.
A Lorica of this kind is described by Virgil:—
Loricam consertam hamis auroque trilicem
A hauberk of linked mail and triple tissue of gold.
JEneid, iii, 467.
Mail coats of this kind were well known to the Celtic and Teutonic
tribes. Such a mail coat is carved, together with Runic writing, on an
eighth or ninth century whalebone casket in the British Museum, 1 2 and
a hringde by man is described in Beowulf where we read:—
Beowulf madelode—on him byrne scan,
Searo-net seowed smiles or-kancum.
Beowulf spake, the byrnie on him shone,
The armour-net linked by the skill of the smith.
Beowulf, 405, 406.
Loricae of this type have been recovered by excavation from
Teutonic sites from Switzerland to Sweden,* and it is evident that
such armour was widely known in barbarian Europe. 3
1 The “ Franks Casket ” figured in the Facsimiles of the New Palaeographical Society ,
plate 229.
2 Cp. S. R. Meyrick, Archaeologia , xix, p. 336 ; W. M. Wylie, Archaeologia , xliv, p. 100;
Sophus Muller, Nordische Altcrtumskunde> ii, p. 128; Lehmann, BrUnne und Helm , 1886;
J. R. Clark Hall, Beowulf ", London, 1911, p. 228.
* G. Baldwin Brown points out, however, that coats of mail, though widely distributed,
are yet rare in Teutonic graves, though from literary sources we derive the impression that
such pieces of armour were common. The coat of mail, though perhaps of Roman origin, was,
at times at least, of Teutonic workmanship.—“ Arts and Crafts of our Teutonic Forefathers,"
Edin., 1910, pp. 113 and 117.
Section of the History of Medicine
127
The special liturgical use of the word lorica is probably derived
from passages in the Vulgate where St. Paul speaks of those who
have “ put on the lorica of righteousness/* “ induti loricam justitiae **
(Ephesians, vi, 14), or are “covered with the lorica of faith and love,**
11 induti loricam fidei et caritatis (I Thess. v, 8). 1 In connexion with
the later development of the idea of a lorica of prayer, the former of
these passages may be considered in its context.
Ephesians vi.
Vulgate Version.
10. . . . Fratres confortamini in
Domino, et in potentia virtutis
ejus.
11. Induite vos armaturam Dei, ut
possitis stare adversus insidias
diaboli.
12. Quoniam non est nobis colluctatio
adversus carnem et sanguinem,
sed adversus principes, et potes- j
tates, adversus mundi rectores
tenebrarum harum, contra
spiritualia nequitiae, in caeles-
tibus.
13. Propterea accipite armaturam
Dei, ut possitis resistere in die |
malo, et in omnibus perfecti i
stare.
14. State ergo succincti lumbos I
vestros in veritate, et induti i
loricam justitiae;
15. Et calceati pedes in praeparatione
Evangelii pacis ;
16. In omnibus sumentes scutum
fidei, in quo possitis omnia tela
nequissimi ignea exstinguere.
17. Et galeam salutis assumite, et
gladium spiritus, quod est
verbum Dei.
English 1 rc in slat ion.
10. . . . Brethren be ye strong in
the Lord and in the power of
His might.
11. Put on yourselves the aimour of
God that ye may be able to
stand against the wiles of the
devil.
12. Since for us the struggle is not
against flesh and blood but
against principalities and
powers, against the rulers of
the world of this darkness,
against the Church (spiritualia)
of wickedness in the heavens.
13. Wherefore take up the armour of
God , that ye may be able to
withstand in the evil day and,
being perfected in all things, to
stand.
14. Stand therefore having girded
your loins with truth and
having put on the lorica of
righteousness.
15. And having feet shod with
preparation of the gospel of
peace;
16. Above all taking up the shield of
faith with which ye may be
able .to extinguish all the fiery
darts of the most evil one.
17. And take the helmet of salvation ,
and the sword of the spirit ,
which is the word of God.
1 In the original Greek the word translated lorica is in both cases.
128
Singer: The Lorica of Gildas the Briton
A similar range of ideas is encountered in Isaiah lix, 17, and in
Psalm xci. In the former we read of one who “ has put on righteousness
as a lorica and a helmet of salvation on his head,” indutus est justitia
tit lorica, et galea salutis in capite ejus. It is interesting also to
observe that Psalm xci is treated in Babbinic literature as a protection
against demoniac foes and against disease, and used in much the same
way as the lorica that we here describe.
In early Christian Europe the devotee regarded himself as surrounded
constantly by devils who were always thrusting at him and endeavouring
to pierce his breast-plate of good deeds and Christian observance.
It became an ecclesiastical commonplace to speak of those protected
from such attacks by a life of devotion, chastity and asceticism as
loricati. Thus the demon- and sin-repelling apparatus of prayer and
mortification was conventionally looked upon as itself a lorica.
This feature is well brought out in the Irish hymn attributed to
Bishop Sanctan, an early saint of Welsh origin, which begs that:—
To my soul for every black sin
Let never demons’ godlessness visit me.
I shall utter the praises of Mary’s son
Who fights for good deeds.
And God of the elements will reply
For MY TONGUE IS A LORICA for battle.
In beseeching God from the heavens
May my body be incessantly laborious
That I may not come to horrible hell. 1
Certain prayers regarded as of special efficacy, to which the name
of some well-known and much tried saint was sometimes attached,
thus came to be called loricae. In Ireland a special lorical value was
attached to the prayers of St. Patrick; thus in an early Irish poem in
praise of him we read that “ a hymn which thou hast chosen in thy
lifetime shall be a lorica of protection to all.”
The most famous of all the loricae is indeed that which claims to
have been written by St. Patrick himself. Whether the claim is a just
one or no, the composition is certainly very ancient and perhaps dates
back to the fifth or sixth century, since it was written in a period
when paganism had still considerable influence. The “Lorica of
1 Printed and translated by J. H. Bernard and R. Atkinson, “ The Irish Liber Hymnorum,”
Lond., 1898, i, p. 129, and ii, p. 47.
Section of the History of Medicine
129
St. Patrick,” the “fneth fiada ” or “cry of the deer ” as it is called, 1 *
betrays its early origin by the call for protection “ against incantations
of false prophets; against black laws of paganism . . . against deceit of
idolatry and against spells of women, smiths and druids.” Tn the first
lines of this text we read how “ Patrick made this hymn ... for the
protection of himself and his monks against the enemies that lay in
ambush for the clerics. And it is a lorica of faith for the protection
of body and soul against demons and men and vices. When any person
shall recite it daily with pious meditation on God, demons shall not
dare to face him, it shall be a protection to him against all poison and
envy, it shall be a guard to him against sudden death ; it shall be
a lorica for his soul after his decease.” The Lorica which bears the
name of Gillus or Gildas, which we here discuss, is of a somewhat
similar type and designed for a like purpose to that of Patrick, which it
closely resembles in tone and style.
The earliest copy of the Gildan Lorica that can be dated with any
accuracy is a Cambridge MS. of Anglo-Saxon workmanship. This MS.
has been recognized on palseographical grounds as a product of the
ninth century, while its date can be more narrowly determined by its
acrostic containing the name Aedeluald Episcopus . a This Aethelwald
was Bishop of Lichfield between 818 and 830. But the composition of
the Lorica is anterior to the earlier of these dates, since it is clearly
Celtic in origin and character, and there could have been little direct
Celtic influence on the liturgy of the English Church in the ninth
century. The Welsh frontier had been flung back across the Severn fifty
miles and more from the seat of his bishopric well nigh two centuries
before Aethelwald occupied it, so that by the eighth century Mercia
was politically cut off from Wales. 3 To separative political elements
must be added the odium resulting from the schismatic character of
the British Church after the Council of Whitby (664), reflected even in
the writings of so gentle a soul as Bede (672-735). Thus to explain the
Celtic source of the Lorica and to reach a point when a Mercian would
1 Bernard and Atkinson, loc. cit. t i, p. 133, and ii, p. 49. The interpretation of the term
fdeth fiada is disputed. Some would read it feth fiada and consider that it- was a spell
peculiar to Druids and poets who by pronouncing certain verses of the hymn could make
themselves invisible. The point is one that only Celtic scholars can decide. See Hugh
Williams’ “ Gildae de excidio Britanniae,” Hon . Soc. of Cymmrodorion, 2 vols., Lond., 1899,
ii, p. 292.
* The entire document is printed by A. B. Kuypers, “The Book of Cerne,” Cambridge,
1902.
3 It is, however, probably incorrect to suppose that the so-called “ Offa's Dyke ” was a work
of this period.
130
Singer: The Lorica of Gildas the Briton
have adopted a prayer of British origin, we must certainly look further
back than the days of Aethelwald, and at least to the seventh century.
There is, moreover, external literary evidence that the composition of
the Lorica was anterior to the eighth century. Aldhelm of Malmesbury
(died 709) appears to have known of it, and his peculiar expression tnta
pelta protegente is, it has been suggested, a reminiscence of stanza 16. 1
Further, all the MSS., except that at Vienna, associate the Lorica with
one Laidcend, Loding or Lodgen. The Leabhar Breac or Speckled
Book , a work of the fourteenth century, speaks of the prayer as intro¬
duced into Ireland by Laidcend , son of Baeth the Victorious. This
Laidcend, according to the Irish annals, died in 661, and if the Laidcend
of the Leabhar Breac is the same as Lodgen or Loding the prayer
must be earlier than this date.
The opening sentence of the Leabhar Breac runs Gillus hanc loricam
fecit ad demones expellendos eos qui arduersauerunt illi. It has been
suggested that this Gillus is identical with Gildas the “ British
Jeremiah.” Gildas Badonicus, the earliest British historian, was born
in 516, the year of the battle , of Mount Badon, and died about 570.
Gillus or Gillas is known to be a common form of Gildas, especially in
Irish documents. 2 His well-known history, De cxcidio Britanniae was
written about 560, and a date about the middle of the sixth century
must be ascribed to the Lorica if it is from his hand. The evidence of
the Gildan origin of the work is however by no means conclusive, though
it was most probably composed in tbe century in which Gildas lived, to
which period other specimens of Hibernian Latin have been attributed, 3
though it is probable that most of them are at least a century later.
If Gildas were really the author we could regard the mortalitas huius
anni , referred to in the text as the yellow plague , which is said to have
ravaged Britain about 547, at which date the composition of the
Lorica would then be approximately fixed. 4
1 F. J. H. Jenkinson, “ The Hisperica Famina,” Cambridge, 1908, p. xxii.
*For instances of this see H. Williams’ “ Gildae de excidio Britanniae, fragmenta, liber
de paenitentia, accedit et lorica Gildae,” Hem. Soc. of Cymmrodorion , 2 vols., Lond., 1899 and
1901, ii, p. 289.
* The view that the Lorica is of the sixth century, and the work of Gildas, is upheld by
H. Zimmer, “ Nennius Vindicatus,” Berl., 1893. It is regarded as of the seventh century (circ.
660) by R. Thurneysen in Zeit. f. deutsche Philologie , xxviii, p. Ill, and by Hugh Williams,
Gildas , Lond., 1889-1901, p. 295, and “ Christianity in Early Britain,” Oxford, 1912. There
is general consent that it is not later than the seventh century.
4 The dates of this plague lie between 543 and 548. The occurrence of this plague is
doubted by C. Creighton, “ A History of Epidemics in Britain,” Cambridge, 1912, 2 vols.,
i, p. 4. It is thought that the story may have arisen as a rumour of the great plague at
Byzantium and elsewhere in 543 and subsequent years. Cp. O’Donovan, “ Annals of the
Four Masters,” Dublin, 1851, i, p. 183.
Section of the History of Medicine
131
Before we discuss the language of the Lorica we may remind the
reader of some of the contemporary political and literary events in the
midst or, rather, at the periphery of which, the conjectural date of 547
would place our text. Augustine of Hippo had been dead for over a
hundred years, and no mission had yet gone forth from Rome to the
English, for Gregory the Great was yet a child and the chair of Peter
was occupied by the vacillating weakling Yirgilius. Within the Empire
the reign of prosperity of Theodoric the Ostrogoth was over and disorder
had broken out. In 547, the alleged date of the Lorica, Rome, having
been besieged by the Goths, had been recaptured by Belisarius, only to
fall again into the hands of the northern hordes two years later. In
the literary world the Lorica is intermediate in time between the
swan-song of the Platonic philosophy, the last utterance of the spirit
of the classics, that came from the lips of Boethius (480-524) in his
prison in Pavia, and the first works bearing the authentic stamp of
mediaevalism flowing from the pen of Cassiodorus (490-585) in his
years of learned and verbose retirement at the other end of Italy at
Calabrian Squillace.
(Ill) Language.
The language of the Lorica of Gildas has attracted a great deal
of attention. The difficulty presented by mediaeval Latin is usually in
the vocabulary, and is seldom constructional. To this rule the
Lorica is no exception, for, with a very simple structure, it presents a
most extraordinary collection of out-of-the-way and exotic words.
The Latinity has been much studied in connexion with the Hisperica
Famina, a curious document of the seventh century in the Vienna
Library, which the Lorica in many ways resembles. 1 2
A similar specimen of the so-called Hibernian or Hisperic Latin
is encountered in a hymn attributed to St. Columba (died 597),
known from its opening words as Altus pronator} This composition
1 The text of “ The Hisperica Famina ” is easily accessible in Migne’s Patrologia Latina ,
xc, p. 1186. Important discussions containing the bibliography of the text will be found in
H. Bradshaw, “Collected Papers,” Camb., 1889, p. 453 (reprinted from a publication of
1872), and by H. Zimmer, Nennius Vindicatus, Vber Entstehnng , Oeschichte xmd Quellen
dcr Historia Briitonum , Berl., 1893, H. Zimmer in the Nachrichten von d. Konigl. Ges. der
Wissenschaften zu Gottingen , 1895, Heft. ‘2. Another curious specimen containing many of
the “ Hisperic” words of the Lorica is encountered in the Luxemburg folio transcribed by
J. Rbys, Revue celtique , i, p. 346, Par., 1871. An excellent review of Hisperic or Hibernian
Latin texts is given by H. Williams, loc. cit., p. 298 ff. Lastly, the text of the Hisperica
Famina has been critically edited and compared with other specimens of Hibernian Latin
by F. J. H. Jenkinson, The Hisperica Famina , Camb., 1908.
2 Reprinted by Bernard and Atkinson, loc. cit., i, p. 62 ; ii, pp. 23 and 140,
132
Singer: The Lorica of Gildas the Briton
is known only in two late eleventh or early twelfth and one four¬
teenth century MS., but there can be no doubt that it is far more
ancient than the eleventh century. The Altus pronator also, we are
assured, renders the reciter thereof secure from all manner of spiritual
destruction, and further “ protects against every death save death on
the pillow.”
Another early fragment of Celtic origin, the Leyden Lorica,
enumerates the parts of the body in great detail, in the same way as
does the Lorica of Gildas, and uses much of the same obscure
vocabulary. The Leyden Lorica is, on the whole, however, much
simpler and less interesting than is the Gildan document. 1
Modern research tends more and more to show that the earlier
stages of the process by which the Anglo-Saxon replaced the British
tribes was one of infiltration and penetration rather than of invasion
conquest and extermination, although doubtless both elements were
present. On this view we should expect to find connecting links
between the Anglo-Saxon and the Celtic languages, yet such links are
extraordinarily difficult to trace, and the classical Anglo-Saxon tongue
—early literary English—contains no more Celtic words than does
modern English. Such Celtic rests as are to be discovered in Anglo-
Saxon documents must be sought either in Hisperic texts or in
magical formulae. To find any real connexion or fusion between the
two languages, if any such ever existed, we should probably need to
look much further back than the formed literary English of which the
best examples are of the tenth century, beyond the Danish devastation
of the ninth century, beyond the racial bitterness of the eighth, beyond
the schism of the seventh century, perhaps even beyond the Roman
missionary effort of the sixth century under Augustine of Canterbury.
Now although the race and language movement was always west¬
ward, yet the cultural advantage for centuries was on the side of the
receding peoples. The Celtic and English idioms are so vastly different
that then, as now, little mixture of the two can have taken place, but
there was a cultural diffusion in an eastward direction which is traceable
in written documents. Celtic magic and folklore spread among men of
English speech, carrying its characteristic ideas with it. Of this influ¬
ence the Leechdoms give evidence in many places. To the Anglo-
Saxon clerics, who shared a knowledge of Latin with their Celtic
colleagues, there was an easy means of communication, and of this
interchange the Lorica of Gildas is an early, perhaps the earliest,
V. H. Friedel, “La Lorica de Leyde,”in the Zeit. f. celtischePhilologie, 1898, ii, p. 64.
Section of the History of Medicine
133
monument. It is written in that very peculiar form of Latin known
as Hisperic or Hibernian that was affected in south-west Britain and
Ireland in the sixth and seventh centuries. Considerable remnants of
what must have been an extensive Hisperic literature have now been
recovered. 1 In this surviving Hisperic literature the Lorica of Gildas
stands almost alone in that, while thoroughly Celtic in tone and style,
and in use moreover by both the Irish and Welsh, it was yet popular
with the English. This curious fact is sufficiently proved by the
existence of three copies of the Lorica of Anglo-Saxon workmanship,
two of them fully glossed in the Anglo-Saxon language. The Gildan
Lorica is thus perhaps the earliest surviving literary link between
the two rival cultures and rival tongues.
That the Lorica of Gildas was not the only specimen of Hibernian
Latin that had reached the Saxon monasteries we learn from the
occurrence of many of its difficult words in Anglo-Saxon vocabularies
from the eighth to the eleventh centuries, and occasionally in the
writings of Aldhelm (died 709). Through the medium of these glosses
and vocabularies the combined efforts of mediaevalists, and Greek,
Semitic, Celtic and Anglo-Saxon scholars have now extracted the
meaning and source of nearly all the obscure terms. There are also
several passages in the Leechdoms which must have been written
under Hisperic influence. 2
It is not easy to understand how a knowledge of Hebrew sufficient
to suggest to its author some of the out-of-the-way words here included
can have reached Britain in the sixth or seventh century, nor is any
help obtainable from the extant work of Gildas. It should be noted,
however, that the Book of Kells, which is assigned by some of the best
critics to the seventh century, 3 contains on its first leaf a number of
Hebrew words with their Latin equivalents. 4 It must be admitted that
1 A readable account of the literature of Hibernian Latin is contained in the article on the
Celtic Church, by H. Zimmer, in the Realencyclojmdie /. prot. Theologie und Kun&t, and has
been conveniently translated into English by A. Meyer as “ The Celtic Church in Britain and
Ireland,” Lond., 1902.
7 These are to be found in vol. i, p. 386 and pp. 388-390 ; vol. ii, p. 112 and pp. 348-360 ;
vol. iii, p. 26, p. 78, pp. 288-290, and p. 294 of 0. Cockayne’s “ Leechdoms, Wortcunning and
Starcraft of Early England,” 3 vols., Lond., 1864-66.
