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EDINBURGH MEDICAL JOURNAL

PRINTED BY

GREEN AND SON
EDINBURGH

EDINBURGH

MEDICAL JOURNAL

EDITED

BY

ALEXANDER MILES & J. S. FOWLER

NEW SERIES

VOL. XXII

Published for the Proprietors by

W. GREEN & SON, LTD.

EDINBURGH AND LONDON

1919

^XBRA^-

^ JAN 1 6 2003

JANUARY 1919.

EDINBURGH
MEDICAL JOURNAL.

EDITOEIAL NOTES.

CASUALTIES.

Killed in action on 21st March, Captain Eobert Ferguson;
Copland, E.A.M.C.

Captain Copland graduated M.B., CLB. at Aberdeen University
in 1915.

Died on service on 15th November, Lieutenant-Colonel Matthew
Holmes, New Zealand Medical Corps.

Lieutenant-Colonel Holmes was educated at Edinburgh, where he
graduated M.B., Ch.B. in 1902 and M.D. in- 1908, also taking the diploma
of F.B.C.S.(Edin.) in 1905.

Died on 18th November, Lieutenant-Colonel James More Eeid,
E.A.M.C. (retired).

Lieutenant-Colonel Reid graduated M.B., CM. in 1878 and M.D. in
1880 at Edinburgh University. Entering the R.A.M.C. in 1884, he served
in the Tirah Campaign of 1897-98, and in the third China War of 1900.
He rejoined for service in the present war in January 1915.

Died on service, Captain Edward Dawson Keane, E.A.M.C.

Captain Keane graduated M.B., Ch.B. at Aberdeen University in 1901.

Died on 21st November, Lieutenant-Colonel William Malcolm
Sturrock, E.A.M.C.(T.F.).

Lieutenant-Colonel Sturrock was educated at Edinburgh, where he
graduated M.B., CM. in 1883.

Died on service on 10th November, Major Eobert Charles
Irvine, E.A.M.C.

Major Irvine graduated M.B., Ch.B. at Edinburgh University in 1913.
E. M. J. VOL. XXII. NO. I. 1

2 Editorial Notes

Died of influenza on 9th November, Captain Henry Paterson
Crow, R.A.M.C.(S.R.).

Captain Crow graduated M.B., Ch.B. at Glasgow University in 1915.

Died of influenza on 5th November, Captain John Dow, Indian
Medical Service.

Captain Dow was educated at Elgin Academy and at Aberdeen
University, where he graduated M.A. in 1910 and M.B., Ch.B. in 1914.

At a meeting of the College held on 18th December
Surgeons ofBdSbinffe. the following gentlemen, having passed the requisite

examinations, were admitted Fellows : — John Ellison,
L.M.S.S.A.(Lond.), M.B., B.C.(Camb.), St. Helens, Lancashire ; Robert Joseph
English, M.B., Ch.M.(Sydney), Yass, New South Wales, Australia ; James
Burnett Hogarth, M.B., Ch.B.(Edin.), Captain, R.AM.C.(T.), M.O. City of
London Military Hospital ; Robert Lyle Hutton, M.B.(ToroDto), M.C.P.
& S.(Sask. and Alberta), Captain, R.AM.C, Brantford, Canada ; Millen
Alexander Nickle, M.B. (Toronto), M.C.P. & S.(Ont. and Sask.), Captain,
C.A.M.C, Saskatchewan, Canada; Ibrahim Abdell Razzak, M.R.C.S.(Eng.),
L.R.C.P.(Lond.), Cardiff; James Ness MacBean Ross, M.B., Ch.B., M.D.
(Edin.), Temp. Surgeon, Royal Navy, Galashiels ; Augustus George
Stewart, M.B., Ch.B., M.D.(Aberd.), Captain, R.A.M.C, Medical Superin-
tendent, Paddington Infirmary, London ; David Laurence Tate, M.B., Ch.B.
Glasg.), Captain, R.A.M.C., Surgeon i/c Tankerton Hospital, Whitstable,
Kent ; William Robert Tutt, M.B.(Toronto), M.C.P. & S.(Ont.)., Captain,
R.A.M.C. ; Wilson Tyson, M.R.C.S.(Eng.), L.R.C.P.(Lond.), B.C., M.D.
(Camb.), Lowestoft, Suffolk.