*Cp. Johan Adolf Bruun, “ An Enquiry into the Art of the Illuminated Manuscripts of
the Middle Ages, Part I, Celtic Illuminated Manuscripts,”Edin., 1897, andEdward Sullivan,
“ The Book of Kells,” Lond., 1914.
4 A Gallician psalter with Hebrew equivalents dating from the tenth century has also been
described, F. E. Warren, “Un Monument in^dit de la Liturgie Celtique,” Par., 1888, Revue
Celtique , ix, p. 88. It may have been from some source such as this that Bede derived his
slight knowledge of Hebrew. A Hebrew alphabet and the equivalents and meanings of the
letters is attached to a tenth century MS. of Rabanus Maurus at Exeter Cathedral.
134
Singer: The Lorica of Gildas the Briton
more modern study of the Hisperic Latin literature has reduced the
number of words to which a Semitic source was ascribed by the earlier
investigators. There still remains, however, a small group which
appear to be indeed of Semitic origin, and cannot be otherwise
explained. Prominent among these are iduma — hands ; gibrae
"W. -- man; and senas — Jtt’ tooth. While the source of such
words cannot yet be fully explained, there are certain points in con¬
nexion with this peculiar Semitic relationship that may be borne in
mind.
(a) From an early date interest in the works of Jerome attracted
attention to the words of Hebrew origin used by him, and information
as to the meaning of these and, perhaps, of other Hebrew words thus
reached these shores. Two very early vocabularies of Anglo-Saxon
origin contain a considerable proportion of Hebrew words. 1 Bede
seems to have had a vestigial knowledge of Hebrew.
(b) It is possible that writers of Hibernian Latin may have had
direct access to Jewish sources. No evidence is, however, forthcoming
that there were Jews in England before the Conquest, though there
are ample records of their presence in Gaul. 8
(c) Kecent research has demonstrated unexpectedly early Arabian
influence in southern Gaul beginning not later than the early part of
the eighth century. 8
(i d ) Syriac influence has been traced also in the Lorican vocabulary.
It seems clear that from an early date Syrian wanderers, travelling
perhaps for trade purpose, had reached the West. Thus a Spanish work
on Alchemy of about the year 700 contains many Syriac terms. Again,
Gregory of Tours (538-594) who was contemporary with the supposed
date of our Lorica, tells that he learned the story of the Seven Sleepers
of Ephesus from the mouth of a Syrian. 4 The same writer preserves
also the Syrian legend of Cosmas and Damian. 5 Syrian influence in
1 J. H. Hessol’s “ An Eighth Century Latin*Anglo-Saxon Glossary ” (The Coi'pus Gl&ssnri/),
Cambridge, 1890, p. 3 ; and “ A Late Eighth Century Latin-Anglo-Saxon Glossary (The
Leyden Glossary), Cambridge, 1906, pp. 27 and 221.
*S. A. Hirsch, Trans. Jewish Historical Soc . Eng., Lond.,1915, vii, pp. 3 and 4.
3 Leo Wiener, "History of the Arabico-Gothic Culture,’* New York, 2 vols., 1917. The
conclusions in this work arc generally unsound, but the important chapter on Virgilius Maro
contains valuable material that has been commented on by H. Bradley in the Eng. Historical
Rev., Lond., 1918, xxxiii, p. 252.
4 Gregory of Tours, Dc gloria mart grunt, Ch. xcv.
u
'Charles and Dorothea Singer, 44 Miniature of an Operation of Cosmas and Damia
attributed to Mantegna," Osier Presentation Volume , New York, 1919.
Section of the History of Medicine
135
art was also prominent about 781 in Carolingian times, as we learn
from the Godescalc Gospels written for Charlemagne. 1
The knowledge of Greek, on the other hand, which the Lorica
displays in common with other specimens of Hisperic Latin was no
very unusual accomplishment in Ireland from a date placed by some
scholars as far back as the fifth century. 2 Throughout the Dark Ages
Ireland was the chief, if not the only, centre of Greek study in north¬
western Europe. 8 This knowledge may have reached the island from
Southern Gaul, where, as we know from Apollinaris Sidonius (430-487)
Greek was well-known in the fifth century. The special magic value
attached to the Lorica of Gildas alike by the Celtic and English
speaking peoples, arose perhaps from this mysterious and exotic
character of its phraseology.
(IV) Manuscripts.
The Lorica of Gildas is known from the following six manu¬
scripts :—
(A) Early Ninth Century. —Cambridge University Library L1.I»
10, fo. 43. This MS. is known as the Booh of Cerne, but is better
described as the Prayer Book of Aedeluald the Bishop. The section
containing the Lorica is fully glossed in the Kentish dialect of
Anglo-Saxon by a hand that is probably of the tenth century. These
glosses are valuable as giving the meaning of many words which
would be otherwise untranslatable. The latest edition of it is con¬
tained in Dom. A. B. Kuypers O.S.B. The Book of Cerne, Cambridge,
1902, p. 85. The drawings and illuminations of this volume are
discussed by J. O. Westwood in his Facsimiles of the Miniatures and
Ornaments of Anglo-Saxon and Irish MSS. London, 1868, p. 43.
The text is also printed and elaborately compared with the other MSS.
and discussed by R. P. Wiilker, Bibliothek der Angelsdchsischen Prosa,
Bd. vi, Hamburg, 1905. See also H. Sweet, The Oldest English Texts,
“Early English Text Society,” London, 1885.
’A Michel, Histoire de VArt , Par., 1905, p. 336; J. A. Herbert, Illuminated Manuscripts ,
Lond., 1911, p. 99.
* Among them so eminent an authority as Ludwig Trauhe. See L. Traube, “O Roma
nobilis. Philologische Untersuchungon aus den Mittelalter,” Munich, 1891. Sec also K.
Meyer, “ Learning in Ireland in the Fifth Century and the Transmission of Letters.”
Dublin, 1913.
* A popular account of the part played by Irishmen in the spread of learning during the
Middle Ages is given in “The Irish Element in Mediaeval Culture,” by H. Zimmer,
translated by J. E. Edmunds, New York, 1891.
136
Singer: The Lorica of Gildas the Briton
(B) Eighth or Ninth Century .—British Museum Library, Harley,
2965. A manuscript formerly belonging to St. Mary’s Abbey or
Nunnaminster at Winchester. The text is printed by W. de Gray
Birch, in An Ancient Manuscript of the Eighth or Ninth Century ,
published by the Hampshire Record Society, Winchester and London,
1889. We have in the main reproduced this text. See also New
Palseographical Society Facsimiles , plate 163,
(C) Ninth Century .—Cologne Cathedral Library, formerly at Darm¬
stadt, where it was numbered 2106. It has been copied from a glossed
original and has several corrections in a later hand. The text is printed
by Mone in Lateinische Hymnen y Freiburg, 1853, vol. i, p. 367.
(D) Late Tenth Century .—British Museum Library, Harley, §85,
fo. 152, The Lorica is here placed in the midst of an ^.nglo-Saxon
medical receipt book known as the “ Lacnunga ” (i.e., Medications,
recipes), and is fully glossed by an Anglo-Saxon hand of the eleventh
century. This version has been printed by 0. Cockayne, Leechdoms ,
Wortcunning and Starcrajt of Early England , London, 1864, vol. i,
p. 73.
(E) Fourteenth Century. —Royal Irish Academy at Dublin, the
Leabhar Breac or Speckled Book . This MS. is an immense collection
of ecclesiastical pieces, and has been published in facsimile by the
Royal Irish Academy, Dublin, 1876. The text of the Lorica is glossed
in Irish, and text and glosses are printed and discussed by Whitley
Stokes, Irish Glosses , Dublin, 1860, p. 133. It has been printed again
by Bernard and Atkinson in the Irish Liber Hymnorum.
(F) Sixteenth Century .—Vienna Royal Library, 11, 857. This text
has been printed by Daniel in the Thesaurus Hymnologicus , 1855^
vol. iv, p. 364.
(V) Text and Translation.
We have in general followed the text of B as being probably the
most ancient. Where we have diverged from B we have indicated the
fact in afoot-note.
Gillus hanc loricam fecit ad
demones expellendos, eos qui aduersa-
uerunt illi.
Peruenit angelus ad ilium, et dixit
illi angelus : Si quis homo frequent-
auerit illam addetur ei seculum septim
annis et tertia pars peccatorum
Gildas made this lorica to drive
out those demons who pestered him.
An angel came to him, and the
angel said to him “ If any man should
recite it constantly, a period of seven
years would be added to his life and
a third part of his sins blotted out.
Section of the History of Medicine
137
delebitur. In quacumque die can-
tauerit hanc orationem ... es,
homines uel demones, et inimici non
possunt nocere; et mors in illo die
non tengit. Laidcend mac Buith
Bannaig uenit ab eo in insolam
Hiberniam; transtulit et portauit
super altare sancti Patricii episcopi,
saluos nos facere, amen.
Metrum undecassillabum quod et
braoicatelecticon dicitur^ quod un-
decem sillabis constant; sic scan-
ditur. 1
J. Suffragare trinitatis* unitas
unitatis miserere trinitas
2. Suffragare quaeso mihi posito
maris magni uelut in periculo
3. Ut non secum trahat me mortalitas
huius anni neque mundi uanitas
4. Et hoc idem peto a sublimibus
celestis militiae uirtutibus
5. Ne me linquant lacerandum
hostibus %
sed defendant me iam arm is
fortibus
6. Ut me illi praecedant in acie
caelestis exercitus militiae
7. Cherubinn et seraphinn cum
* milibus
Michael et Gabrihel similibus
8. Opto tronos uirtutes 3 archangelos
principatus potestates angelos
9. Ut me denso defendentes agmine
inimicos ualeam prosternere
On whatsoever day he should chant
this prayer . . . men, demons or
enemies cannot harm him, nor death
touch him on that day.” Laidcend,
son of Baeth the Victorious, came
from him to the island of Ireland ; he
brought it over and placed it upon the
altar of Saint Patrick the Bishop, to
make us whole. Amen.
The metre is hendecasyllabic and
is also called brachycatalectic because
it consists of eleven syllables. It is
scanned thus :—
Help 0 oneness of Trinity
have pity O threeness of unity,
I beseech thee to help me who am
placed
in peril as of a mighty sea,
So that neither the pestilence of this
year
nor the vanity of the world may suck
me under.
And this I beg from the might
of the powers of the high heavens ;
that they may not leave me to be
torn by foes,
but may defend me with their
mighty arms;
that they may' stand before me in
battle array
as the army of heaven’s levy.
Cherubim and Seraphim with their
thousands
Michael and Gabriel and their like,
I conjure the thrones, the virtues,the
archangels,
the principalities, powers and angels
that, shielding me in dense formation,
I may stand strong to strike down
the enemy
B has Hanc luricam lodgen in anno periculoso
Si ter in die cantatur. A has only Hanc
1 This introduction is inserted from E;
constituit. Et alii dicunt magna sit uirtus eius.
luricam loding cantauit ter in omne die.
B reads trinitas. Our reading is inserted from E.
3 A reads inucntes. B reads uiuentes. Uirtutes is inserted from E.
Singer: The Lorica of Gildas the Briton
138
10. Turn deinde ceteros agonifchetas
patriarchas quattuor quater pro-
phetas
11. Kt apostolos Dauis Christi pro-
retas
et martyres omnes peto anthletas
12. Atque adiuro et uirgines omnes
uiduas fideles et confessores 1 * *
13. Ut me per illos salus sepiat
atque omne malum a me pereat
14. Christus mecum pactum firmum ;
fereat
timor tremor tetras turbas terreat.
Finit primus prologus graduum
angelorum et patriarchum
apostolorum et martirum cum
Christo.
Incipit prologus secundus de
cunctis membris corporis usque
ad genua.*
15. Deus inpenetrabili tutella
undique me defend© potentia
16. Meae gibrae pernas omnes libera
tuta 8 pelta protegente singula
17. Ut non tetri demones in latera
mea librent ut soleant iacula
i
18. Gigram cephale cum iaris et conas i
pattham liganam sennas atque j
michinas
19. Cladum crassum madianum talios
bathma exugiam atque binas
idumas
20. Meo ergo cum capillis uertice 4
galea salutis esto capite
21. Fronti oculis et cerebro triform i
rostro labie facie timpore
22. Mento barbae superciliis auribus
genis buccis internaso naribus
(I beg) then the other chieftains,
the patriarchs and the four times four
prophets
and I beg the Apostles, the pilots of
the ship of Christ,
the martyrs, yea, all of them captains,
and I adjure also all virgins,
faithful widows and confessors,
that for their sake salvation may
circle me
and all evil may perish from before me,
that ChriA may make a strong
alliance with me
that terror and fear may affright the
foul host.
Here ends the first prologue of the
degrees of angels and patriarchs, of
apostles and martyrs with Christ.
Here begins the second prologue
concerning all the members of the
body as far as the knees.
0 God with thy inscrutable
saving power defend all my parts
deliver the whole trunk of my body
with thine own protecting shield
that foul demons may not hurl,
as is their wont, their darts at my
flanks,
skull, head with hair and eyes,
forehead, tongue, teeth and nose,
neck, breast, side and reins
thighs, bladder and two hands.
To my head, with hairs on top of it,
be a helmet of protection,
to forehead, eyes and triformed brain,
to nose, lip, face and temple
to chin, beard, eyebrows, ears,
cheeks, lips, internasal septum and
nares,
1 The whole of stanza 12 is omitted by A and B but found in E.
* The two clauses between stanzas 14 and 15 are omitted by A and B and inserted from E.
8 A and E read tuta, B tua.
4 A reads capiti, as also E.
Section of the History of Medicine
139
23. Pupillis rotis palpebris tautonibus
gingis anile 1 inaxillis faucibus
24. Dentibus linguae ori uuae 11 * guttori
gurgulioni et sublinguae ceruici
25. Capitali ceotro cartiiagini
collo clemens adesto tutamini
[Obsecro te domine Iesu Christe
propter nouem ordines
sanctorum angelorum. 8 ]
26. Deinde esto LORICA tutissima
ergo membra ergo mea uiscera 4
27. Ut retrudas a me inuisibiles
sudum clauos quos fingunt odibiles
28. Tege ergo Deus fortis lurica
cum scapulis humeros et brachia
29. Tege ulnas cum cubis et manibus
pugnos palmas digitos cum ungibus
30. Tege spinam atque costas cum
arctibus
terga dorsumque neruos cum
ossibus
31. Tege cutem sanguinem cum renibus
cata crines nates cum femoribus.
32. Tege cambas surras femoralia
cum genuclis po(p)lites et genua
33. Tege ramos con crescentes decies
cum mentagris ungues 5 6 binos
quinquies
34. Tege talos cum tibiis et calcibus
crura pedes plantarum cum bassibus.
35. Tege pectus iugulam pectusculum
mamillas 0 stomachum et umbilicum !
to the round pupils, eyelids and eye¬
lashes,
gums, breath, jaws, fauces,
to the teeth, tongue, mouth and throat,
uvula,larynxand frenumof thetongue,
to head-pan, brain and gristle,
and to my neck be thou a protection
in thy mercy ;
[I beseech thee, O Lord Jesus Christ
for the nine orders of holy angels,]
Be thou a secure Lorica
both to my members and to my viscera.
So that thou turn back from me
the invisible
points of the shafts which transfix
the abhorred.
Cover (me) then, 0 God, Thou strong
lorica
as to my shoulders, arms and fore¬
arms ;
Cover arms with elbows and hands
fists, palms, fingers with nails.
Cover the spine and ribs with their
joints,
the rear and back with nerves and
bones.
Cover skin, blood with kidneys
haunches and rump with thighs.
Cover hams, calves and thigh parts
with knee caps, poplites and knees
Cover the tenfold branches (of the
fingers)
with toes and their twice five nails.
Cover ankles with shanks and heels
legs, feet, soles with insteps.
Cover breast, peritoneum and breast
bone, ,
mammae, stomach and navel.
1 B reads Anale. The reading anile is inserted from A.
* B reads ubae only. The reading ori uuae is inserted from A.
* This invocation is absent in A and B and is inserted from E.
4 The order of Membra and uiscera is inverted in B.
5 B has iunges. The reading ungues is from A.
6 B has mamellum. The reading mamillas is from A and E.
140
Singer: The Lorica of Gildas the Briton
36. Tege uentrem lumbos genetalia
et aluum et cordis uitalia
37. Tege trifidum iecor et ilia
marsem reniculos fithrem cum
obligio.
38. Tege toliam toracem cum pulmone !
uenas fibras fel cum bucliamini
39. Tegecarnem inginem 1 * cum medullis |
splenem cum tortuosis intestinis !
40. Tege uesicam adipem et pantes 3 *
compaginum innumeros ordines
41. Tege pilos atque membra reliqua
quorum forte praeteribi nomina
42. Tege totum me cum quinque
sensibus
et cum decim fabrefactis foribus
13. Ut a plantis usque ad verticem
nullo membro foris intus egrotem
44. Ne de meo possit uitam trudere j
pestis febris languor dolor corpore
45. Donee iam Deo dante seneam
et peccata mea bonis deleam
46. Et de carne iens imis caream
et ad alta euolare ualeam
47. Et miserto 3 Deo ad etheria
laetus regni uechar refrigeria
Amen. Amen.
Cover belly, groins, genital parts
and paunch and vital parts of the
heart.
Cover the trifid liver and ilia,
scrotum, kidneys, intestines and rete
mirabile.
Cover tonsils, thorax with lung,
vessels, sinews, gall with pericardium
Cover flesh, groin with marrow,
spleen with tortuous intestines
Cover bladder fat and all
the innumerable sorts of structures.
Cover hairs and the other members
of which the remaining names are
numerous.
Cover all of me with my five senses
and with the ten doors that were
contrived (for their use,)
that from the soles to the top of the
head
in no member, without or within, may
I be sick ;
that there may not thrust the life
from my body
neither pest nor fever nor languor nor
pain,
while by God’s grace I may reach
old age
and may wipe out my sins with good
deeds,
And leaving the flesh I may be
blameless
and may be worthy to pass on high
And by God’s pity I may rise happy
to the refreshing ether of His kingdom.
Amen. Amen.
1 B has iunginam, as also A. The reading inginem is from E.
- B has partes. The reading pantes is from A and E.
3 B has misero. The reading miserto is from A and E.
Section of the History of Medicine
141
(VI) —Obscure and Difficult Words.
The references are given below under the numbers of the stanzas.
The capital letters refer to the MSS. enumerated in Section IV. We
have relied largely on the renderings of W. de Gray Birch and
Cockayne, loc. cit.
Stanza 10. Agonithetas from tvywv carps — combatant. A has the A.S. gloss
cempan = chieftains . E contains a long gloss on this word which
yields the same result as A.
Stanza 11. Proretas must be for n rpqyparas = look out men. A is glossed A.S.
stioran from steorra *== a star. Steor-redra. — steersman occurs in
the Blickling homilies (late tenth century): Crist waes on daem scipe
swa se steorrel^ra — Christ was in the ship as a steersman. E has a
long gloss on the word deriving it from Latin prora — the helm.
Antliletas for d&Xprds = champions. A is glossed A.S. cempan = chief-
tams. E principes belli.
Stanza 16. Gibrae , suggested origin is — man, homo. A glosses A.S.
lichoman. Lie and lichama are recognized A.S. forms for body or
corpse , cp. German leichnam. E glosses, id est hominis, gibre.
Pernas appears to be equivalent to flank or trunk ; as such it appears
in an eighth century A.S. glossary thus: perna, flicci — flitch}
E glosses id est artus id est compur inchleib — trunk (?) of the chest ,
according to Stokes.
Pelta probably for rreXrp — shield. E glosses sciath — shield.
Stanza 17. Tetri for taetri.
Stanza 18. Giqram is glossed by A as A.S. hnoll — crown of the head , and by
E with Irish words of the same significance. The origin of the word
giqram is unknown. Cockayne’s suggestion is neck (rather
nn,pil). Giqram might also be fancifully rendered high top (O’! 33).
Cephale for tce<f>d\r)v — head.
laris , W. Wright suggests this word is from -- hair as by error for
Siaris. The connexion seems distant, but E glosses capillis.
Conas , Cockayne’s suggestion for — eyes giving the full guttural sound
to the V seems very strained. That conas means eyes seems clear
from the fact that E is glossed oculos and D egan — eyes . Conas is
glossed oculos in another tenth century MS. (Wright, vol. I).
Patiham is shown by Irish gloss of E to mean forehead. For a source oi
the word the commentators are driven to Syriac. A glosses onwlite
- — face.
1 Thomas Wright, Anglo-Saxon and Old English Vocabularies, edited by R. P. Wiilker,
2 vols., London, 1884, I, 38, 34.
142
Singer: The Lorica of Gildas the Briton
Liganam is glossed by E dontengaid to the tongue. The word must
therefore stand for linguam.
Sennas is glossed by A toed — teeth , and by E dentes. Cockayne suggests
from 11? --- tooth.
Michmas is glossed by A as naesdyrel nostrils. A connexion has been
suggested with fivtcTgpa? nostrils. E glosses with the Irish
equivalent of teeth.
Stanza 19. Cladum glossed by A as swiran and swioran - sweoro, neck or
column. E glosses collum. For a source W. Wright is again driven
to Syriac or Arabic: Arabic kadhalun, Syriac kedala; D reads
chaladum.
Crassum glossed by A breost and by E pectus. There can therefore be
little doubt of its meaning, though no likely suggestion has been made
for its source. Crasum is glossed dorsum in a tenth century MS.
(Wright.)
Madianmn glossed by A sidan - side and by E latus.
Talias glossed by A lendana lendenu loins , reins , and by E with the
Irish equivalent of bowels.
Bathma glossed by A deeoh - thews or thighs , and by E with the Irish
equivalent of loins. Bathma is perhaps from fiadfioi ^ steps , a word
which there is evidence from Hesychius Lexicographus (probably fifth
century) was used as an out of the way term for thighs as ftadfioL
Xx^V woSe? — thighs , legs , feet.
Exugiam glossed meaninglessly by A midirnan and by D miegemu,
Micge is the usual A.S. for urine and miegemu the place of the urine.
i.e., the bladder. To regard it as equal to kidneys, as some have done,
is to attribute to the author of the Lorica a physiological conception
that he probably did not possess. For him it is probable that the
kidneys would have been the seat of some mental rather than urinary
function.
Idumas glossed by A hondas hands , and by E manus. The word itself
is probably from — hands.
Stanza 21. Timpus is the usual mediaeval form of tempus.
Stanza 23. Tautonibus glossed by A ofer bruum upper brows — eyebrows ,
and by E with the Irish equivalent of eyelids , the eyebrows being
considered the guardians (tutores) of the eyes ; or perhaps the bony
orbit of the skull is meant, cp. Aelfric vocabulary Tauco (? for Tauto),
hringban daes eagen ring-bone of the eye.
Gingis glossed by A todreomum tooth-holder. D reads ignis but gives
the same gloss. The word is probably for gingivis aud not a form of
A.S. cin chin .
Anile glossed by A orode breath
anliclae.
Section of the History of Medicine
143
Stanza 24. Uuae glossed by A hreectungan — throat tongue — uvula.
Gurgulioni glossed by A drotbollan = throat pan — Adam's apple -- larynx.
E agrees with this.
Suhlinguae glossed by A tungedrum — tongue thread or tongue cord - under
tongue cord . D has undertungedrum. The meaning is surely the
frenulum linguae of anatomists.
Stanza 25. Capitali glossed by A haefudponnan — head pan ; by D heafodlocan
— head guard , head cover .
Ccotro : A reads centro and glosses swiran = neck . D reads ceotro;
E reads ceotro and glosses with Irish equivalent of neck . Cockayne
suggests from but an eighth century gloss reads ceruellum,
id est centrum braegen — brain , and this may well be the meaning.
Cartilagini glossed by A gristlan.
Stanza 27. Sudum for sudium.
Stanza 29. Cubis glossed by A faedmum elbow, arms ; by D elnbogan
-- elbows.
Pugnos glossed fyste Jist by both A and D.
Ungibus glossed naeglum — nails by both A and D.
Stanza 30. Arctibus glossed by A liodum, by D lid — joints.
Stanza 31. Cata crines is glossed by A huppbaan = hip. The source of the
term cata crines is obscure and any derivation from Karatcpivo)
= deliver judgment, seems very difficult, though there was a school
of mediaeval thinkers who made the* loins the seat of judgment.
Williams (loc. cit.) thinks that cata may be the Greek Kara , which
was commonly used in the Latin of the sixth century as equivalent
to ad or juxta.
Stanza 32. Gambas. E reads gambas; A reads cambas, and is glossed
homme ~ hams.
Genuclis , glossed by A cnielnim — knees, written above an older and erased
gloss that was perhaps hweorfbanum, a word which would bear the
meaning joint bones.
Stanza 33. lxamos con cresccntcs decies — the ten growing branches . i.e., the
lingers. Cp. Hesiod. Works and days: 742 a7ro irevrotjoto avov
diro Tdpveiv — to cut the withered front the quick from the
five-branched — to cut the nails of the hand.
Mcntagris, glossed by A tanum = toes . No source for the word can be
suggested. An eighth century glossary, printed by T. Wright, gives
mentagra, bituihn, which helps no further.
Stanza 34. Bassibus from £— step glossed by A staepum =- steps.
9
144
Singer: The Lorica of Gildas the Briton
Stanza 35. Iugulam. Bosworth and Toller (A.S. dictionary, Oxford, 1898)
suggest that jugulam = collar bone , but the word is glossed by A
dearmgewind, which must mean abdominal cavity or peritoneum
from )?earm = intestine , dearmgewind being thus the parts that
enwrap the intestine.
Pectusculum is glossed by A briostban — breastbone. E gives an Irish
gloss equivalent to the breast of the palm.
Stanza 37. Marsem perhaps for marsupium — pouch. The word is glossed
by A bursan — purse ; by E selg — spleen .
Fithrem is glossed by D snaBdeldearm - intestine .
Obligio is glossed by A nettan = net, the usual mediaeval term for the
rete mirabile to which especial importance was attached by Galen
and all mediaeval writers. E has an Irish gloss, inglais, to which no
meaning can be attached.
Stanza 38. Toliam glossed by A readan. In Wright's vocabulary there is
a gloss; reada tolia vel porunula (I, 4446-48.) Reada — red , and
Dr. Henry Bradley suggests that toliam may represent the Middle
English tuly or tewly purple , a word which may possibly be derived
from or from and DJDW — worm and also scarlet , i.e.,
the colour obtained from the worm of the shell-fish murex. Thus
tuly and toliam may be the red worm-like structure, the uvula.
Fibras glossed by A and D smael — small. E gives Irish gloss — sinews.
Smael perhaps refers to the small ends of the muscles.
Bucliamini glossed by A and D heorthoman, for heort-hama = heart
cover pericardium or midriff.
Stanza 39. Inginem perhaps for inguinem. B reads iunginam and A glosses
J>a sceare : shears or scissors — perhaps for the crutch or fork of the
legs.
Stanza 40. Panics for 7 t«Vt€9 - all. B reads partes, D pantas. A and H
gloss ealle all. E glosses omnes.
Stanza 42. Scnsibus cum decim fabre factis foribus. A and D gloss mid ten
durum - with ten doors. The ten doors or portals of entry of
sensations is a mediaeval commonplace. The mouth counts for two
(oesophagus + trachea) the others being eyes, ears, nostrils, urethra
and anus. Or the five senses may be more strictly followed and the
hands reckoned as the organs of feeling.
The author has to thank Dr. I. Abrahams, Reader in Rabbinic and Talmudic
in the University of Cambridge, for suggestions and corrections in connexion
with the Hebrew words and sources.
Section of tbe t>iaton> of flfeebidne.
President—Sir D’Arcy Power, K.B.E., F.R.C.S.
On tbe Physical Effects of Consanguineous Marriages in the
Royal Families of Ancient Egypt.
By the late Sir Marc Armand Buffer, C.M.G.
(Alexandria , Egypt.)
Prefatory Note by Lady Buffer.
My late husband left this paper unpublished with five others, all
on pathological subjects from Ancient Egypt.
His intention was to reprint them, with twelve others which
he had already published and many future ones for which he had taken
notes merely, in the form of a book under the title of “ Studies in
Palseopathology. ’ ’
Before undertaking the journey to Salonika from which he was
destined not to return, he had sent a copy of this paper for approval
to his friend, Dr. Singer, of Oxford; and though he never received
the paper back, I have adopted Dr. Singer’s suggestions with regard
to several points. Therefore I gratefully acknowledge his kind help,
on giving to the world this note of my husband’s on the “ Con¬
sanguineous Marriages of Ancient Egyptian Kings.”
Alice Buffer.
The question of the effect on the offspring of marriage between
blood relations is still an open one. Whereas the view that the children
of consanguineous marriages are likely to be weak and to be the bearers
of some congenital defect is widely held, some students of heredity
maintain that the facts on which this view is based are not convincing;
146 Buffer: Physical Effects of Consanguineous Marriages
and it must be admitted that, from the same data, divergent con¬
clusions have been drawn. Thus the Veddahs of Ceylon systematically
practise consanguineous marriage, and some years ago a lurid picture
was drawn of the evil effects of these unions. The race, it was asserted,
was becoming extinct, the people were stupid, sullen, and degenerated,
children had disappeared from the villages, in which adults only were
to be seen, and so on. Yet these fears were groundless, for the Veddahs
have remained a very simple, harmless, and monogamous tribe.
In Europe the marriage of first cousins is not uncommon, but the
effect of such unions the offspring is still a matter for controversy,
and some medical men categorically deny its dangers. Again, the
evidence is conflicting. At the Institution for Deaf-mutes in Paris,
for instance, the percentage of deaf-mutes born from consanguineous
marriages was 28*35 per cent., whereas, in similar Scotch and English
institutions, it amounted to 5*17 per cent. only.
The investigations of George Darwin did not reveal any distinct
connexion between infertility, deaf-mutism, insanity or idiocy and
consanguineous marriages; but this observer thought that the vitality
of the children of first cousins was somewhat below normal, and that
the death-rate was slightly higher than in the offspring of other unions.
Observations made in France and in Denmark do not seem to prove
the peril of such unions, and the facts collected in non-European
countries are not convincing. When, for instance, the enormous
mortality among Persian children is attributed to consanguineous
marriages, the fact that in certain Eastern towns the death-rate in
children less than one year old amounts to 30 per cent., should be first
accounted for.
Nevertheless, the majority of modern peoples exhibit in their
legislation a conviction of the perils of consanguineous marriage, and
believe that all kinds of evils threaten the offspring of such unions.
It is strange, however, that this idea appears to be entirely modern,
for although some ancient peoples were opposed to incestuous marriages,
there is no reason to believe that this prohibition was due to a belief
in evil results to the offspring.
Marriage 1 with a half-sister, not uterine, occurred in Athens, in
late times. The Greeks and Bomans of the classical period looked
upon incest as a crime, though voices occasionally inquired the reason
for this opinion, and the fable of Myrrha, 3 who conceived an incestuous
1 Robertson Smith, “ Kinship and Marriage,” p. 191.
* Ovid, 14 Metamorphoses,” x, Fable 8.
Section of the History of Medicine ,, 147
passion for her father is well known. The heroine pointedly asks why
incest should be a crime among men when it is the rule among animals.
“ Defend me,” she cries, “from a crime so great! if indeed this be a crime.
It is not considered shameful for the heifer to mate with her sire ; his
own daughter becomes the mate of the horse ; the he-goat, too, consorts
with the flocks of which he is the father; and the bird conceives by
him from whose seed she herself is conceived. Happy they to whom
these things are allowed ! The case of man has provided harsh laws,
and what Nature permits, malignant ordinances forbid.” Myrrha goes
on to envy the fate of the nations which allow incestuous relationships.
Consanguineous marriages were not uncommon in early Hebrew
records: Sarah was Abraham’s 1 2 3 half-sister; during Jacob’s life mar¬
riages between first cousins were allowed; Moses* sprang from a
marriage between a nephew and his paternal aunt; and even in David’s
time 9 a marriage between half-brother and sister was allowed.
* In Egypt, from very early times, marriages between brother and
sister were fashionable, whereas incestuous unions between father and
daughter, or mother and son, were very rare, if indeed they ever took
place. The Egyptian gods themselves had set the example of incest;
Keb, the earth god, and Nut, the sky goddess, had four children—two
sons, Osiris and Set, and two daughters, Isis and Nephtys, and children
were taught that Osiris married Isis and Set took Nephtys to wife.
Isis’ lament at the loss of Osiris leaves one in no doubt as to the rela¬
tionship between the two: “Come to her who loves thee, who loves
thee, Wennoffre, thou blessed one. Come to thy sister, come to thy
wife, thou whose heart is still. Come to her who is mistress of thy
house. ■ I am thy sister, born of the same mother, thou shalt not be
far from me . . . Thou lovest none beside me, my brother, my
brother.”
The royal families followed this lead. Throne and property being
inherited through the woman, mother or wife, as legal head of the
house, it was very doubtful, says Petrie, “ whether a king could reign,
except as the husband of the heiress of the kingdom.” As the king was
the ruler, while the queen, though the heiress to the throne, had no
executive power, the only way to keep the regal power in the family
was for the nearest male descendant of a king to marry the heiress, who
was very often his sister. In considering this relationship, as described
1 Genesis xx, 12.
2 Numbers xxvi, 59.
3 2 Samuel xiii, 13.
148 yRuffer: Physical Effects of Consanguineous Marriages
in Egyptian records, caution is however necessary. The word “sister,”
often a euphemism for mistress or concubine, also meant sometimes
the wife of a temporary marriage, or was even used as a term of
endearment. The confusion has been increased by the fact that
“ Royal Sister,” was one of the queen’s titles, which did not imply that
Her Majesty stood in that relationship to her consort. Therefore, in
this study, I shall consider a king and queen to have been brother and
sister only when there is sure evidence that they were so related.
The marriages of brothers and sisters were frequent among common
people also as late as Greek, Roman, and early Christian times.
Diodorus Siculus, 1 at the beginning of our era, mentions such marriages
among Egyptians. An Amherst papyrus 2 contains an application from
a woman, asking that her son Artemon might be admitted to the list
of privileged persons wholly or partially exempt from the poll-tax.
The basis of the claim is that the ancestors of the boy on both sides
were descendants from a gymnasiarch, and that therefore the boy
himself had the right to be included among those “ of the gymnasium.”
The genealogy of Artemon reveals, on the mother’s side at least, three
successive cases of intermarriage between brother and sister.
The custom persisted during the early Christian era. A papyrus, 8
dating from a.d. 108, gives a marriage contract between a certain
Apollonios, a Persian rf;? eiriyovrjs, and his sister Tapeutis; another
Persian married his sister Marouti, and a third married his sister
Erieus. Wessely 4 published several genealogical tables of Egyptian
families, from which it appears that in four well-to-do families
incestuous marriages were in the majority, and it has been stated 5
that, under the Emperor Commodus, two-thirds of the citizens of
Arsinoe had married their sisters.
As consanguineous unions were so common, the evil, results should
have been numerous and have attracted popular notice. Yet, as far as
I know, no such observations are recorded in Egyptian literature. In
what follows we shall select for illustration only those royal'families
the physical and mental characters of the individuals of which are
known.
1 Diodorus Siculus, i, 1.
* Grenfell and Hunt, “Amherst Papyri,” No. 75, p. 90.
* J. Nietzold, “ Die Ehe in Aegypten,” p. 13.
1 Ibid. Loc. cit.
* Erman, “ Life in Ancient Egypt,’’ p. 153.
Section of the History of Medicine
149
Eighteenth Dynasty Kings.
Queen Aahotep I, the heiress of the royal line of Hierakonpolis,
married first a man (name unknown) who was certainly her brother,
for on the stela of Abydos, put up in honour of his (and his wife’s)
grandmother, Tetishera, her son Ahmose I exclaims : “ I it is who have
remembered the mother of my mother and the mother of my father,
Tetishera.” 1 The queen’s second husband was Seqenenra, who was a
relative, and perhaps a brother. The mummy of this slim and remark¬
ably muscular king, who died fighting the Hyksos, measures 1'702 m.
in length, and the cranium is 0'195 m. long and 0131 m. broad. The
portrait of Queen Aahotep I, on the lid of her coffin in Cairo, is that
of a well nourished young person with good features. She had eleven
children by her two husbands. 2 *
Ahmose I, who was thus the son of an incestuous union, married
his sister or half-sister, Nefertari (figs. 1 and 2), whose wooden statuette
at Turin represents a buxom, well-formed woman, with no obvious sign
of degeneration. After reigning for twenty-five years with Ahmose I,
she acted as adviser to her son, Amenhotep I, and must have been
fairly advanced in years at the time of her death. She was “ the first
of those queens by divine right who, scorning the inaction of the
harem, took on themselves the right to fulfil the active duties of a
sovereign.” 8 After her death the people raised her to divine rank ; she,
together with her son, Amenhotep I, sprung from the marriage with
her brother, were regarded as specially “gracious and helpful.” Her
name was put on the same plane as those of the great, gods, and she
was worshipped for six hundred years after her death.
Table I. 4 * *
? = Tetishera
Brother = Aahotep I = Seqenenra (?)
Kemose Skhentnebra Ahmose I = Nefertari
1 Petrie, “A History of Egypt,” i, p. 225.
2 Ibid., “ Abydos,” iii, plate LII.
* Ibid.
4 In this and the following tables I have underlined the descendants of consanguineous
marriages with a full line, and the rulers (who succeeded to the throne for the most part by
right of marriage with their sister-wives) with a dotted line,—A lice Buffer.