Owing to the increased cost of production the subscription to the
Edinburgh Medical Journal has been raised to thirty shillings per
annum.

A New Method of Wound Treatment

A NEW METHOD OF WOUND TEEATMENT BY THE
AGENCY OF LIVING CULTUKES OF A PROTEO-
LYTIC SPORE-BEARING ANAEROBE INTRODUCED
INTO THE WOUND.*

By ROBERT DONALDSON, M.A., M.D., Ch.B.(Edin.), ER.C.S.(Edin.),
D.P.H., Pathologist, Royal Berks Hospital, Reading ; Bacteriological
Specialist, War Hospital, Reading, etc.

The most efficient method of treating wounds is one of the oldest
of medical problems, and one which, after years of Listerian
practice, still awaits solution. If antiseptics be the last word in
wound treatment, then the ideal antiseptic yet remains to be
discovered. It is possible, however, that there are other ways
of dealing with the problem, and the new biological method
advocated in these pages is a step in this direction. It constitutes
a complete break with tradition since, instead of attempting to
kill the organisms present in a wound by means of antiseptics,
other organisms are actually introduced, and their services
enlisted on the side of the surgeon.

To many this will sound like rank heresy. So contrary
indeed is it to all that has been taught since the time of Lister
that one must expect it at first to be regarded with suspicion if
not with actual disfavour. Facts, however, are difficult obstacles
to put aside easily, and after all it is a comparatively simple
matter for the sceptic to convince himself of the practical utility
of the new method.

In order, however, the better to follow the evolution of the
theories on which this new method is based, I may perhaps be
excused if I make brief reference to the chief methods of wound
treatment in common use prior to the war.

Broadly speaking, these may be divided into two: viz. pre-
Listerian and the antiseptic. The former rested on empiricism
and gave place to the second, which originated as a result of the
epoch-making discoveries of Pasteur and the application of his
discoveries to surgical practice by Lord Lister. To Pasteur we
owe our knowledge of the reason why wounds go wrong — the
significance of organismal implantation — while to Lister we are
indebted for our knowledge of how this may be prevented.
Lister's work lay in the direction of prophylaxis — prevention of

• Extracted mainly from a thesis awarded the degree of M.D.(Edin.) with
commendation.

4 Robert Donaldson

the entry of organisms by the use of antiseptics — and from this
it was but a step to the employment of antiseptics in wounds
which had already become infected ; in this way the era of anti-
sepsis was ushered in.

Wounds came, however, to be differentiated into two categories
— those made by the surgeon into non-infected tissues, and those
inflicted by other means and in which pathogenic germs had
already gained a footing. With a recognition of this important
distinction came a modification of Listerian practice. It was
argued that since a wound made by the surgeon into non-infected
tissue contains no organisms, it was therefore unnecessary to
introduce an antiseptic into such, especially as the chemical
employed often possessed irritating properties which militated
against rapid healing. It was sufficient simply to render the skin
more or less sterile by the use of some antiseptic, while instru-
ments, etc., were freed from organisms by boiling. In this way
the aseptic method of treatment came into existence as an off-
shoot of the antiseptic.