AhiiiosR I, her - broth** aud husband, ascended the throne about
im u.c., when Egypt, w»;$ epilc&voiiring to throw .off the yoke of
foreign conquerors, the bated Hyksos, who for nearly two hundred
yen r:;. f.Hcl ruled the country. During his biilbant reign of twenty-four
H m
Hra
Fier. l. Via. £
Pfijr, f&fytfeMitieii v *. =.
Fijg. i — Queen Kofcfttuu; mf& M ^bruo^e 1* .From a wooden suit if Ton n (A li nan)
years this great king drove the aliens out of Egypt, and by carefully
jitb'tegtiiig the frontier made a new invasion extreraiely difficult. He
thus made Egypt a strong military state and established the dynasty
Section of the History of Medicine 151
on a firm footing. His successors conquered Syria and held it for
several generations in spite of the repeated risings of local chiefs.
Ahmose also began the restoration of the buildings of Upper Egypt,
which had fallen into decay under the Hyksos rule. He died at the
age of 55. His mummy measures 1*63 m. in length. The face, like
that of all the rulers of the earlier eighteenth dynasty, is comparatively
small, the nose prominent, though in the dried body this organ looks
small and narrow; the face is ovoid, the chin narrow, the superciliary
ridge fairly marked, and the upper teeth are prominent as in the women
of the family and in Thutmose II. The length of the head (including
wrappings) is 207 mm., and the breadth (without wrappings), 156 mm.
Table II.
(Brother) = Aahotep I = Seqenenra
i i
Ahmose = Nefertari
I i l ^ I ~\ I
Mervtamen Satamen Sapair Satkames Amenhotep I Aahotep II
Table III.
Brother = Aahotep I = Seqenenra
i i
Ahmose = Nefertari
Senseneb — Amenhotep I = Aahotep II
i i i. r i
Thutmose I — Aahmes Nebta Amenmes Uazmes
Amenhotep I, son of Ahmose I, reconquered Nubia, repelled an
attack of the Lybians, invaded Syria and reached the Euphrates. He
added to the temple of Karnak and to those on the opposite bank of the
Nile. The divine honours which were paid to him for nigh six
hundred years after his death bear witness to the strength of his
personality (fig. 3). He reigned twenty-one years, and died when
56 years old. 1 His mummy in the Cairo Museum, not yet unrolled, is
that of a short man, measuring 1'65 m. in length.
Of his sister and wife, Aahotep II, little is known. The union
1 Petrie, “ A History of Egypt,” i, p. 54.
PP T'nffer: Vkysh-vd. Btfe&s : "pf Cortsanguitmm* Marriages
bvou^'ht: forth four children—two forts, Amemncs and Uazmes,* and
twd/daughters, Aalimefi artd Nobta. One of tlm sons Was associated
for a time with his fat her in governing, the' HHmtry. Ope daughter,
Afifaiiies, married he*halt-brother. Thot,nurse I, the son of her father
by ^ensenetv'probably a slave Her portrait-adorns' the wails of the
temple, of i.Mi{■-<*}• Huhart dig.-V 1 . and without, doubther.' expression ||
Fit,. ,a ■
■ .•
Ani.iTiho'Up. I' fBf’aidh MuftHm.) (W, A Mansoti;}
f&seifmtifig , the leattnLe? A** 'ntsfim-d, and; $ w<>i$fto find
a nobier countenance than that bf this queen, the descendant of
incr-Htuous marriages of giroat graiKlparents, grandparents, and parents.
The length of. her life is unknown.
• BuCUt'S, *' !h<: Qut.Ofir V. i \r 'll.
From U. Elliot Sftmh, ' ii-alui. jjj&ftt'-ruJ »Je? z»tUi<put&<
diiiiC^j^e^VCrtirQ, !$}%■
Thutmost I
•• ' V' 1 ' - • t^lO;'. 5. • . ;
QiJMM A'ahifafc V'iom E Nav»lN\ Tii* Tfristfe of !*vir-eF£*&>ici$
154 Buffer: Physical Effects of Consanguineous Marriages
Her husband and half-brother, Thutmose I, ascended the throne
about 1535 B.c., led an expedition into Nubia, forced his way through
the cataract, and seized and strongly fortified the country. He then
invaded Syria and reached Naharin, that is the country from Orontes
to the Euphrates and beyond, where he slew or made prisoners many
of his foes. At home he was a passionate and successful builder. He
built the temple of Set at Nubt, near Negadah, the great temple of
Medinet Abou, probably designed the temple of Deir-el-Bahari, added
pylons and an obelisk to the temple of Karnak, and protected his
country by rebuilding the frontier defences. He died at the age of 43,
after celebrating the thirtieth anniversary of his coronation.
The authenticity of the mummy (fig. 4) supposed to be that of
Thutmose I is not quite certain, though the likeness to Thutmose II
leaves little doubt that this mummy is that of Thutmose I or of some
near relative. It is 154 m. long. The cranium measures 018 m. by
0'133 in., and the narrow, long, refined face is that of a clever and
cunning person.
The marriage of Aahmes with her half-brother, Thutmose I, had issue
two sons and two daughters, of whom both boys and one daughter died
young. The second daughter, Queen Hatshepsut I, in spite of opposi¬
tion, was associated with her father in the government of the kingdom.
Thutmose I had married, beside Queen Aahmes, a woman of only half
royal lineage, Mut-nefert; and Hatshepsut, following the royal tradi¬
tion, married her half-brother, Thutmose II, born from the latter
marriage.
Thutmose II added a pylon to Karnak, decorated the temple with
statues, and inscriptions relating to his work are met with as far as
Barkal in the Sudan and the Oasis of Farafra. The mask, statues, and
mummy of Thutmose II (fig. 6) represent a smiling and amiable coun¬
tenance, with features somewhat weaker than those of Thutmose I,
whom he otherwise resembles. The body is thin, somewhat shrunken,
and not very muscular, and measures 1 684 m., the bald head being
0'191 m. long by 0149 broad, and the face wrinkled.
Thutmose’s half-sister and queen, Hatshepsut, proved an exception
to the rule that the female members of the family inherited the
Egyptian crown but exerted no authority, for she overshadowed her
husband and was the actual sovereign, and he merely the king-consort.
She “ acted as master of the country. The kingdom was subjected to
her will. Egypt bowed it's head.” 1
i Maspero, “ The Struggle of the Nations,’’ p. 42.
Section of Hui&rg pf Medicine
1 'Ai,t,S tv.
•^Tf^nh^p l . Aaitotop II
Sciisunfli
Ti utmost ,1
Alui-n^Cert
Hatshb'r^uV
Morvtra Uatahepdut
Tbutiopsa 1II
. X!^
■ ■ M '■••1 / . . ■
. Thutmose If 4( Cairo;
After d§atb of Thutmoisti XI ..W:'tSe;cn6ti#3
of five eouotry. shared U*e kmgiioijj with her neu-iv.&i vo&U- ratat;**,
Tbnfetnose III, the sou of her former husband by Ami. who, apparently
was -not of rov.il birth.
/XV strengthen Her position the queen ofaitued direet descent froyi
the god AiiiOf), and her UHriteuious conception. birth and -education are
jreec'l'ded ciri the walls of the Jhfttoi temple, "With rematkabte Vftefcgy
sire- restored many bnildiugs, built the toniple: of l>eir^ebBahftii ? began
fcha facade at Specs' Arfcemides; brought aw obelisk from Nubia to
156 Buffer: Physical Effects of Consanguineous Marriages
Luxor and fitted out an expedition to the land of Punt, which returned
with great treasure, quaint animals and plants. Her reign was perhaps
too peaceful, as it was probably during this period that some of the
Asiatic provinces were lost to Egypt. A wise ruler, she exercised her
power with justice and moderation during her long reign, and through¬
out the Nile Valley, from Buto in the Delta, by way of Beni-Hasan,
Karnak and Thebes, El Kab, and Kom Ombo, to Assouan at the First
Cataract of the Nile, and from the far rock cliffs of Sinai, sculptured
stone and inscribed stelae record the reign of Hatshepsut, fulfilling the
wish voiced in her temple that her name may remain and live on in
temple and land for “ ever and ever.” Nothing, unfortunately, is known
about her personal appearance, as the Luxor and Deir-el-Bahari
portraits are conventional and for the most part obliterated by her
successors.
No less remarkable than Hatshepsut was her nephew and step-son,
Thutmose III, 1 the son of a father descended from a series of incestuous
marriages, and of a mother who was not of royal blood. After Hap-
shepsut’s death he became one of the strongest rulers in Egyptian
history ; during her lifetime his influence had not been felt. His
Majesty was somewhat short, measuring 1'615 m., his cranium was
0'196 m. long and 0T50 m. broad, and though he died at an advanced
age his mummy with its distinguished features gives, in spite of the
bald head, the impression of a youngish person. The upper teeth
project greatly (fig. 7).
His character a stands forth with more of colour and individuality
than that of any king of Early Egypt, except Akhnaton. We see the
man of a tireless energy unknown in any Pharaoh before or since, the
man of versatility, designing exquisite vases in a moment of leisure;
the lynx-eyed administrator, who launched his armies upon Asia with
one hand and with the other crushed the extortionate tax-gatherer.
Thutmose III left his mark on Heliopolis, where he erected the two
famous obelisks, on Abusir, Memphis, Gurob, &c. Koptos was entirely
rebuilt, Karnak was extended, Medinet Abou and Deir-el-Bahari were
completed, more than thirty different sites in Egypt and Nubia were
built over, and innumerable fragments of statues, sphynxes, statues, &c.,
testify to the building activity of this great warrior. His reign marks
1 Thutmose III is held by some to have been the son of Thutmose I and not of
Thutmose II. If that be true, be married not his sister but his niece. See Petrie, “ A
History of Egypt/’ ii, p. 78.
5 Breasted, 14 A History of Egypt."
. Section of'ikt- History of Medicine 157
an epoch not only in Egypt, hat m : the whole East as we know it in Isis
age, Kevet before in history bud «. single brain wielded they resources-
of so great a nation and wrought 'them into finch centralized, permanent,
and at tha sattte time, niahile: Wtftdetteyu that for years they could be
brought to bear with, incessant ijopitct. upon another eomirte&t ;»?• ■'<
skilled artizan .manipulates a hundred-ton forgo hemulct ;• although
■
Th III. \
that figure is inadequate unless we rein ember that Thutmose forged his
own hammer. The genius which rose from iih obscure priestly oibce
to accomplish this for the first 'time, in history reminds us of -u.
Alexander or of a Napoleon. He built the first real empire, and is thus
the first character possessed of .riniversiii aspects,, the first -world '..hero,
He made not only a world-wide impression upon bis age, but ».uf
Buffer: Physical [Effects -of . Citf0angi^f(efms- Marriages
His commanding figure, towering tike fln
impression ol a new order,
embodiment of righteous penalty among the triAd^l ptote and trea^hcrbns
: -schemes', of the petty Syrian dynasts, must have clarified the atmosphere
of Oriental politics as a strong wind drives 'away' iniasmic vapours,
The. inevitable eha«tiseifierit, of bis strong arm was held in awed
remembrance by the men of HAh&rin for three generations^ His name
was one to eonjttre with, and centuries after his empire had crumbled
to pieces, it. was placed on amulets as a word, of power. He died at the
age of 68. •<. , /- . ‘ •
Amoabobcjj II, Knrri&k, VVur» Legrmu’s “ Calftk^tin gf-imra'i ifc rtn,Ui|uIl^
Cftire t ^ Gftiro f 1<XX»;
Thufcmose lO loartidd his luilhsister, Meryt-Ha Hatshepsut, Qti$jjpj
Hatshepsuf ’s daughter, and «dk> another -woman, Ssat-Aab The number
of bis child con dk an known, but he Is said to have bad eight .denghters
Ainenbotep II, the soft of; Tfeptmose. III and. Meryt-sia .Hatsbepsufc,
was 108 m. in height; He was associated with his father in govern¬
ment for some time, and ascebd«i the throne when about 18 to 20
years old, reigned tor-iweinyahp years, and died at the age of 40.
Hja physical ittrength was exteaordiharv, and he clatinfed that no one
On the death of Thutmose HI, the Syrian tribes almost sitnaliac-
eou&iy rose m revolt, but they had not reckoned with the boundless
energy of the new" king. Ameoliotep II left Egypt with hig amry in
. Htxtwi of the EiMory -nf Medicine 169
April and already in May defeated the Bvrjans m a battle, in which he
with hie own hand .look eighteen prisoners arid fifteen horses. He
advanced with-irresistible power, crossed the Euphrates triumphantly,
returned to Egypt, and equally successful in the South, he- conquered
part M the Sudan
Aiuealiotep II married 1 Tiaa, who may have been hw ijalf-ftister by
a. mother not of royal birth. Their amp Thutmosir I V (fig. 0), an
cnei^etfe lion hunter in his youth, canie to the throne at the age of 24,
and showed his efcergy.by lea^rsig to e^editron to. Syria, from which he
returned with a cargo of cedar and many prisoners.• He contracted an
Pic. ».
Tbutmose IV Ptoni l-Ohot rfiea-Ji. •• (VihUffau: nf-ii..r«| d<;» iMitiqeiius
,.-.gypt)oiuie'..s iiu Miatc -in OcHft Cupi JpiUf,
alliance with Babylonia and with, thy Mi tan ns ah king, whose daughter,.
Mutemuya,* he married. He died at the age of
Tbutmose IV was' followed by his. Hi*years old son, Amehhptep III.
who married the celebrated Tiy (fig. Ill, a womftn of itnoertaio. origin,
perhaps a Syrian princess uf partly Egyptian descent, and also another
Syrian princess, Eirgipa or Giiukhipa The reign of this king was
putties!,: * 4 T\m Q meug oi pt, 1 * p. 1QL
lirioasifc^^ * x HfoWjr
10
Ruffer; I‘h>jxical Effects of
Consanguineous Marriages
'
Am‘$r)hri66p Ul.
si.
.
* fotn LegrnijrV CitjfttqgM tintiquiUs ^’ptsemae*
a u Mu see d it Ca i re:, ’ • Ch j to* VjLriy.
'MKlfiSWfiliL lUJKvW/iwl)} *
,
.
y. | 'i'. 1 *«*•*•* ^; »*\.*.\ t . j •
M <»• V* * i vyyJy.'
'.i i A'. .'17 f . f « f *
Smiwv of rhti llis/n) if uf MtJieitit' 1 QI
market) 'by great expansion of art and rumuierce drte t<> peaceful
dovdoptUKOi at home rather than by /grunt fcoy<(ucsi.s. ffo tsigned for
tHrrty-'Sfo y«sn> furd/diod: when about b’Ayenr* oh) {%•. 10), Owing to
their rdi ruder reigns, Anienhotep IT. ThutM.o~e IV and Aiuenhotep III
butifc far less. than their prei'foeesso);$>,
Aryenhoiep JY (figs. it! and l.Hi. -«.*• Akbrmton, the lust king of this
dy nasty to play a leading (taffc vh history, was.tbe grandson of MUteniuta,
AnitittfetiSf i V-
a Syrian woman, and tbs soy of Tiy, whose 'nationality, as just. said,
WMrrneerfcain; and hi« pnadlfori'gttefiina therefore may have .been due, to
the foreign blood it> hi.* voids or lb the powerful u<fhM-,nce exerted on
hoy by'bis JUdthor,
. The chiitkcterjhtio traitt qi Afchihjiton werfojfobgand
S} ;
BKv’.jf®
V*''» \/ m + v ?• i
m
162 Buffer: Physical Effects of Consanguineous Marriages
a high moral standard. As Weigall has pointed out, he was the first
Egyptian monotheist, 1 and monogamist at a time when polytheism and
polygamy were the fashion, and a pacifist when Egyptians were enjoy¬
ing the fruits of their conquests. He erected an entirely new town,
Akhetaton, now Tell-el-Amarna, which he adorned with the temples of
Queen Tiy, of Baketaton the king’s sister, of Queen Nefertiti, and last,
but most important of all, with the great temple of Aton. An
“ intellectuel ” of the first order, he patronized a new and realistic
form of art, but his fanatical hatred of the ancient religion led to the
destruction or mutilation of countless ancient artistic treasures, and his
neglect of royal duties, his inertia and physical laziness brought about
the loss of the Syrian kingdom. In truth, he showed in some of his
actions as little common-sense as some other religious reformers have
done. Nevertheless, a monarch who founds a monotheistic religion in
the teeth of the opposition of a most powerful priesthood, who builds a
new town where he worships his god away from old associations and
among congenial surroundings, who endows that new town with
beautiful temples, who patronizes a new form of art and who perhaps
composed the magnificent hymn to Aton, cannot be considered as lacking
in energy, or as a degenerate, or an effeminate person (fig. 14;.
Table V.
Merytra-Hfttshepsut = Thutmose III
Amimjotcp II = Tiaa
Thutmose IV = Mutcmuya
Amenbotep III = Tiy
Amcnhotep IV (Akhtiatou)
The characteristics of the Eighteenth Dynasty were thus tireless
energy, which enabled Egypt to resist its foreign foes, to carry the
Egyptian flag abroad and to establish wise government at home, and an
enlightened taste for the fine arts most forcibly shown in the artistic
reforms of Akhnaton. In these nine generations, issued from con¬
sanguineous marriages, there is no diminution of mental force. The
Weigall, “ Akhnaton.”
“■MTl
fyhiitiit of the MitfipWj ofM'^dwinf'
energy.cha.rocb eristic of Ahnmsc I is fuund twcffeundied years afterwards
in AkimatiHi. used it ■ in t rue for different .olyjvets anti higher ideals, hut
as intense in 1T>75- as it. v.as- w . I T>BO-1A57. Akhnato»> ideal may
).V or Aklmatwi. Front *t? iift th$..Loa«r&
have Wen suggested f>y 1m mother, the clever Queen Tiy. his energy
and ..Keen intellect.be■. inherited, in part, at least, from his father .
In the absence of jwy ditto regarding the average number of children
an Egyptian families, it is not possible to compare accurately the fertility
164 Buffer: Physical Effects of Consanguineous Marriages
of the consanguineous unions of the Eighteenth Dynasty with that of
unrelated people from the same period ; all that can be said is that
without doubt these incestuous unions were blessed with many children.
Moreover, the sexual power of the male members of the family is proved
bv the fact that they had families by their sisters, wives, and by other
women as well. Table VI giving the children known to have been born
to the kings and queens of this dynasty is necessarily incomplete, as the
number of children born in and out of wedlock cannot even be guessed
at, and indeed many of those mentioned in the table would have been
entirely forgotten had it not been for the accidental discovery of some
document or object inscribed with their names. The infants who died,
the miscarriages, and the illegitimate children, &c., must remain an
unknown quantity, though it can be asserted that the number of
children born was certainly larger than that given in this table. In
the case of the Eighteenth Dynasty therefore, loss of prolificity did
not follow consanguineous marriages.
Table VI.—Eighteenth Dynasty Kings.
A brother = Queen Aahotep I = Seqenen-ra (a brother ?)