In the use and application of these two methods, the younger
generation of medical men at least have been trained, and in view
of the facilities existing in civil life for the rapid and thorough
treatment of freshly infected wounds, coupled with the progress
made in hygienic matters, these methods have been found on the
whole satisfactory in perhaps the majority of cases. With various
adjuncts, such as vaccine therapy, wound infections had largely
been robbed of their terrors. Notwithstanding this, the ability
to stay the progress of infection in a wound by these means was
still of the nature of a variable quantity. The mortality from
wound infections had been tremendously reduced, but no one
antiseptic had been found, the employment of which could always
be depended upon to render a septic wound rapidly sterile.
Hence there arose a rivalry between various types of antiseptic
and various methods of application, exaggerated values being
attached to these various substances as a result of deductions
drawn from in vitro experiments. To the surgeon the septic
wound was one containing organisms. These had to be exter-
minated. In vitro this was easily achieved by means of anti-
septics, therefore, it was argued, the latter ought to be equally
efficacious in wound treatment. The all-important fact was not
grasped that the living wound is very far from being on all-fours
with a test - tube experiment. The former contains complex
bodies not present in the test-tube where two factors only are in

A New Method of Wound Treatment 5

operation, viz. the organism and the antiseptic to which it is
exposed. It is this failure to recognise anything else in a septic
wound, saving the presence of the infecting organism, that is
responsible for the continued efforts to find the ideal antiseptic the
application of which to such a wound would speedily and certainly
put an end to organismal life without, at the same time, inflicting
a fresh injury on the tissues. The ideal antiseptic, however, is a
veritable Will-o'-the-Wisp that has so far eluded capture, although
from time to time someone comes forward to claim the honour
of having at last found it. As a result of the various tastes and
fashions in antiseptics, the Listerian school became subdivided
into various coteries, each coterie the advocate of its own par-
ticular antiseptic to which it pinned its faith.

With the outbreak of the present war, however, the false
sense of security engendered in civil life by circumstances already
alluded to was rudely shattered.

Like a bolt from the blue it was found that the antiseptics
hitherto in general use were comparatively powerless to stay the
ravages made by infecting organisms in modern gunshot wounds.
Men were unaccustomed to deal with such wounds, or with such
heavy and virulent infections. Apart from the extensive lacera-
tion and destruction of the tissues, the mode of infliction, by its
very nature, carried infection deeply into the wound. Moreover,
the infecting flora were of such variety and virulence as had
hitherto been unknown in the course of ordinary civil practice.
It was easy to understand that it should be so when we consider
the very highly manured state of the soil on which the fighting
is taking place. Further, the conditions of trench warfare, which
evolved after the preliminary manoeuvring of the hostile armies,
were such as literally to saturate the clothing and to plaster the
bodies of the soldiers with mud and filth highly charged with
organismal life. These were factors entirely new to men who had
had to deal only with the wounds and infections of civil life.

Eecourse was therefore had to the strongest weapons known
for combating infection. It was the supreme test of the efficacy
of such antiseptics as were then in use. How they failed is now
common knowledge. In many, many cases they were useless in
the hands of the surgeon, and it was at this juncture that Sir
A. Wright came forward as the determined opponent of antiseptic
methods, and the apostle of the so-called "physiological treat-
ment," by means of hypertonic saline solutions. In this way the
first blow was delivered against Listerism, and the physiological