I I I I
Kemose Skhent-nebra Ahmosc = Nefortar i
i i ; ! "“i r 1
Meryt-amen Sat amen Sapair Sat-kames Senscneb — Amenhotep I = Aahotep II
I III I
Mutncfert = Thutmose I = Aahmos Nebta Amenmes Uazmes
, Aset - Thutmose II = Hatshepsut
Thutmose III = Merytra Hatshepsut
Amenhotep II = Tiaa (half-sister ?)
Mutumaya = Thutmose IV
(Akhnaton) Amenhotep IV Nefertiti
Section of the Hhtoty of Medicine
The second evil umially attributed tiv «ot5Sa,5?giiineons marriages is
diminished duration of life in the offspring. • The figures referring, to
this point given in Table "ViI are approximate fni? "stdHii? tnouArciis
may have lived a few- .years more or-Jess,, and ibrthmv as; the mean
dwrattoa M hfe us lusoiirnt I'.gjpt is infknrnvn
Uitomisfed ; but in any ease, an average* duration of hf- of 4 J years
cannot&eon)Mdere?d as short. • . [ '• : ••;
T^ftvh-nVi 5 b
f: Atbnaton
Vli
• :<■'<•££. i ** ' v -•■
v : ; ,',4 MV-S’ pi
: ■ •
M r,; *■ •
- „ i t*gT m -. &> -
., ■ s „
. Mi! ::’V- p .,
,. .... vmm* v- IT -. „.
Ahmose 1
}
Thutmoso I
TiiutinosO III
AniftiilmtBp TI
Tinitmose i V r
A05tihotVp11I
A’Tf^^bffeplV
him! «t r.r,
There is bo- •evidence to show that id«oey, deaf-mntism. or other
diseases gecnralfy attributed t>* ^unsangimieous marriage, ever occurred
among the tuembers of this dywwtv, and as far as «aq be ascertained
from ruotnonfied bodies, masks and statues, the- features of both men
166 Buffer: Physical Effects of Consanguineous Marriages
The heights and cranial circumferences are shown in Table VIII.
The kings, though not tall men, were by no means undersized and their
height is well maintained during nine successive generations. The
cranial measurements of 413 living modern Egyptians 1 give an average
of 0T84 m. by 0'133 m. which almost exactly corresponds with the
cranial measurements of Thutmose I.
Ahmose
Amenhotep I
Thutmose I
Thutmose II
Thutmose III
Amenhotep II
Thutmose IV
Amenhotep III
Amenhotep IV
Table VIII.
Height
1-63 m.
1*65 m.
1-54 m.
1*685 m.
1*61 m.
1*67 m.
1-65 m.
1*56 m.
mummy
incomplete
Cranial measurements
Length
Breadth
0-207 m.
0*156 m.
0180 m.
0 133 m.
0*191 m.
0*149 m.
0*196 m.
0 150 m.
0 191 m.
0*144 m.
0*184 m.
0 *143 m.
0*194 m.
0*148 ra.
0-189 m.
0*154 m.
The portraits and mummies are those of stout, well-nourished
persons. Although the mummified body of Thutmose II, for instance,
is now reduced to little more than skin and bone, the redundancy
of the skin of the abdomen, thighs and cheeks is a proof of the
obesity of the king. Perhaps the most typical instance of patho¬
logical obesity in the family is seen in the portraits of the heretic
King Akhnaton (1374-1356 b.c.) who is represented as a man with
a thin face, neck and legs, but with a very protuberant abdomen.
There is no reason to doubt that the portraits of the monarch are
faithful likenesses. True, the abdomen is rather prominent in
other people represented at Tell-el-Amarna, owing chiefly to the
cut of the dress, which, firmly tied below the umbilicus, caused the
lower part of the abdomen to protrude; but in persons not wearing
this dress the abdomen is flat, and even in men attired in the garment
just described, it is never as protuberant as in King Akhnaton. Where
the King is represented distributing collars of gold his abdomen actually
hangs over the edge of the balcony, a most realistic piece of portraitnre.
The very thin calves of Akhnaton show that the artist faithfully copied
nature. The king’s obesity may have been partially responsible for his
politics. Corpulent subjects generally dislike physical exertion, and his
“ Archaeological Survey,” p. 25.
Section of the History of Medicine
167
stoutness may have been the reason why, when the outlying provinces
of his kingdom were threatened, he left unanswered the appeals for
help, and thus became responsible for the loss of some of the foreign
possessions of Egypt. Another picture from Tell-el-Amarna may be
referred to here. 1 It is divided into two halves, the left representing
the household of Akhnaton, the right the household of his father,
Amenhotep III. It shows that Akhnaton’s obesity was inherited, for
father and son show the same abdominal deformity. Indeed, the whole
royal family is distinctly stout, in contrast with the three lean female
servants on the extreme right. The mummy of Amenhotep III
(1411-1375 B.c.) is in the Cairo Museum, and it is unfortunate that
the body is in such a wretched state that its examination gives little
information as to his corpulency.
The skull attributed to Akhnaton, according to Elliot Smith, presents
a number of interesting and significant features. The cranium is broad
and relatively flattened, its measurements being 0189 m. in length and
0T54 m. in breadth; 0’136 m. in height; 0099 m. minimal frontal
breadth, with a circumference of 0‘545 m. The form of the cranium
and the fact that it is exceptionally thin in some places, and relatively
thick in others, indicates, in Elliot Smith’s opinion, that a condition of
hydrocephalus was present during life; and Professor A. R. Ferguson
is of opinion that the signs of this disease are unquestionable. Whether
the skull is Akhnaton’s or not, it is interesting to find that hydrocephalus
existed about three thousand five hundred years ago.
The result of this inquiry is that a royal family, in which consan¬
guineous marriage was the rule, produced nine distinguished rulers,
among whom were Ahmose the liberator of his country, Thutmose III
one of the greatest conquerors and administrators that the world has
ever seen, Amenhotep IV the fearless religious reformer; the beloved
queen Nefertari, who was placed among the gods after her death;
Aahmes, the beautiful queen, and Hatshepsut, the greatest queen of
Egypt. There is no evidence that the physical characteristics or mental
power of the family were unfavourably influenced by the repeated
consanguineous marriages.
1 “El Amarna,” i, ii, xviii.
Hj8 Buffer: Physical lifted* of Consanguineous Marriages
The . kisigs.; of the- Nineteenth % rert^rkaMy
handsome set of people, were probably bneal descehibun..-. of those nt
the Kigfoieenth Dynasty.• ( ' • ; _ . ? ';
Keti I (ftgfh to,and 10), m spits-: of his big and heavy jafr... presents
j*. moat nofahj and dignified appearance ; he measures 1 fi»5§ m. in 'height,
hp .<3 hife cranium 0T*i»3 m by 0\H:'i tu, BaniseiS fl (fig- 17), the great
historical figure of'this'.dynasty, married two of his sisters, find had four
chiidi'e.B by the first, find three, or possibly four, by 'tjw second sister.
He is said to have married two of. his daughters, leu the evidence on
Set.i f. olforir.jv, (.» bycVis.)
this point k 1 pot conclusive; By;o.tlfeh-’yi?iv«? '-and c-oneubmeE the king
is said to have had It Hi other sous and forty-seven daughters, therefore
this descendant' of a long Uhr of consaugnmeesus marriages cannot be
said.to have been infertile His feature): are strong and refined, the
teeth eftebllerd, and the onlyblemish, ir iim ; «ompleie baldness. The
body measures l'7;bi us „ ami his cranium h i9u by 0T8t> m, (fig. 18).
Liitlfe is. known about liamses D's children (fig. *20). One son.
Khenjwe.se,"became high priest of. f't-ih, org.ani7.ed the thirtieth anni¬
versary- of las father's -reign, xv'irS: associated with the king in the
administration oi Kg}pi and piedewm-d ins father. The other
Children forttH'd the powerful tribe of the ihunessides, which exerted
Section of the History of Medicine
Set r k >1 njwsjim..)
Ratn&fck II
Ramses
R Muetim )
170 Ruffer: Physical Effects of Consanguineous Marriages
considerable influence for many generations ; one daughter, Ben-anta,
was charmingly pretty.
Table IX.— Nineteenth Dynasty Kings.
Seti I = Tuaa
1
1
Two sons
Astnefert I =
i i
Ramses II = Nefertari-mery-mut
|
1 1 1
Benanta Khaemuas Ramses
(Khemwese)
1
Astnefert II =
1 III
Merenptah Meryt-amen Nebenkharu Nebtani
Seti
II = Takhat, a daughter of Rameses II
i
Amenmeses
Seti II had by an Seti II had by an
unknown wife unknown wife
I _L
Setnekht | |
I Sephtbah = Tausert
Ramses III . .
I both of whom reigned
I " I
Ramses IV Ramses VI
Merenptah (fig. 19), the son of Ramses II, by his first sister, was
more than middle-aged when he succeeded his father, and he, in spite
of his years, dealt energetically with the foes of Egypt. When the
Lybians threatened the very existence of Egypt, he assembled his
nobles, stirred up their enthusiasm by an eloquent speech, and with their
help inflicted a crushing defeat on the Lybians and their European
mercenaries. Turning then to Palestine, he subdued the country and
levied tribute on the land.
“ All lands are united, they are pacified. Every one that is turbulent
is bound by King Merenptah.’’
Merenptah’s building activities were not great, and his method of
obtaining stone by breaking up ancient monuments, though closely
imitated afterwards by Mehemet Aly and in still more recent times by
British administrators, is not to be commended. He died after a reign
of ten years, when approximately 70 years old, and is probably the
Pharaoh of the Exodus, commonly believed to have been drowned in
the Red Sea. His mummy measures 1‘714 m. His cranium 0'185 m.
by O'160 m. The aorta was calcareous.
Section-of the History of Medicine
Fig.. W.'-Mer<nipinL>. £Sr*v granite figure from his temple (Thelie»j,
Fig. SO. — Mtrytnmra, liaaelnct of Ramses II.
Ffc. 21.
Set! H, . Fcoiii his Statue.
•
.
:K; , wmg:
172 Buffer: Physical Effects of Consanguineous Marriages
Merenptah married Ast-Nefert II, most probably his sister. Their
son and successor, Seti II (fig. 21) died (murdered ?) after a very short
reign, during which he carried out many important public works. He
was probably fairly advanced in years at the time of his death.
The heights and cranial measurements of the Bamessides are shown
in Table X.
Table X.
Height
Cranial measurements
Seti I
1-665 m.
0*196 m.
by 0*143 m.
Ramses II ...
1-733 m.
0*195 m.
,, 0*136 m.
Merenptah ...
1*714 m.
0*185 m.
,, 0*160 m.
Seti II
1*640 m.
0*187 m.
,, 0*141 m.
Sephtah
1*638 m.
0*189 m.
,, 0*147 m.
(Kiug Sephtah suffered from left talipes equinovarus.)
Table XI gives a resume of the chief marriages of the twenty-first
Dynasty, and shows that consanguineous marriages were common, and
marriages between brother and sister very few.
Table XI.— Twenty-fibst Dynasty, Kamesside Line.
Of Thebes. Of T&nis.
i i ' ”i
Heritor = Nezemt (?) Nebseni ^ Then tarn cn = Nesibaneb-dadu
18 Princes 19 Princesses Piankhi — Hent-taui I Pasebkhanu I (?)
Pinezem I = Maatkara
. I i
I Masaherta
1 I
I ' I
Menkheper ra = Astemkheb I
Hent-taui II (2) = Tahenthuti (1) — Nasibadadu
Nesikhonsu = Pinezem II = Astemkheb II
i . .
i
N esi tan e basher u
Section vf the llizfcrij M^ietne
King Herbor married Nfefce-tiifc, who probably. St-'ueiu relative and
possibly bis sister, and at Karnak she is represented at the head of a
long list of hdr ifailttrea, eighteen princes ancf nineteen princesses The
grandson Pinezmu I, reigned over forty years, but veryhttie is known
about the vest of the family.
Tiiktmi. From tomb oi Amcamosos
Ameumeses. From iiis tomb
Ethjoi’I.us Kn\ua
'Phe fithiopian Dynasty also' followed the. custom of dose inter--
'm&mage. Queen Ameoerfcas married her brother I’i&nkhi II, and
their daughter Hhepemtpt ill married her half-brother, Taharka, the
of AkaiouJka, an.0 a child, Amemutab II (and possibly others) was born
from this Sofe3ii|^|5^e^s : iSiiifpia^e..:'. TabArka was a man of foresight,',
power and courage, hut unfortunately., we know practically nothing of
Amenertas If.
Ta BLlf Xit.
Sb^petnypt II
ivtiHlita
Fitubkfu M
Ataiou^i
Amanert^s
III
TiVhvi>ka
Ameti.ertas It
174 Ruffer: Physical Effects of Consanguineous Marriages
Ptolemaic Kings.
(1) Direct Line.
The history of the Ptolemies is of special interest to the student of
heredity, because the first four kings of the family not sprung from con¬
sanguineous unions, can be compared with the later kings who were
born when such marriages had become the rule.
The founder of the dynasty, Ptolemy I (Soter I) (fig. 27,1) a favourite
general and companion of Alexander the Great, enjoyed so great a popu¬
larity and influence that at the death of Alexander the satrapy of Egypt
fell to him without any opposition, and he lost no time in establishing
himself firmly in his new government. He first guarded himself
against an attack from the West by occupying Cyrene, which became
a province of Egypt, murdered Cleomenes, the financial Controller who
had been appointed by Alexander the Great, defeated the regent,
Perdiccas, who had marched against Egypt, and put him to death.
At the second settlement of the Empire (321 b.c.), Ptolemy was
again awarded Egypt, with whatever lands he could conquer to the
west. He seized both Cyprus and Syria, but he evacuated the last
province temporarily, as his large army and the powerful fleet he
had equipped were only just strong enough to rule and defend Egypt,
Cyrene and Cyprus. Indeed, Ptolemy was averse to any increased
responsibility unless quite sure of his ground, and hence he prudently
declined the royal dignity, which some of his followers endeavoured to
thrust on him, until the death of the sons of Alexander the Great had
removed the only legitimate claimants to the throne.
The fleet and fortifications secured Egypt against every attempt at
invasion from the Eastern • frontier. The strength of the Egyptian
preparations was demonstrated when the attack of Antigonus by land
and by sea failed to reach Alexandria, and the would-be invader
finally asked for peace. Later on, Antigonus and Demetrius were
defeated by the great coalition, and then Ptolemy who, it must be
confessed, had been but a luke-warm supporter of the allies, secured
lower Syria and Phoenicia as his share of the plunder. Shortly after¬
wards, the re-occupation of Cyprus, which he had given up temporarily,
his appointment as protector of the league of free cities on the coast
and islands of Asia Minor, and his settlements on the coasts of the Red
Sea gave him, backed by his fleets, the command of the sea.
At home, the relations between the king and the native Egyptian
Section of the History of Medicine
175
population were so friendly that the latter gladly enlisted under Ptolemy’s
banner, and the large turbulent population of natives, Greeks, Persians,
Syrians, &c., was kept well in hand. Ptolemy succeeded—and that
was perhaps his most wonderful achievement—in founding in Egypt
the cult of Serapis, a divinity adored by both Greeks and natives.
Science and art were encouraged, the celebrated Museum was founded,
Alexandria became the great scientific centre of the world, trade was
encouraged, agriculture developed, exchange made easier by the new
coinage, and every department of state was improved by the new ruler.
Ptolemy abdicated in 285 b.c. and died two years afterwards at the
age of 84. He had married, probably at Alexander’s instigation, a
Persian princess, Artakama, about whom nothing is known. Far more
celebrated than this first wife was his mistress, Thais, the courtesan, who
had at least two children by him. His second legitimate wife was
Euridike, the daughter of Antipater, and by her he also had several
children. His third wife, Berenike I, a grand-niece of Antipater,
supposed without any reason to have been Ptolemy’s step-sister, was
the mother of several children by another husband at the time of her
marriage with the king. Her influence over him was so great that she
persuaded him to put aside Euridike’s son and to adopt her own son as
his heir. Several other children were born, and the king added to his
family, already very large, by adopting all his step-children. Divorce
from his second wife is nowhere mentioned, and Ptolemy was doubtless
living with both his second and third wife at the same time.
The bold and patient father of the Ptolemic dynasty was a political
genius of the first order, a great soldier, a cunning diplomat, an able
financier, a promoter of exploration, a master of foreign and home
affairs, a religious reformer and a protector of art, science, commerce
and agriculture. His private life, on the other hand, judged by our
present standard, was far from edifying.
Ptolemy II (fig. 24) (Philadelphus, born 309, died 246), son of the
first king, married Arsinoe I (fig. 25), the daughter of the king of Thrace,
and later on his own sister, older than himself, by whom he had no issue.
His character, like his father’s, was bold and cunning, and again like his
father, he had in spite of his devotion to his sister, many mistresses 1 :
Didgona, a native of Egypt, Bilisticha, Agathoclia, Stratonice, Clio his
cup-bearer who, clothed in a tunic only and holding a cornucopia in her
hand, was represented in many statues, to the scandal even of Alexandria,
11
1 Atheneeus, “ Deipnosophists,” xiii, p. 40.
17<» EnfEfer : Physical E0cts of Cmsm0ineom Marriages
Myrfcimi'i, a nm&t notoriout- and; common prftfititufce. who awne^^Phe
finest hoii^': in Atexanflp#, Mnesih an*! Pothina the flute-^^er, iinii
many otluus. tfis effigies on the coins of the period show o ste>ni,
|,'leth(ii i-, man dig 27.,7) with rut her fine classical filatures. and hie sister,
Arsiuoi -Phii a^fyl jiho» f ftg. 27, witift
[ V&lu :4a, k'mv.i
At? i.o*; LI, U\.. Philftdelphu,
i VtftiPkip. KqttiP j /
Section of the History of Medicine 177
regular features. The king died at the age of G3, after having been a
martyr to gout.
To look upon Ptolemy II as a common debauchee is doing him a
great injustice. He patronised science and art, subsidized the Museum
and added considerably to the library, which owned the unprecedented
number of 400,000 volumes. The famous Septuagint version of the
Bible possibly dates from this time. His foreign politics were successful,
and at home his reign appears to have been peaceful.
Allowing for all exaggeration, the “ Praise of Ptolemy ” by
Theocritus shows in what esteem he was held by his contemporaries :—
That king surpassingly is excellent
For wealth, wide rule by sea and o’er much continent.
in many a region many a tribe doth till
The fields, made fruitful by the shower of Zeus ;
None like low-lying Egypt doth fulfil
Hope of increase, when Nile the clod doth loose,
O’er-bubbling the wet soil: no land doth use
So many workmen of all sorts, enrolled
In cities of such multitude profuse,
More than three myriads, as a single fold
Under the watchful sway of Ptolemy the bold.
Part of Phoenicia, some Arabian lands,
Some Syrian, tribes of swart Aethiopes,
All the Pamphylians, Lycians he commands,
And warlike Carians ; o’er the Cyclades
His empire spreads; his navies sweep the seas ;
Ocean and rivers, earth within her bounds
Obeys him : and a host of chivalries,
And shielded infantry, with martial sounds
Of their far-glittering brass, the warrior-king surrounds.
For o’er the broad lands of that happy sept
The bright-haired Ptolemy strict ward hath kept.
Ilis whole inheritance he cares to keep,
As a good king. Himself hath garnered more :
Nor useless in his house the golden heap,
Increased like that of ants.
(Theocritus. Idyll XVII.)
The third Ptolemy (fig. 27, 2) (Euergetes I) married Berenike of
Cyrene (fig. 27, 3). He was a successful warrior and diplomatist, and
178 Buffer : Physical Effects of Consanguineous Marriages
a patron of science and religion. The Museum and Library continued
to flourish under his reign ; he invited great savants, including Erasto-
thenes, to settle in Egypt, reformed the calendar, and built the temple
of Edfou. Of all the Ptolemies, he was the only one whose private
life was exemplary. He died when about 63 years old. Physically,
there was a great resemblance between him and his father.
Ptolemy IV (Philopator) (fig. 27, 4), the son of Ptolemy III by a
princess of Cyrene, succeeded his father, and his life is of great interest,
for had he been the child of a consanguineous marriage,.his shameful
characteristics would doubtless have been attributed to the close rela¬
tionship between the parents.
The king succeeded 1 “in the heyday of youth, with his education
completed by the greatest masters, to a great empire, a full treasury,
and peace at home and abroad. Yet, in the opinion of our Greek
authorities, Polybius and Strabo, no member of the dynasty was more
criminally worthless, nor so fatal to the greatness and prosperity of
Egypt.”
Shortly after his ascent to the throne, the Queen-mother Berenike,
and his brother Magas were murdered. Whether Ptolemy IV had a
share in planning these murders is uncertain, but undoubtedly the fact
that Sosibius, the chief actor, had considerable influence on the king
threw some suspicion on the latter. His debauchery shocked his con¬
temporaries. He loved to surround himself with low courtesans who
treated him with scant respect, and his Greek mistress, Agathoklea,
and her brother Agathokles, at one time the real rulers of the country,
prevented him from taking a legitimate wife until the mistress had
given up all hopes of having a child. So great was this woman’s
influence over him that Strabo simply calls him: “ Philopator, he of
Agathoklea.” Finally he married his sister, Arsinoe III (fig. 27, 5),
who was afterwards murdered by Agathokles.
The disreputable private life of Ptolemy IV did not interfere with
his considerable diplomatic ingenuity, administrative skill and military
efficiency. On Antiochus attacking Egypt, an army was quickly raised,
and the king, accompanied by his sister Arsinoe, defeated his foe at
liapha, and this victory and his strong government so impressed his
neighbours that, during his life time, Egypt was not attacked again.
In spite of his debauchery, he interested himself in intellectual pur¬
suits, wrote tragedies, added to Philae, to Ar-hes-Nefer, 2 and built
1 Mahaffy, “ A History of Egypt; Ptolemaic Dynasty,p. 127.
* Mahaffy, loc. cit., p. 138.
Section of the History of Medicine
179
temples at Edfou, Alexandria, and probably at Naukratis also. His
handling of home affairs, on the other hand, was not altogether
successful; rebellion in lower Egypt had to be quelled, and at the
time of his death, Egypt and Nubia were in a state of anarchy.
The employment of native officers and soldiers ultimately led to a
revolution, for he realized as little as some administrators do now,
that one cannot give away power, and at the same time retain it.
Allowing then for the exaggerations of Polybius, of Strabo and
of the Jews, whom he had offended, the king may be described
as a man whose life was soiled by culpable weakness and debauchery,
but to some extent redeemed by a love of art and letters, and who, in
his political actions, showed considerable ability and originality. The
only known child of Ptolemy IV and his sister was Ptolemy V,
Epiphanes (209), and as both king and queen died in 204, their other
progeny, if any, cannot have been numerous.
Ptolemy V was only 5 years old when he came to the throne. He
was betrothed to Cleopatra, a Syrian princess, when 11 years of age
(198 B.c.) and married her five years afterwards.
On the coins of the period we see a stout, distinctly good-looking,
young man (fig. 27,6). He enjoyed a great reputation as an athlete and was
fond of field sports, and like his forefathers, he was cruel, treacherous,
and tyrannical whenever it suited his purpose to be so. His foreign
policy certainly was not a success, but, as Mahaffy explains, he is hardly
to be blamed for the sore diminution of the Egyptian empire during
his reign; for the rise of the Eomans, the astuteness of Antiochus, the
invasion of his island empire by Philip, and his predecessor’s mistaken
policy of arming the natives, were all factors which would have beaten
the strongest man. He died at the age of 29, and it is not improbable
that he was murdered.
The marriage of Ptolemy V (Epiphanes) with the Syrian princess
was blessed with at least four children. One son, Ptolemy VI (Eupator),
died young. Another son, Ptolemy VII (fig. 27, 9) (Philometor), the
descendant of consanguineous grandparents, was 7 years old when he
ascended the throne (181 B.c.), and was killed at the age of 43 (145 B.c.).
When still a boy of 15, he, with his sister-wife Cleopatra II, success¬
fully organized the resistance to King Antiochus, quelled rebellions in
Upper and Lower Egypt, reconquered and pacifidd Nubia. In Upper
Egypt he did considerable building work. His quarrels with his
brother, the clever and unscrupulous Ptolemy IX (Euergetes II), would
fill a volume. His treatment of his brother was magnanimous for,
180 Ruffer: Physical Effects of Consanguineous Marriages
having taken him prisoner, he spared his life and forgetting the past,
suggested they should form a new alliance by a marriage between his
own daughter and Euergetes, to whom he left Cyrene. The fear of
the Romans may possibly have made these arrangements advisable,
but it is only fair to assume that his natural kindness and the ties of
blood urged him to follow this course. King Philometor was the
Ptolemy, “ virtuous, pious, and kindest of men ” to whom the com¬
panions in arms in Cyprus dedicated a crown of gold in the temple
of Delos. They thank him for his benefactions to them and their
homes, but they especially admire the kindness and magnanimity with
which he made friendship and peace.
Table XIII.
Ptolemy IV (Philopator) = His sister Arsinoe
Ptolemy V (Epiphanes) = Cleopatra (Syrian princess)
Ptolemy VI (Eupator) Ptolemy VII = Cleopatra II = Ptolemy IX (Euergetes II)
(died young) (Philometor) ■ • . TT77777777777r
Cleopatra Thea, one of the children born of the incestuous marriage
between Philomator and his sister, was married to Alexander Bela,
King of Syria, and when her father and husband quarrelled, she left the
latter and married her husband’s rival, Demetrius II. The fortunes of
war having compelled her second husband to fly the country and to
marry the daughter of his captor, Cleopatra Thea at once retaliated
by marrying Demetrius’ brother, Antiochus YII Sidetes. The Queen
had children by all these husbands. She was not as has been suggested,
a weak simpleton, but a wicked, energetic woman, who shed blood
whenever the success of her plans required it. She betrayed her
husband, Demetrius II, who was assassinated with her knowledge,
murdered her son, Seleucus, and another son, Antiochus VIII, escaped
the same fate only by compelling his mother to drink the poison she
had prepared for him. There was no lack of energy, though for evil,
in this queen, the offspring of an incestuous union.
Table XIV.
Cleopatra Thea = 1° Alexander Bela — 2 Demetrius II — 3 Antiochus Sidetes
i i i
i ii!
Antiochus VI (Epiphanes) Seleucus Antiochus VIII Antiochus IX
(Grypus) (Cyzicunus)
Section of the History of Medicine
181
After her brother-husband’s death, Cleopatra II married her other
brother, Ptolemy IX (Euergetes II) (fig. 27, 10), by whom she is
supposed to have had one son, Memphites, who was assassinated by
his own father. The story however is so obscure and improbable that
its truth may well be doubted. Ptolemy Euergetes II, nicknamed
Physkon (Sausage), also married his wife’s daughter, Cleopatra III,
(fig. 27, 11), at once his niece and step-daughter, after, it is said,
outraging her.
It is difficult to estimate justly the character of this king, the
greatest historians differing in their opinion of him ; but the appreciation
given by Mahaffy, appears so equitable and temperate that I cannot do
better than reproduce it here : 1 “ Our Greek authorities tell us of
nothing but the crimes and follies of Physkon, tempered by Greek
distractions of writing memoirs, and of discussions with the learned
Greeks of the Museum. All the world, not to say his own nation,
are described as filled with horror at his enormities. If we turn
to inscriptions and to papyri we find the king and his queens
commemorated in friendly dedications to and by his officers in Delos,
in Cyprus and in Egypt. He extends the commercial bounds of Egypt
to the south and east; he keeps Cyrene perfectly still and undisturbed,
probably under the vice-royalty of his son Apion. He so far manages
to control two ambitious queens, probably at deadly enmity, that at the
very close of his life they both appear associated with him in the
royalty as if nothing had happened to disturb the peace of the palace.
Throughout the country the legal and fiscal documents still extant show
the prevalence of law and order.
“ Modern criticism, suspicious of the exaggerations familiar to ancient
rhetoricians, may lighten the burden of crimes and maledictions with
which he is charged, but it is not possible to wipe out all the lines of
this repugnant caricature. He was, in any case, an energetic figure,
a despot without scruples, but not without intellect, who seems to have
summed up in himself and carried away all the virility of his race.”
His wife and niece, Cleopatra III, a masterful woman, had an
almost pathological hatred for her first son. Again and again did she
endeavour to remove him from the throne and to place the crown
of Egypt on the head of her second son, Ptolemy XI (Alexander).
“ Never, that we know of,” wrote Pausanias, “ was there a king so
hated by his mother.” For many years, the history of Egypt is that
Mahaffy, loc. cit., p. 202 a.
182 Ruffer: Physical Effects of Consanguineous Marriages
of the quarrels and intrigues of this strong-minded woman and her
two sons. The first son, Ptolemy X (nicknamed Lathyros), married
his sister, Cleopatra IY, during his father’s reign and a son had
been born, when his mother, Cleopatra III, compelled the young king
to repudiate his wife and to marry his other sister, Cleopatra Selene,
who had two sons by him. When Lathyros had to fly from Egypt,
Selene retired to Syria where she married three husbands in succession,
and was finally put to death by Tigrane, King of Armenia, after having
had four, probably five, and perhaps more sons, by her four husbands;
of these the first was her brother, the second and the third her cousins
(the second being himself a descendant of an incestuous marriage), and
the fourth her step-son and second cousin. She is the only Cleopatra
who is not guilty of one or more murders during her adventurous
career.
Table XV.
Ptolemy VII = his sister, Cleopatra II = also her brother, Ptolemy IX,
Philometor i . Euergetes II
Cleopatra III = her uncle, Ptolemy IX
Ptolemy X, Soter II = l c Cleopatra IV and 2° Cleopatra
... .. Selene
(Lathyros) .I.
Cleopatra Ptolemy XI
Tryphaena (Alexander I)
m. Berenike III
One son Berenike III Two sons
Meanwhile, Cleopatra IV, the first wife of Ptolemy X Lathyros, had
gone to Cyprus, enlisted a number of mercenaries, proceeded to Syria,
married Antiochus IX, and attacked Antiochus VIII the husband of
her sister Tryphaena. The sister, getting the upper hand, had her
put to death.
Cleopatra Ill’s last daughter, Tryphaena, married Antiochus VIII
Grypos, and after perpetrating the crimes mentioned above was herself
murdered by Antiochus XI.
The history of the four Cleopatras, the daughters and granddaughters
of incestuous marriages, is a long relation of intrigues and appalling
crimes. All had sons and grandsons of whom some are known by name.
Very probably many more have been entirely forgotten.
Ptolemy X (Lathyros) died in 80 B.c. at the age of 62. His brother
Section of the History of Medicine
183
and rival Ptolemy Alexander I had been killed in 88 B.c. He was
probably about 40 years old at the time, and was said to have repaid
his mother’s kindness to him by murdering her. He resembled her
physically for she was nicknamed * 0**17 and he * 0 ** 17 ?, “ the red one.”
It is difficult to form an estimate of these two brothers’ characters,
so completely overshadowed are they by the striking personality of the
queen-mother. She it is who occupies the stage: a clever, daring,
ruthless, intriguing woman, who for thirty years was the all powerful
ruler in Egypt, and certainly her incestuous origin did not prevent her
from displaying remarkable energy.
Lathyros by his marriage with his sister Cleopatra IV had a daughter,
Berenike III, who married her uncle Ptolemy XI Alexander I, and
one son, who was murdered. Posidonios of Rhodes, a contemporary,
draws a portrait of this sovereign which is not without humour: “ The
dynast of Egypt, hated by the people, but flattered by those round him,
lived in great luxury, and could not walk otherwise than supported by
two acolytes; but in banquets, when he became excited, he jumped
from the couch, and executed, barefoot, dances with greater agility than
professional dancers.” When Ptolemy XI Alexander I, died, his son,
Ptolemy XII Alexander II, by a second wife, following the advice of
Sylla, married his step-mother, and was murdered shortly afterwards,
after putting his wife to death.
The direct line of the Ptolemies now comes to an end, not because
the women had become barren, or the men unable to beget children,
but because all the male descendants born in legitimate wedlock had
been killed or exiled.
Ptolemaic Kings.
(2) Indirect Line.
Ptolemy X (Lathyros) (fig. 27, 12) had left two illegitimate
sons, and one of them, nicknamed Auletes, the flute player, now laid
claim to and ascended the throne, the other son being made king of
Cyprus. The latter retained his throne until the Romans occupied the
island, when rather than submit to this indignity he poisoned himself.
Auletes married Cleopatra V (Tryphaena II), who was called his
sister in official records, though there is no proof that she stood
in such relationship to him. His daughter, Berenike IV, was prob¬
ably by this wife, and by a second wife the king had another family,
the most prominent member of which was Cleopatra VII, the great
Cleopatra.
184 Ruffer : Physical Effects of Consanguineous Marriages
Auletes is stated to have been an idle, drunken and wicked man,
the whole of these accusations resting on about half a dozen anec¬
dotes, which have as little value as have nowadays the countless stories
about royalty. A curious passage of Strabo 1 shows that a good deal of
the indignation of ancient Greek authors was due to the king’s passion
for what would be now considered an artistic occupation. “Besides other
deeds of shamelessness,” says Strabo, “ he acted the piper; indeed, he
gloried so much in the practice that he scrupled not to appoint trials of
skill in his palace : on which occasions he presented himself as a com¬
petitor among other rivals.” What would Strabo have said of
Frederick the Great, or of Ludwig of Bavaria, or of the Royal Duke
who played the violin obligato for a distinguished singer at a public
concert ?
The king had no easy task. Qe, a bastard, had to defend his
throne against those who had perhaps a more legitimate claim to the
throne. No doubt he fleeced his country, but let it be remembered in his
favour that his only chance of keeping the throne was by bribing the
whole of the Roman Senate, and by becoming the prey of Roman money¬
lenders. His financial struggles, and indeed his whole history, curiously
resemble the history of some very modern rulers. To keep himself on
the throne at all was a truly marvellous feat, and however disgraceful
his private life may have been, his cleverness and genius for intrigue
were remarkable.
Table XVI.
Cleopatra V = Ptolemy XIII Auletes = N. N.
. j . I
Cleopatra VI = Archelaus I
(murdered)
i
Ptolemy XV
Ptolemy XIV
1
Arsinoe
i
Cleopatra VII
(murdered)
(died young,
probably poisoned)
(drowned)
m. her brothers
His son, generally described as a puppet in the hands of his
attendants, clearly was not responsible for the murder of Pompey.
He fought a gallant fight against Julius Caesar, and though but a boy
without experience, behaved with decision and bravery and perished in
battle.
A just estimate of the great Cleopatra (fig. 26) is an almost hopeless
1 Strabo, loc. cit., xvii, C. I., s. 11.
Section of the History of Medicine 185
task, for the accounts of her life, as Weigall has pointed out, are written
by her enemies. Her amours with Caesar and with Antony must not be
judged according to our standard, and though it would probably be
going too far to maintain that her intrigues with these two men were for
political reasons only, there can be no doubt that, had she resisted either
of them, Egypt w T ould have been lost to her and to her dynasty. It is
sheer nonsense to look upon Caesar or Antony as the unfortunate victim
of a designing woman. By the time Caesar met Cleopatra, he was an
elderly man, who had ruined the wives and daughters of an astonishing
number of his friends, and whose reputation for such seductions was
of a character almost past belief. Antony also was not a boy but a man
of the world, “ un homme a femmes,” who had seduced many women.
Cleopatra at that time was a girl of 21 years old, against whose char¬
acter not one shred of trustworthy evidence had been advanced. The
prodigality, the luxury and licence of her court were those of every
Eastern court of her time, and no great blame can be attached to her
endeavouring to please Caesar and Antony by sumptuous entertainments.
The responsibility for such waste of money should be put with much
greater justice at the door of those who allowed her to squander fortunes
on their amusement.
Certainly, the audacity, cleverness, and resources of this Egyptian
queen, the last offspring of many incestuous marriages, compel our
admiration, and had not Caesar’s murder put an end to her ambitions,
she might have become the empress of the world ! She was musical,
artistic and encouraged science ; her good spirits were proverbial, and
induced her to play harmless and rather pointless practical jokes. She
was considered a very fine linguist, perhaps not a great achievement
in a town where, to this day, every inhabitant speaks three
languages as a rule, where many can converse in five, six or seven
tongues, and official correspondence is carried out in three languages.
Of her physical appearance we know but little. Her portraits, if
authentic, do not give one the idea of a very beautiful woman, and her
charm was probably one of manner. “ She was splendid to hear and
to see,” says Dion Cassius, “ and was capable of conquering the hearts
which had resisted most obstinately the influence of love and those
which had been frozen by age.” Another author expresses himself
as follows : “ Now t her beauty, 1 as they say, was not in itself altogether
incomparable nor such as to strike those who saw her: but familiarity
1 Plutarch, “ Life of Antonius,” xxvii.
Table XVII.— Ptolemaic Dynasty.
186
Buffer: Physical Effects of Consanguineous Marriages
4/[
with her had an *rt---.••'twrh, and -hex' Uxx.m. ooinb'ned with in i
pfcjfSita&ive the £ikiea&e£; w$icii \t\ a iuanner was
diffused ahotst hfet ?>irhavi.tShc, in-tidfeed a ddwth't 'p*\daitc\f; ’Thft«? wae
. . . .. . , . . . ,
asweetnessm tLav^mind bti»' vdiee \vh.eun>h6 !>poke
Rj
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r. * -
1:31
HI < i.'Ut’i
1 (Soto*)
IT,
Moleni^- ]V Ii. Arsm-w ill (Hi^ rA-i* u&'j Y.HIppiwua*}.