6 Robert Donaldson

method introduced to take its place. It is not my purpose here
to discuss the question of antiseptics versus hypertonic saline, nor
do I propose to canvass the theories or criticise at any length
the methods of treatment advocated by Sir A. Wright. These
theories have already been subjected by other and more com-
petent workers to sufficiently trenchant criticism. Moreover, that
Wright himself has not only modified his original methods of
application of hypertonic solutions, but has even modified his
original views regarding their mode of action, seems to point to
the fact that a complete understanding of the physics and of the
biological properties of hypertonic saline has yet to be achieved.
From the practical point of view, while it might only show
ignorance on their part or inability to use the method of treat-
ment so strongly advocated by Wright, the fact that it has been
abandoned by many surgeons for other methods seems peculiarly
significant. The chief merit of Wright's work consists, in my
opinion, in the fact that he helped to break the spell which had
hitherto bound surgeons to the exclusive use of antiseptics. To
the surgeon the septic wound was a solution of the continuity of
some part of the body into which organisms had gained an entry.
The chief factor, if not the only one which rendered the wound
unhealthy, which prevented its healing, and which, in certain
cases, even menaced the patient's life, was, in his eyes, the infect-
ing organism. Obsessed with this idea, his one aim was to rid
the wound of its infecting flora, and for this purpose the chief
weapon in his armamentarium was the antiseptic, and this weapon
had failed him. Wright then came forward and directed the
surgical mind to a second factor in wound treatment, the import-
ance of which had not been sufficiently emphasised, viz. the
protective mechanism of the patient's own tissues. This, he
argued, ought to be given full scope for action, best achieved by
abstaining altogether from the use of antiseptics and by employ-
ing, instead, hypertonic solutions of salt. The fact that he laid
emphasis on the ability of the patient to combat his own infection
if given a chance seems to me of more importance than the
particular method which he devised to attain this end. The
disappointment following on the comparative failure of antiseptics
thus found expression in the dogmatic statements of Wright.

In this way, so far as their methods go, there came to exist
side by side two diametrically opposed doctrines of wound treat-
ment. Both, however, are based on the idea that the infecting
organism is the chief, if not the only, factor to be considered in

A New Method of Wotmd Treatment 7

a gunshot wound. One school endeavours to exterminate the
infection by the use of such artificial means as chemicals, the
other relies on the living defensive mechanism of the patient.
Both equally fail, however, to grasp all that is involved in the
term "infected gunshot wound." The latter is not merely a
solution of the body's continuity which has become infected.
There is a third factor whose importance has hitherto not been
sufficiently realised, viz. the presence in that wound of devitalised
or dead tissue. The missile which inflicts the trauma does not
merely cause a solution of the body's continuity, through which
pathogenic organisms enter ; it also devitalises more or less of the
living structures, and it is this last factor whose significance has
been overlooked. Force of circumstances, however, has compelled
surgeons to take cognisance of it. Dissatisfaction with the older
antiseptic methods and with the newer physiological treatment
has led them to advocate complete and immediate excision of the
wound, so that a third method of treatment has come into vogue,
which in the following pages I shall call the Surgical method.
The increasing tendency on the part of surgeons to employ the
latter indicates a tacit recognition of the fact that neither the
antiseptic nor the physiological method can be implicitly relied
upon for success, and both, it is well known, are liable to fail,
with 'disastrous consequences to the patient. There must be
some explanation, common perhaps to both, to account for the
frequent failure attending their use, and this explanation, I
venture to submit, will be forthcoming only when we can visualise
the role played by the dead tissues in a wound, and the biological
processes occurring therein as a result of bacterial implantation.
The third, or surgical, method of treatment was introduced
ostensibly to remove infecting organisms before they had had
time to proliferate seriously. To do so obviously involved
removal of a certain amount of tissue, mainly dead or badly
damaged. The significance of this dead tissue seems to me to be
of such importance that I would here urge a revision of the usual
surgical text-book definition of a wound. I would suggest that in
that definition be incorporated due reference to the fact that a
wound consists not merely of a solution of the continuity of some
part of the body, but a solution accompanied by devitalisation or
even death of part of the tissues involved. Such a definition
would emphasise the importance of the damaged tissue in the
wound, and an appreciation of this fact would lead to a clearer
understanding of the sequelae of wound infection. From the