A> Jois»VII ^j’liiioindtor)
Afsiiio^ ii
l‘i <.vk:iin H i L LIiadoi j
‘ rtol^iny L\
U'A'Je.i^Obes Hi
C Leapt* era VII
Cloopatr* III
Section of the History of Medicine
189
The two charges of cruelty always brought against her are that she
murdered her sister, Arsinoe IV, and her brother, Ptolemy XV. The
blame for the murder of her sister is minimized by the fact that Arsinoe,
who had declared war against her, would have shown no mercy had she
won the day ; and with regard to Ptolemy XV, there is no proof that
he was murdered, and if he was, the deed was done at Rome when
Cleopatra was entirely under Caesar’s influence, and in his power. Her
end, when rather than grace her conqueror’s triumph she committed
suicide, was that of a plucky woman (fig. 27, 13).
Cleopatra had one son by Julius Caesar and three children by
Antony. The son was murdered and two children are known to have
married and to have had children.
Summary of Ptolemaic Section.
The Ptolemies born from consanguineous unions were neither better
nor worse than the first four kings of the same family issued from non-
consanguineous marriages, and had the same general characteristics.
Their conduct of foreign affairs and of internal administration was in
every way remarkable and energetic. They were not unpopular in their
capital, and the Alexandrians rallied round their rulers when the Romans
entered Egypt and resisted the foreigner.
Though much has been written about the awful sexual immorality of
the Ptolemies, they must not be judged by comparison with the morals of
this century, but an opinion must be based on the study of the literature
and customs of the time. The chief characteristic of the Alexandrian
literature is its eroticism, and the standard of morality was as low as it
possibly could be. The spirit of disparagement which existed always
led to a systematic slandering of the reigning king ; and, later on, the
Romans industriously blackened the character of their future opponents.
Thus it is not unlikely that the Ptolemies were better than they have
been painted. Their standard of morality was certainly not lower than
that of their fellow townsmen.
The children from these incestuous marriages displayed no lack of
mental energy. Both men and women were equally strong, capable,
intelligent and wicked. Certain pathological characteristics, doubtless,
ran through the family. Gout and obesity weighed heavily on the
Ptolemies, but the tendency to obesity existed before consanguineous
unions had taken place.
The male and female effigies on coins are those of very stout, well-
190 Buffer: Physical Effects of Consanguineous Marriages
nourished persons. The theory that the offspring of incestuous marriages
is shortlived receives no confirmation from the history of the Ptolemies
The length of life of the Ptolemaic kings was as follows :—
Ptolemy I, Soter
Ptolemy II, Philadelphia
Ptolemy III, Euergetes I
Ptolemy IV, Philopator
Ptolemy V, Epiphanes ...
Ptolemy VI, Eupator ...
Ptolemy VII, Philometor
Ptolemy IX, Euergetes II
Ptolemy X, Soter II (Lathyros)
Ptolemy XI, Alexander I
Ptolemy XII, Alexander II
Ptolemy XIII, Auletes ...
Ptolemy XIV and Ptolemy XV
Died at 84 years old
62
>»
68
»>
39
t*
(murdered ?)
28
»•
(killed ?)
—
11
(?)
42
»»
(killed)
60
»>
61
*>
62
»»
29
»»
(killed)
,,
59
i»
»»
—
»»
(both killed young;
Omitting those who died violent deaths, the average length of life of
the Ptolemies was 64 years. Several women of the family reached an
advanced age, amounting in three cases over 60 years. Owing to the
lack of statistics in ancient Alexandria, it is impossible to compare the
length of life of Ptolemaic kings with that of other Alexandrian families.
But when we consider the nature of these lives, diversified by intrigues,
murders, wars and debauchery, we may admit that the Ptolemies
possessed remarkably strong constitutions.
Sterility was not a result of these consanguineous marriages. No
case of idiocy, deaf-mutism, &c.,* in Ptolemaic families has been
reported. With regard to the theory that hereditary pathological
tendencies are “ reinforced ’’ by consanguineous marriages, cousins
or near relatives who marry are not usually affected with nor pre¬
disposed to deaf-mutism, idiocy, epilepsy, nor to the other infirmities
which are said to threaten the children of consanguineous parents.
There can be no question of any reinforcement of a hereditary tendency
which does not exist on either side. The history of the Ptolemies does
not show that their predisposition to obesity or to gout was increased
by their consanguineous marriages. Had the families of these monarchs
suffered from some hereditary disease, the local satirists would have
made capital of it, with due exaggeration, and the fact that they were
silent is of the utmost importance.
INDEX
(Compiled by Mr. A. L. Clarke, Assistant Editor)
Ager, infantile paralysis in Anglo-Indian children in 1800, quoted, 15
Albrecht, of Hildesheim, typical case of encephalitis letbargica described by (1095), 11
Altus 2 >rosator, hymn attributed to St. Columba, 131
Ambrose, St., observation of Dies Aegyptiaci forbidden by, 109
America, North, influenza and epidemic convulsions in (1772), 14
Amputations, history of, suggested, 24
Anatomy, early history of, not yet worked out, 26
Andry, case of acute bulbar encephalitis (1775), 14
Aneurysm, treatment, surgical, date of general adoption, 63, 64
- f history of, contribution to, from notes of Dr. Charles T. Maunoir (1802), 63-69
-, secondary htemorrhage following, 64
Anthologia Latina, verses enumerating Dies Aegyptiaci in, 113
Antwerp, experimental ligature of arteries carried out on dog at, by Charles T. Maunoir
(1802), 66
Aorta, calcareous, in King Merenptah, 170
Arteries, femoral, of dog, experimental ligature of, carried out by Charles T. Maunoir at
Antwerp (1802), 66
Artery, ligature above and below opening and complete division between ligatures in
prevention of secondary haemorrhage in surgical treatment of aneurysm, 64
-, direct, when inefficacious in preventing secondary hemorrhage, 64
-, femoral, aneurysm of, operation on, performed by Astley Cooper (1802), 68
-, peroneal, aneurysm of, operation on, performed by Astley Cooper, 66 *
-, popliteal, aneurysms, operations on, performed by Astley Cooper, 64, 65, 68
Artes Reales vel Physic®, 75
Artes Sermocinales, 75
Astronomy, St. Isidore’s views on, 83, 84
Athens, schools at, suppression of, by Justitian, 71
Augustine, St., “ De Civitate Dei,” writings of Varro contained in, 77
-, observation of Dies Aegyptiaci forbidden by, 109, 119
Baden (Switzerland), as a health resort, 61
-, visit of Montaigne to, 49
Badham, cases of infantile paralysis recorded by, in England (1835), 16
Ballonius, forerunner of pandemic influenza of I860, quoted, 7
Bartholin, epidemic of lethargic encephalitis at Copenhagen (1657), description quoted, 9
Basle, visit of Montaigne to, 49
Bath, Royal Mineral Water Hospital at, pewter bowls in, description of (C. J S. Thompson),
122
Bede, hymns of, verses enumerating Dies Aegyptiaci in, 112
1
11
Index
Belgium, outbreak of bacterial botulism in, 18
Benedetto, recognition of connexion between diseases now known as polio-encephalitis and
poliomyelitis with epidemic catarrh, 7
Benedict, St., foundation of monastery of Monte Cassino by, 71
Bibliographies and references :—
Dies Aegyptiaci, 121
Epidemic encephalo-myelitis, history of, 21
Evidences of disease in Shakespeare’s handwriting, 38
Isidore, St., and his book on medicine, 95
Birth-figures, copper-plate illustrations of, in “ The Woman’s Boke ” of Eucharius Rhodion, 25
-in medieeval manuscripts, information as to origin required, 25
Blackfriars Theatre, mortgage deed, signature of Shakespeare on, 29
-, purchase deed, signature of Shakespeare on, 29
Blood, human, medical uses of, history yet to be written, 25
Blood-letting, connexion with days of peril, earliest documents showing, 120
-, origin, rationale and decline of, historical information as to, required, 25
-, prohibition of, in verses enumerating Dies Aegyptiaci, 113
Bodleian Library, medical manuscripts dating from before sixteenth century contained in,
specimens of, 103-107
Body, arrangement of, into strata, 80
-, constitution of, mixture in, 82
- f relation to four elements and four humours, 82
-, surface of, diseases of, described in Isidore’s book, 93
Bostrom, nature of Upsala fever, 14
Botulism and acute encephalitis in Wiirtemberg, 1834-35, 16
-and encephalitis, outbreaks in Wurtemberg (1850-51), 17
-, bacterial, outbreak in Belgium, 18
-, first occurrence of, 14
-records of, 15, 16
-, myth of, 4
Brandenburg, Kriebelkrankheit at (1741), 13
British Isles, medical manuscripts in, dating from before the sixteenth century, survey of
(D. W. Singer), 96-107
-Museum, medical manuscripts dating from before sixteenth century contained in,
specimens of, 103-107
Britons, Early Medicine of, sources of knowledge as to, 125
Cadius Aurelianus, works of, 87
Calendars, mediseval, record of Dies Aegyptiaci in, 108, 109
Camerarius, Elias, description of epidemic at Tubingen (1729), 12
Cassiodorus, “ De Artibus ac Disciplinis Liberalium Litterarum,” 76
-, monastery founded by, at Viviers, 71
Cassirer and Opponheim, encephalitis acuta h senior rhagica, IS
Cassius Felix, compendium of, 90
Catarrh, epidemic, polio-encephalitis, poliomyelitis, and cerebro-spinal meningitis, relation¬
ship between, 19
Caul, as preservative against drowning, 25
Celsus’s operation of lithotomy, how interpreted, 62, 63
Celtic and Roman devotional literature, characteristics contrasted, 125
-magic and folklore, spread of, evidence iu Anglo-Saxon Leechdoms, 132
Cerebral fever accompanying influenza epidemics (1800-1803), 15
Chardel, description of cerebral fever or primary inflammation of brain, 15
Children, epidemic stupor in, during influenza epidemic (1837), 16
-. poliomyelitis in, accompanying influenza in Hindostan (1800-3), 15
Classical learning, effect of extinction of Roman Empire on, 71
Clifdcn, Lord, library of, medical manuscripts dating from before sixteenth century contained
in, 104
Index
111
Colic, attacks of, endured by Montaigne, 49, 50
Columba, St., hymn attributed to, 131, 13*2
Consanguineous marriages, see Marriages , consanguineous
Conjoint scheme of medical education, project for, in Middle Ages, 26
Convulsions, epidemic, and influenza in North America (1772), 14
Cooper, Sir Astley, operations on aneurysms of popliteal, peroneal and femoral arteries
performed by (1802), and recorded by Charles T. Maunoir, 64-68
Copenhagen, epidemic of lethargic encephalitis at (1657), 9
Cbookshank, F. G.—Discussion on evidences of disease in Shakespeare’s handwriting, 40
-, a note on the history of epidemic encephalomyelitis, 1-21
Cumston, Charles Greene.—C elsus’s operation of lithotomy, 62
-, contribution to the history of the surgical treatment of aneurysm from notes of Dr.
Charles T. Maunoir made during the year 1802, 63-69
Daremberg, “ De l’Ecole de Salerne,” quoted, 94
-, edition of Oribasius, reference to Renzi’s Collectio Salernitana, 90
“De Artibus ac Disciplinis Liberalium Litfcerarum” of Cassiodorus, 76
“De Medicina,” authorities used by St. Isidore in, 86, 87
“ De Natura Rerum ” of St. Isidore, 73
Diaconus, Paulus, works by, 77
Dies Aegyptiaci (Robert Steele), 108-121
-, dates of, 109, 110, 111
---, earliest reference to, 108
-, observation of, 109
-of, forbidden by early Christian fathers, 109, 119
-, probable origin of, 112
-, record of, in mediaeval calendars, 108, 109
-, rubrics of, 111, 112
-, verses enumerating, 112-119
Disease, causation by excess of two humours, early view as to, 82
-, evidences of, in Shakespeare’s handwriting (R. W. Leftwich), 28-42
Diseases, acute and chronic, described in St. Isidore’s book, 92, 93
Dog, experimental ligature of arteries carried out on, by Charles T. Maunoir, at Antwerp
(1802), 66
Doran, Alban, materials for history of surgical instruments collected by, 24
Drowning, caul as preservative against, 25
Drugs, benefit of, mentioned in St. Isidore's book, 93
Education, medical, in early times, information needed as to, 26
Egypt, ancient, Royal Families of, physical effects of consanguineous marriages in (Sir M.
Armand Buffer), 145-190
-, dynasties, tables of, 149, 151, 155, 162, 164-66, 170-173, 180, 182, 184, 186
-, statues and mummies of, and medals representing, 150. 152, 153, 155, 157-61, 163-165,
168, 169, 171, 173, 176, 187, 188
Egyptian days, see Dies Aegyptiaci
Elements and humours, the four, with their qualities, method of mutation, 80, 81
-, the four (fire, air, water, earth), St. Isidore’s exposition of, 79
—--, in man, 80, 81
-, in strata by weight, 80, 81
Empyema, treatment of, historical information as to, required, 25
Encephalitis, acute, and botulism in Wurtemberg (1834-35), 16
-outbreaks in Wurtemberg (1850-51), 17
-, bulbar, acute, case of (1775), 14
-in France complicating influenza epidemics (1831, 1833, 1836-37), 16
-lethargica epidemic at Copenhagen (1657), 9
-in London (1918), similarity of epidemic at Turin (1712) to, 12
la
IV
Index
Encephalitis lethargica, typical case described by Albrecht, of Hildesheini (1695), 11
Encephalomyelitis, acute, cases of, accompanying epidemics ol influenza (1780 82), 14
-, followed by debility of lower extremities (1784), 14, 15
-, clinical occurrences of, nature of, how long recorded in modern times, 20
-, convulsive, accompanying influenza epidemic at Tubingen (1729), 12
-(fever described by Willis, 1061), 10
-, convulsive, reproduced in Queensland (1917), 10
-, epidemic, described in different countries under various names, 5
-, epidemics of, special, appearing shortly after or before major influenzal prevalences,
20
-, history of (F. G. Crookshank), 1-21
-, how represented in various European countries up to 1800, 11
-, lethargic (fever described by Sydenham, 1661), 10
Encephalo-myelo-meningitis, clinical occurrences of, nature of, how long recorded in modern
times, 20
-epidemic, intensive specialized reaction represented by, in relation to pandemic influenza,
20
-, epidemics of, special, appearing shortly after or before major influenzal prevalences, 20
England, infantile paralysis in (1835), cases recorded by Badham, 16
Ergotism confused with influenza, 13
van Ermengem, outbreak of bacterial botulism in Belgium, 18
Eruptions, treatment at baths of Plombieres (1580), 48
Ethiopian kings of Egypt, 173
Kij/mologiae , of St. Isidore, 70, 72
-, books in, of interest medically, 72
-, divisions of, 74
--, fourth book of, 85
-, history of, 74
-, scope and objects of, 74
Europe, endemic-epidemic influenza in (1819-24), 15
Extremities, lower, debility of, cases of, following acute encephalomyelitis (1784), 14, 15
Fistula*, operation for cure of, history suggested, 24
Fletcher, G. R. J.—St. Isidore of Seville and his book on medicine, 70-95
Fcetus, assumption of particular positions in uterus, scientific information as to, required,
25
Fox, R. Hinoston.—D iscussion on evidences of disease in Shakespeare’s handwriting, 41
France, encephalitis and myelitis in, complicating influenza epidemics (1831, 1833. 1836-37),
16
-, first recorded epidemic of poliomyelitis in (1875), 18
-—, prevalence of so-called miliary fever in (1772-74), 14
-, “ trousse-galant ” in, description of, 7
Furius Dionysius, Philocalus, Fasti of, earliest reference to Dies Aegyptiaci found in, 108
Gariopontus, works of, 90
Germany, influenza epidemic in (1742), forerunner of, 13
-, name for iufluenza in (1600), 9
-, South, visited by Montaigne, 49
Gildas, the Briton, Lorica of (? 547) (C. Singer), 124 144
Gintrac, epidemic stupor in children, in year of iufluenza prevalence, 16
Gonville and Caius College, Cambridge, medical manuscript dating from before sixteenth
century, contained in, 105
Goths, influence of, on civilization, 72
Gowers, Sir William, varieties of writer’s cramp described by, 33
Gregory, Pope, character-sketch of, given by Montaigne, 52, 60
-, massacre of St. Bartholomew’s Day, permitted by, 60
Index
v
Guidetti, description of epidemic at Turin (1712), 12
Hemorrhage, secondary, following surgical treatment of aneurysm, G4
Hamer, W. H., identity of sudor Anglicus with influenza, 5
Handwriting of Shakespeare, evidence of disease in (R. W. Leftwich), 28-4*2
-, styles of, prevalent in Shakespeare’s time, 29
Harrogate, Plombieres treatment adopted at, 61
Health, state of, governed by elementary contraries, early view as to, 82
Heavens, the three, early hypothesis of, 84
Hebrew words, knowledge of, among writers of Hibernian Latin, 134
Heine, first cases of infantile paralysis observed by, in Wiirtemberg (1834-35), 16
Heine-Medin disease, convulsive or spasmodic forms of, clinical identity with convulsive
forms of mal mazzuco and raphania, 19
Hesse, influenza epidemic in (1771), 14
Hibernian Latin, Lorica of Gildas written in, 133
Hindustan, influenza prevalence in (1800-03), accompanied by poliomyelitis in children, 15
Hippocrates on paraplegia in Thasus, quoted, 2
History of Medicine, Section, review of work of (1912-18), 24
Hours, list of, in verses enumerating Dies Aegyptiaci, 114, 118
Huguenots, massacre of, on St. Bartholomew's Day, medal commemorating, 60
Humours and elements, the four, with their qualities, method of mutation, 00, 81
-, four, the, and corresponding elements, 82
-, described in St. Isidore's book, 92
Hungary, “ nona” occurring in, 18
Ileus, conditions grouped by older writers under term, require disentangling, 25
Influenza and epidemic convulsions in North America (1772), 14
-, cerebral and nervous forms of (1820), 16
-, endemic-epidemic (1819-24) in Europe, 15
-epidemics (1712) at Tubingen, 11, 12
-at Turin, 12
-, similarity to encephalitis lethargica in London (1918), 12
-, cephalic and nervous nature of, 11
-, description of, 11
-(1727), identification with Willis’s fever, 13
-(1729) at Tubingen, accompanied by convulsive encephalomyelitis, 12
-(1729-33), 12, 13
-, confusion with ergotism, 13
-(1742) in Germany, forerunner of, 13
-(1762) catarrhal, 14
-(1771) in Hesse, 14
-(1780-81-82) accompanied by cases of acute encephalomyelitis, 14
-(1800-1803), cerebral symptoms connected with, 15
-(1824-26) in United States, 16
-(1831, 1833, 1836-37) in Europe, complicated by encephalitis and myelitis in
France, 16
--(1837) accompanied by epidemic stupor in children, 16
-(1841-45) diseases of nervous system accompanying, 17
-(1850-57) “nervous,” 17
-(1866-67) diffuse, 17
-, nervous accompaniment of, 17
-, epidemics preceded by disturbances of nervous system, 16
-, identity of sweat with, 5
-, major, prevalence of, relation of special epidemics of encephalomyelitis or encephalo-
myelo-meningitis to, 20
-, name for in Germany (1600), 9
VI
Index
Influenza, nervous and cephalic, identity of “ Schlafkrankheit ” with, 11, 12
-pandemic (1580), 7
-, forerunner of, 7
-(1847) mainly catarrhal, 17
-(1889*90), diseases of nervous system preceding and following, 18
-, poliomyelitis, polio-encephalitis, and cerebro-spinal meningitis, world-cycle of (1915-
18), 19
-, prevalence (1800-3) in Hindustan, accompanied by poliomyelitis in children, 15
-(1915-16) in United States, followed by epidemic of poliomyelitis in and about
New York, 20
Influenzas, historic, two categories of, formed by Malcorps, 16
Ireland, date of introduction of Lorica of Gildas into, 130
Isidore, St., of Seville (G. R. J. Fletcher), 70-95
biographical notes on, 70
birth of, 71
“ De Medicina ” of, 85
-, chapters in, 91
“De Natura Rerum,” 73
Etymologiae of, 70, 72
indebtedness to works of Suetonius and Pliny the Elder, 77, 78
influence on educational life of Middle Ages, 72
literary works of, 72
, mal mazzuco in, 9, 15
“ Tifo-apoplettico paralytico-tetanico ” in, various diseases with which identified, 17
voyage of Montaigne to (1580), (Leonard Mark), 43-61
Jonson, Ben, on quality of Shakespeare's bandwriting, 30, 41
Justitian, suppression of schools at Athens by, 71
Kammermeister, R. J., description of influenza epidemic (1712), 11
Kerner, first description of botulism by, 15, 16
“ Kriebelkrankheit,” 4, 13
-, convulsive and paralytic, at Brandenburg (1741), 13
-, group of affections known in Germany as, 4
Latin, Hibernian, Lorica of Gildas written in, 133
-knowledge of Hebrew words among writers of, 134
La Villa, baths of, seasons spent by Montaigne at, 54, 57
Leabhar Breac or Suckled Book , reference to Lorica of Gildas in, 130
Leftwich, R. W. (the late).—The evidences of disease in Shakespeare’s handwriting (with
Editorial note), 28-42
Leonardo da Vinci, drawings of, on medical subjects contained in library of Windsor Castle,
107
Le Paulmier, Julien, on epidemic pestilences, quoted, 2
Levy, Michel, on cerebrospinal meningitis, quoted, 1
Leyden Lorica, 132
Library of Royal Society of Medicine, segregation of books of fifteenth, sixteenth, and first
part of seventeenth century suggested, 27
Lithotomy, Celsus’s operation of, 62
- # how interpreted, 62, 63
Lombard, nervous disturbances always preceding epidemics of influenza, 16
Lombardy, “ nona” occurring in, 18
London, encephalitis lethargica in (1918), similarity to, of epidemic at Turin (1712), 12
Looft, clinical and epidemiological relationship between polioencephalitis, poliomyelitis,
cerebro-spinal meningitis, and epidemic catarrh, 19
Lorctto, shrine of, Montaigne’s visit to, 52, 53
Index
Vll
Lorica, meaning of word discussed, 126
-of Gildas the Briton (? 647) (C. Singer), 124-144
-, date of introduction into Ireland, 180
-, earliest copy of, 129
-, evidence of composition before eighth century, 130
-, form of Latin in which written, 133
-, language of, 181
-, manuscripts from which knowledge of is derived, 135, 136
-, obscure and difficult words in, 141-144
-, text and translation, 136-140
-of St. Patrick, 128, 129
-, reference to, in early hymn of Bishop Sanctan, 128
-, special liturgical use of, 127, 128
-see also Leyden lorica
Lucca, baths of, celebrity of long standing, 61
Liineberg, outbreak of palsies of bead and limbs at (1581), 8
Magic and folklore, Celtic, spread of, evidence in Anglo-Saxon Leechdoms, 132
Mai mazzuco, 18
-, convulsive forms of, clinical identity with convulsive forms of Heine-Medin disease,
18, 19
--, epidemic in Italy (1597), 3, 9
Malcorps, two categories of historic influenzas formed by, 16
Man, constitution of, elements in, 80
-, the four elements in, 80, 81
Manuscripts, medical, in the British Isles, dating from before the sixteenth century
(D. W. Singer), 96-107
-, classification of subjects contained in, 100, 101
-, distribution in time, diagram showing, 101
-, languages in which written, 102
Mark, Leonard.—T he medical aspects of Montaigne : a study of the journal which he kept
during his voyage to Italy, with an account of his renal troubles and experiences of
mineral waters, 43-61
Marriages, consanguineous, physical effects in Royal Families of Ancient Egypt (Sir M.