8 Robert Donaldson

wound inflicted by the surgeon's knife, where the devitalised
tissue is small in amount, there range all degrees of damage,
varying according to the instrument producing the trauma and
to the force employed. The gravity of a gunshot wound, for
instance, compared with that produced by an unclean surgical
scalpel, depends, apart from the number and type of organisms
present, on the greater amount of devitalised tissue in the former,
and the opportunities this affords for organismal activity whereby
weapons of offence in the shape of toxins, etc., are formed. The
ability of a patient's own defensive mechanism to deal with
infecting organisms would lead us to suppose that, if it were
possible to inflict a wound without the production at the same
time of even the minutest trace of devitalisation or of necrosis,
any infecting organisms which might find an entrance would be
promptly dealt with by the defensive cells, and sepsis would not
occur, the patient's general power of resistance being normal. In
such a wound antiseptics would be a danger and physiological
saline unnecessary. "Where, however, dead or damaged tissue is
'present, we have a fresh obstacle to successful treatment, whether
hypertonic saline or antiseptics be used. Eemove this base and
either method may then suffice to keep further infection at bay.

I wish, however, to refer again to the physiological method
of wound treatment. The means by which Wright sought to
achieve the end he had in view was indirectly the stimulus
which prompted the present investigation. Wright drew atten-
tion to the use of ordinary salt as the means par excellence of
inducing the body to undertake its own defence against invading
bacteria. Colonel C. B. Lawson and Colonel H. M. W. Gray, C.B.,
A.M.S.,1 basing their theories of treatment on those formulated by
Wright, introduced, in order to promote a so-called lymphagogue
action and to obviate the need for elaborate drainage or con-
tinuous irrigation, the now familiar method of treatment by
means of salt packs.

Briefly put, the merit of the salt pack lies in the ease with
which it can be applied, in the fact that it can be left undisturbed
in situ for five or six days, with great comfort and advantage to
the patient, and in the fact, according to its original advocates,
that it effects more or less closely the changes which Wright
insists upon are necessary for the rapid and successful cleansing
of a wound from infection. Whether or not salt acts physically,
as Wright and his followers seem to think, does not particularly
-concern us at this point. The physics of its action, not to talk

A New Method of Wound Treatment 9

of the biological processes involved, still await more accurate
scientific explanation than has so far been advanced. Suffice it
to say that, according to its advocates, salt acts in the fir3t
instance as a lymphagogue, so preventing a wound from becoming
in Wright's words, lymph-bound ; that the lymph flow also tends
to loosen sloughs so that they separate more readily, and that
later the salt solution of reduced tonicity exercises a chemio-
tactic influence on the leucocytes which, together with the salt
present, complete the victory over the invading bacteria. In
addition to the active defence in the form of phagocytes and
what Wright calls " bacteriotropic " substances there is a passive
defence which he defines as "the protection against infection
obtained by preventing microbes converting to their uses the
nutrient substances of the blood fluids." 2 In other words, there
comes into play the antitryptic power of the blood, a power which
is said to be increased in all severe wound infections.

All this may be true of salt when employed as Lawson and
-Gray recommended, without necessarily being the real explanation
of the success of the salt-pack method of treatment, which, as I
shall try to show, depends on another factor altogether. One of
my colleagues, Major Joyce, K.A.M.C.(T.), in charge of certain
surgical wards at the Beading War Hospital, was in the habit of
employing this salt-pack method of treatment for gunshot wounds
under his care. His results were, as a rule, excellent, and tallied
more or less closely with the published results of others who have
employed this method of treatment. The salt certainly seemed to
be able to effect a marvellous change in the local and general con-
dition of the patient. Admitting for the moment the claims of
the protagonist of the hypertonic saline method as to its action
in the wound, the question arose, Did this action result in a
reduction in number of the infecting bacteria ? At my colleague's
request I made a series of observations on such wounds before the
introduction of the salt packs, and again after their removal. The
results, however, were disappointing, inasmuch as the bacterial
flora seemed to be as numerous immediately after removal of the
salt pack as before its use. To a certain extent this is what one
might have expected, for salt packs practically constitute what is
to all intents and purposes a pus poultice, and produce a totally
different condition from that resulting from continuous irriga-
tion, which, by mechanical flushing, keeps the wound free from
accumulations of pus. Yet that the wounds so treated did well
and recovered probably sooner and with less disturbance than

10 Robert Donaldson

by any other method was a clinical fact clearly proved by the
published experience of several surgeons. Girling Ball,3 for
example, states that " the salt causes an exudation of fluid which
washes out the bacteria not only from the surface of the wound
but also from the deeper tissues, thus affecting them in a manner
which no antiseptic applied to the surface will do. Whether this
is due to osmosis or irritation is difficult to say ; the clinical fact
remains ... it is a great advance in the treatment of infected
wounds." As a matter of fact the outflow of fluid which follows
insertion of the salt bags takes place for the most part entirely
within the first twenty-four hours, whereas the bags remain for
days in situ and, as I have said, come to form a veritable pus
poultice. In spite of such a condition, Koberts and Statham*
declare that cases received from the clearing stations, treated by
the salt-bag method, generally arrived in excellent condition —
much better than those treated by other methods — but they can
offer no explanation of the mechanism by which this is achieved.

Several others have written with equal enthusiasm about the
superiority of the salt pack over other methods of wound treat-
ment, but no one, with perhaps a single exception, so far as I
remember, has recorded any failures. Perhaps they had none to
record. It was a failure, however, that led to my undertaking
the investigation on which the new method of treatment rests.

My colleague, Major Joyce, had noticed that in one or two
instances the salt-pack treatment had been a failure, and in such
this method had to be abandoned for some other. The reason for
these failures was not at first apparent, until he became aware
that whereas all successfully treated salt-bag wounds emitted a
strong offensive odour — a characteristic referred to by all who
have written about this particular treatment — it was completely
absent from certain cases under his care which had definitely
failed to clear up after salt packing. No surgeon hitherto had
coupled absence of smell with failure of the wound to improve
under salt-bag treatment. It was a point, however, of consider-
able importance, for on it hinged the subsequent laboratory work
upon which the new method is based.

Impressed by the observation he had made, my colleague
approached me with the query, Why do some salt-packed wounds
smell while others fail to do so ? The simplest and most obvious
answer to the question was that a certain organism or combination
of organisms, present in some wounds but absent from others,
would probably be found responsible for the odour in question.

A New Method of Wound Treatment 11

To determine if this were so became my immediate aim. In the
course of investigation, however, new ideas occurred to me as well
as fresh problems for solution, and these, when they had been
followed up, elucidated and tested, furnished the data for the
method of treatment as formulated in these pages. In carrying
out this inquiry I am indebted to my colleague, Major Joyce, for
affording me free access to the patients under his care, for granting
me every facility for the collection of material and clinical data,
and for his kind co-operation when the time came to put the new
method to clinical test.

For reasons which I need not enter into here, I resolved in
the first instance to investigate the anaerobic bacteria present in
wounds undergoing successful salt-pack treatment. The first
case from which I made cultures yielded a mixture of two spore-
bearing anaerobes which, as a preliminary to further study, I
ultimately succeeded in separating by a method described
elsewhere.5

One of these organisms possessed round terminal spores, the
other oval subterminal ones. Pure cultures of the latter, grown
for two or three days in cooked meat medium, developed the
same peculiar odour which characterised successful salt-packed
wounds. Further investigation of a series of cases so treated
showed that this bacillus was present in all that were doing well
and smelling, but that it was invariably absent from those which
were making no progress. It established the fact that this
particular odour might be regarded as an indicator of the success
of the salt packs in any given case. The next step was to study
the morphological and cultural characters of the new organism,
and to determine its pathogenicity, if any, towards animals. This
has been fully dealt with in my thesis and an abridged account
of it will be found in another journal.6

For reasons given in that article I have named the organism
thus isolated, the "Eeading bacillus." Comparative work shows
that it is closely related to the B. sporogenes of Metchnikolf.
There are reasons for believing, however, that the latter name
probably covers not one strain but several, all nearly related, but
differing from each other in certain points, and it seems probable
that the Eeading bacillus is one of that group.