Armand Buffer), 145-190
--, perils of, over-exaggerated, 146, 148
-, incestuous, 146, 147
-, among Royal Families of Ancient Egypt, 147, 149
Martianus Capella, the “ Satyricon ” of, 75
Martin, W., on peculiarities in Shakespeare’s signature, 30, 35
Matter, constitution of, St. Isidore’s views on, 79
Maunoir, Charles Th6ophile (1775-1830), biographical memoranda relating to, 64 (footnote)
-, experimental ligature of arteries carried out on dog at Antwerp by (1802), 66
-, letter from surgeons at Antwerp as to result of
operation, 66, 67
-, notes of, relating to history of surgical treatment of aneurysm (C. G. Cumston), 63-69
Maunoir, Jean Pierre (1768-1861), method of preventing secondary haemorrhage in surgica
treatment of aneurysm devised by, 64
Medal commemorating massacre of St. Bartholomew’s Day containing bust of Pope Gregory
XIII, 60
Mediaeval manuscripts, birth figures in, information as to origin required, 25
-science, value of, estimated, 97, 99
Medical books, mentioned by St. Isidore, 94
Medicine, derivation of, in St. Isidore’s book, 91
-. early British, sources of knowledge as to, 125
--, founders of, recorded in St. Isidore’s book, 91
Vlll
Index
Medicine, St. Isidore of Seville's book on (G. R. J. Fletcher), 70-95
-, chapters in, 91
-, scope of, in St. Isidore’s book, 91
-, three sects of, described in St. Isidore’s book, 91
Meningitis, cerebro-spinal, first recognition of, 17
> polio-encephalitis, poliomyelitis, and epidemic catarrh, relationship between, 19
--» poliomyelitis, polio-encephalitiR, and influenza, world-cycle of (1915-18), 19
Merenptali, King, mummy of, 170
-, aorta calcareous, 170
Meteorology, phenomena of, St. Isidore's views as to, 82
Methodist school, method of treatment, 89
-standpoint in regard to medicine, 89
Middle Ages, project for conjoint scheme of medical education in, 20
Midwifery, subjects in, requiring historical treatment, 25
Miliary fever, so-called, prevalence in France (1772-74), 14
Miserere, conditions grouped by older writers under term require disentangling, 25
Montaigne, attacks of colic endured by, 49, 50
-, description of Pope Gregory XIII, 52, 60
-, Essays of, censured at Rome, 51
-, frequency of urinary trouble, 50, 51
-, Journal of, characteristics, 45
-, discovery, 44
-, publication (1774), 44
-, why written, 60
-, journey home by Mont Cenis, 59
-, medical aspects of (Leonard Mark), 43-61
-, visit to baths of Ploinbicres, 47-49
--to South Germany, 49
-to Switzerland, 49
- -to Vitry-le-Francois, 46
-to Shrine of Loretto, 52, 53
-, visits to Rome, 51. 58
-, voyage of, to Italy (1580), 43-61
Moon, list of unlucky days of, 112
Mount joy Deed, signature of Shakespeare on, 29
Myelitis in France, complicating influenza epidemics (1831, 1833, 1836-37), 16
Nervous system, diseases of, accompanying influenza epidemics (1841-45), 17
-, disturbances of, preceding epidemics of influenza, 16
New York, poliomyelitis epidemic (1916) in and about New York following influenza
prevalence, 20
Nona in Lombardy and Hungary following influenza pandemic (1S89-90), 18
Nonius Marcellus, Dc Compendiosa Doctrina, 78
Norway, first outbreak of poliomyelitis in (1868), 17
Ointments mentioned by St. Isidore, 94
Operations, surgical, history of, suggestions for, 24
Ophthalmic surgery, early history of, 26
Oppenheim and Cassirer, encephalitis acuta Inemorrhagica, 18
Oresme, Nichole, Bishop of Lisieux (1377), first scientific opponent of Ptolemaean system, 85
-, “ Traite du Ciel et du Monde,” 85
Origines, see Etijmologiae
Oxford, University of, physiological school at, in sixteenth century, 26
Ozanam, history of epidemic encephalitis, 2
Palsies of head and limbs, outbreak at Luneburg (1581), 8
Index
IX
P&radin, description of “ trousse-galant ” in France, 6
Paralysis, infantile, first cases of, observed by Heine in Wurtemberg (1834-35), 16
-, in Anglo-Indian children (1800), 15
- 7 —, in Eugland (1835), cases recorded by Badham, 16
-, in Sweden, preceding influenza pandemic (1889-90), 18
-, Sir Walter Scott attacked with (1773), 14
Paraplegia in Thasus, 2
Pathology and physiology, classical and mediaeval, basis of, 82
Patrick, St., Lorica of, 129
Perfumes mentioned by St. Isidore, 94
Peroneal artery, see Artery , peroneal
Peschier, cerebral and nervous forms of influenza (1820), 16
Pewter bowls in Royal Mineral Water Hospital at Bath, description of (C. J. S. Thompson), 122
Philadelphia, poliomyelitis epidemic in (1871-75), 18
Phthisis, treatment of, historical information as to stages of, required, 25
Physician, preliminary education of, as laid down in St. Isidore’s book, 94
Physiology and pathology, classical and mediaeval, basis of, 82
-, early history of, not yet worked out, 26
Piles, operation for cure of, history suggested, 24
Placenta, early ideas as to, 25
Pliny, the elder, Natural History of, 78
-, works by, indebtedness of St. Isidore to, 77
Plombi^res (Vosges), baths of, description in Montaigne’s journal, 48
-, method of treatment at, adopted at Harrogate in modern times, 61
-, Montaigne’s visit to, 47-49
-, therapeutic uses (1580), 48
-, mineral waters of, method of taking (1580), 48
Polio-encephalitis acuta htemorrhagica, first description of cases (1880-81), 18
-and poliomyelitis, essential identity, 18
-, poliomyelitis cerebro spinal meningitis and epidemic catarrh, relationship between, 19
-and influenza, world cycle of (1915-18), 19
Poliomyelitis, epidemic (1871-75), in Philadelphia, 18
-(1916) in and about New York, following influenza prevalence, 20
-, first outbreak in Norway (1868), 17
-, first recorded epidemic in France (1871-75), 18
-, polio-encephalitis, cerebro-spinal meningitis and epidemic catarrh, relationship be¬
tween, 19
-and influenza, world-cycle of (1915-18), 19
Pompeius Festus, works by, 77
Popliteal artery. See Artery , popliteal
Poweb, Sir D’Arcy, K.B.E.—Discussion on evidences of disease in Shakespeare’s ‘hand¬
writing, 40
-, President’s address, 23
“ Prata,” lost work of Suetonius, 78
Primary qualities, the four (heat, cold, moisture, dryness), St. Isidore’s exposition of, 79
Ptolemaean system, when first scientifically disproved, 85
Ptolemaic Kings of Egypt, 174, 183
Puerperal fever, history of, before time of Semmelweis, 26
Pulse, in disease, historical information as to, required, 25
Pythagorean system of numbers, 84
Queensland, convulsive encephalo-myelitis reproduced in (1917), 10
Raphania, 14, 15
-, convulsive forms of, clinical identity with convulsive forms of Heine-Mcdin disease, 18,19
-, identity with “ Kriebelkrankhcit ” in Germany, 4
X
Index
Raphania in Scandinavia and Russia (1841-45), 17
-, origin of name, 14
Renzi, “ Collectio Salernitana,” 90
Rhodion, Eucharius, “The Woman’s Boke ” of, copperplate illustrations of birth figures in, 25
Roman and Celtic devotional literature, characteristics contrasted, 125
-Empire, extinction of, by Goths in 476, effect on classical learning, 71
Rome, Montaigne’s “ Essays ” censured at, 51
-, visits of Montaigne to, 51, 58
Ronsseus, epidemic of palsies in head and limbs, described by,
Rottingen, sweating-sickness (so-called) at (1802), 15
Ruffer, Sir Marc Armand, C.M.G.—On the Physical Effects of Consanguineous Marriages
in the Royal Families of Egypt (with prefatory note by Lady Ruffer), 145-190
Ruhrah, first outbreak of poliomyelitis in Norway, 17
Russia, raphania in (1841-45), 17
St. Bartholomew’s Day, massacre of (1572), medal commemoratiug, containing bust of Pope
Gregory XIII, 60
-, permitted by Pope Gregory XIII, 60
St. John’s College, Oxford, medical manuscript dating from before sixteenth century, con¬
tained in, 104
Salmasius, quotation of lists of Dies Aegyptiaci from Greek manuscript by, 109
Sanctan, Bishop, reference to “lorica” in early hymn of, 128
Satyricon, the, of Martianus Capella, 75
Scandinavia, raphania in (1841-45), 17
“ Schaffkrankheit,” name for influenza in Germany (1600), 9
Scheffelius, description of epidemic occurring in 1727, 13
Schenkius, epidemic of palsies and limbs described by, 8
Schiller, description of sweat of 1529 by, 6
“ Schlafkrankheit,” identity with nervous and cephalic influenza. 11, 12
Scott, Sir Walter, attacked with infantile paralysis (1773), 14
Semmelweis, history of puerperal fever before time of, 26
Seven Liberal Arts, the, 75
Sex, determination of, history of, information needed, 25
Shakespeare, cause of death of, 32
-, handwriting of, evidence of disease in (R. W. Leftwich), 28-42
-, quality of, 30, 31, 41
-, shorthand unreliable in time of, 37
-, signature of, Specimens in facsimile of, 39
-, signatures of, abbreviation in second syllable of surname, 29
-:-, copies extant, 29
-, time of, styles of handwriting prevalent in, 29
“ Shank-shrinking,” case of, 15
Shorthand unreliable in Shakespeare’s time, 37
Singer, Charles.- -The Loricaof Gildas the Briton (? 547), a magi co-medical text containing
an anatomical vocabulary, 124-144
Singer, Dorothea Waley. —Survey of medical manuscripts in the British Isles dating from
, before the sixteenth century, 96-107
Spain, historical data in regard to St. Isidore, 71
-, influence of Roman culture on, 71
Steele, Robert.— Dies Aegyptiaci, 108-121
Strumpell, identity of polio encephalitis and poliomyelitis, 18
Stupor, epidemic, in children during influenza epidemic (1837), 16
Sudor Anglicus, maleficent forms, cause attributed, 4
Suetonius, “ Prata,” lost work of, 78
-, works by, indebtedness of St. Isidore to, 77
Surgeons, literary ability of, 23
Surgical instruments, history of, work done as to, 24
Index
xi
Surgical instruments mentioned by St. Isidore, 94
-operations, history of, suggestions for, 24
“ Sweat,” identity with influenza, 5
-not a disease sui r/eneris , 5
-, not confined to England, 5
“ Sweating sickness,” so-called, at Rbttingen (1802), 15
Sweden, epidemics in (1754-57), symptoms accompanying, 18
-, infantile paralysis in, preceding influenza pandemic (1889-90), 18
Sydenham, Thomas, comatose fever described by (1661), (lethargic encephalitis), 10
“ Tempest, The,” high literary quality of, 33
Thasus, paraplegia in, 2
Thompson, C. J. S.—Note on some old pewter bowls in the Royal Mineral Water Hospital
at Bath, 122
Thompson, Sir Edmund Maunde.— On peculiarities in Shakespeare’s signature, 30
“ Tifo-apoplettico-paralytico-tetanico” in Italy, various diseases with which identified, 17
Toledo, Fourth National Council of, educational influence, 72
Tongue as an aid to diagnosis, origin of, required, 24
Trivium and Quadrivium, or Seven Liberal Arts, 75
“ Trousse-galant ” in V ranee, description of, 6
Tubingen, influenza epidemic at (1729), accompanied by convulsive encephalomyelitis, 12
Turin, epidemic at (1712), similarity to encephalitis lethargica in London (1918), 12
Ulcers, treatment at baths of Plombieres (1580), 48
Underwood, M., cases of debility of lower extremities observed by (1784), 14
United States, influenza epidemic in (1824-26), 16
-prevalence in (1915-16), followed by epidemic of poliomyelitis in and about
New York, 20
Universe, arrangement of elements in, St. Isidore’s theory, 80
Upsala fever, 14
Urethra, stricture of, operation for cure of, history suggested, 24
Urinary trouble, Montaigne’s sufferings from, 50, 51
Uterus, assumption of foetus of particular positions in, scientific information as to, required,
25
-, superstition respecting nature of, 25
Varro, “ Antiquitatum Rerum Humanarum Rerum Divinaruin” of, 77
-, “ Disciplinarum ” of, 77
Vedr&nes, interpretation of Celsus’s operation for lithotomy, 63
Verrius Flaccus’ “ De Verborum Significatu,” 77
Virginity, physical Bigns of, ancient interest takeu in, 26
Vitry-le-Frangois, Montaigne’s visit to, 46
Viviers, monastery at, founded by Cassiodorus, 71
Ward, Rev. John, cause of Shakespeare’s death, 32
Weber, F. Parkes. —Discussion on medical aspects of Montaigne, 60
Wernicke and Etter, first descriptions of cases of “ Polio-encephalitis acuta hemorrhagica ”
(1880*81), 18
Will of Shakespeare, containing his signatures, 29
Willis, Thomas, fever described by (1661). (convulsive encephalomyelitis), 10
-, fever described by, identification of epidemic of 1727 with, 13
Windsor Castle, library of, drawings of Leonardo de Vinci, illustrating medical subjects
contained in, 107
World, the, four quarters of, and four seasons of the year, design showing, 81
Writer’s cramp, causes of, discussed, 40
-, evidences of, in Shakespeare’s signature, 33
-, signs of, 33-36
Xll
Index
Writer’s cramp, signs of, all present in Shakespeare’s signatures, 37
-, those specially important, 34, 35
-, varieties of, 33
Wiirtemberg, botulism and acute encephalitis in (1834-35), 16
-, first cases of infantile paralysis observed by Heine in (1834-35), 16
-, outbreaks of botulism and encephalitis in (1850-51), 17
Year, four seasons of, and four quarters of the world, diagram showing, 81
Zeviani, epidemic of mal mazzucco in Italy (1597), 8, 9
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