The Beading organism is a spore-bearing anaerobe possessing
strongly proteolytic properties. Its behaviour in a medium of
cooked meat at once suggested to my mind the possible role it
played in septic wounds, viz. that it broke down or hydrolysed

12 Robert Donaldson

the dead protein tissue, and by so doing destroyed the pabulum
•on which pathogenic organisms flourished. Other possibilities
were investigated later, but this seemed at first the simplest
explanation of its action. Given suitable conditions for active
growth and proliferation, it probably did in the dead tissues of
the wound what it obviously did in vitro, viz. it digested them.

Further laboratory work showed that this bacillus possessed no
directly inhibitory effect — for example, by the production of organic
^icids detrimental to organisms grown in symbiosis with it — and
no bacteriolytic property was demonstrable. These experimental
results agreed with observations made on the bacterial content
of salt-packed wounds, to which reference has already been made.

In view of the strong proteolytic properties of the Reading
bacillus — its chief characteristic in fact — I felt that here was the
explanation of the success following salt-pack treatment. This
view was further supported by the clinical phenomena seen in
wounds so treated. Previous to the introduction of the salt packs
the wound is lined with devitalised or dead tissue in greater or
less amount. On removal of the packs from a successful case in
five, seven, or nine days' time, it will be seen after irrigation that
the previously black sloughy material has disappeared — has been
digested, in fact — and in its place bright red healthy granulations
are visible, with perhaps a few somewhat emaciated sloughs loosely
adherent. The bulk of the damaged tissue has disappeared, and
with its disappearance there has been a steady improvement in
the patient's general condition.

Bacteria require sufficient pabulum for their successful growth
and proliferation. This, as a rule, is an easy matter in vitro and,
given a proper adjustment and supply of this pabulum, will go on
indefinitely because unhampered. In the human body, on the
other hand, it is quite another matter, since the body cells are
endowed with a complex mechanism of defence having for its
object, amongst other things, the destruction of pathogenic organ-
isms which may threaten the well-being of that body. The
unfettered growth and proliferation of bacteria are thus held in
check by this defensive system, and unless the latter be naturally,
or at the time of attempted bacterial invasion, imperfect, or unless
the mass attack by the bacteria be overwhelming, the body is
quite able to conduct its own defence and to destroy the invading
organisms.

Many of these bacteria will not grow on healthy living tissue
but only on what is damaged or dead. The latter forms the base

A New Method of Wound Treatment is

from which they draw their supplies, and from which also they
produce those substances which may be regarded as their weapons
of offence. These weapons are toxic in character — the degradation
products of organismal activity — and they act as a set-off against the
body's defensive mechanism. A wound, as I have said, implies the
presence of devitalised or dead tissue — tissue no longer in posses-
sion of the full powers of defence which it possessed previous to
infliction of the trauma. Such material constitutes a more favour-
able culture medium for bacterial growth than do the uninjured
tissues of the body, and the bacteria very properly make use of it.

It is not quite such a favourable breeding ground, however, as,
for example, is the medium contained in our culture tubes, since
the proximity of the living to the dead tissues allows a certain
degree of scope for the body's defensive mechanism to come into
play in the shape of phagocytes and bactericidal substances. A
single or an occasional attempt to invade the body may be easily
repulsed by its defensive mechanism, but when a base has been
established in the shape of devitalised tissue it is quite another
matter to deal with repeated attempts of this kind. The danger
lies in frequent small attacks made by bacteria or their toxic pro-
ducts and continued over a period of time. This mode of attack
may be compared to the " wearing-down tactics " of warfare, and
its severity will depend, amongst other things, on the size of the
base from which the organisms operate. The larger the base, the
greater the opportunities for organismal proliferation, and con-
sequently the greater will be the amount of toxic material
available. The danger to the patient will depend on the length
of time we allow the infected base to exist and on the volume of
dead tissue present in the wound. The latter may actually tend
to increase, for not only do the toxic substances operate injuriously
on the patient's general condition, but they may also exert a local
effect on the adjacent healthy tissues whereby the latter in turn
become damaged and finally die. Hence, both a general and a
progressive local destruction may occur simultaneously.

The danger would be entirely eliminated or at least largely
minimised if one could ■ destroy the base from which the hostile
activities proceed without at the same time laying the foundation
for a fresh base. This is exactly what the Eeading bacillus does,
and what to a large extent is achieved by the surgical method
which, in this respect, is superior both to antiseptic and to physio-
logical measures. Wound excision, however, possesses certain dis-
advantages which detract from its value and render it inferior to

14 Robert Donaldson

treatment by means of the Reading organism. For instance, the
exact amount and extent of dead or dying tissue cannot always
be appraised by the naked eye, and, moreover, the very act of
excision inflicts a fresh trauma, leaving behind it a zone of death
liable to become immediately re-infected. It is equivalent to the
substitution of a small amount of dead tissue and presumably a
minimal infection for a large mass of damaged tissue and a heavy
infection. The surgical method is, moreover, a gross and mutilat-
ing form of attack, and, for anatomical reasons, is not always
possible.

The Eeading bacillus, on the other hand, is able to dissect
away, as it were, not only the macroscopically but also the micro-
scopically dead material in a way that no surgeon's knife ever can,
and that without at the same time inflicting any fresh trauma.
The devitalised tissues are largely all removed in the course of
a few days, and with their disappearance the breeding ground of
the pathogenic organisms is destroyed. The Eeading bacillus acts,
in short, as a bacteriological scalpel. The living tissues, relieved
of the strain of ever having to withstand a continual bombardment
from bacteria and their toxins, while endeavouring at the same
time to cast off the dead sloughs, are now able to throw all their
energies into the work of repair, as is evidenced by the rapid
formation of healthy granulation tissue which quickly becomes
an effective barrier against further organismal advance.

Hence the importance which I attach to the presence of dead
tissue in a wound, and it is precisely because of this dead material
that the antiseptic and the physiological methods so often fail.
They take account of the bacteria, in different ways it is true,
but fa^l to appreciate the importance of getting rid of the base.
The larger this is, the more inaccessible are the bacteria to the
influence of the antiseptics. Unless the latter are such that they
can saturate every part of the damaged tissue and act on all the
organisms there breeding in the same way that they will act on a
simple suspension of organisms in a test-tube, they must to that
extent be regarded as failures, and so far as I am aware no
antiseptic has yet been devised which will fulfil these conditions.
The most that an antiseptic can do is, by frequent and it may
be by prolonged application, to kill off a sufficient number of
bacteria to allow the defensive mechanism of the body to get
the upper hand. Hence the time factor comes into play, and
is important for two reasons. At the present juncture it is
essential that the period of convalescence be reduced to the

A New Method of Wound Treatment 15

minimum. As a rule antiseptics do not achieve this. The wards
of any hospital will furnish many, cases that have gone on sup-
purating for weeks under and in spite of antiseptic treatment.
Further, it is important, from the patient's point of view, to
hasten recovery, inasmuch as the longer the dead tissues are
allowed to remain, the longer is the body likely to be exposed to
the sustained action of bacteria and their toxic products. This
continued absorption spells serious, often permanent, damage to
the more highly specialised cells of various organs, and may in
time so exhaust the defensive mechanism that the patient finally
succumbs to his infection. A fatal septicaemia may follow the
prolonged toxaemia. The same objection applies in a certain
measure to the physiological method, with this difference — that
the latter is not liable, like some antiseptics, to cause further
death of the tissues, and does not therefore increase the area
suitable for bacterial activity.

It is perhaps an error to place all antiseptics in the same
category, since hypochlorous acid preparations ought more
properly to be regarded as exceptions. These, it is interesting to
note, have proved themselves so superior in many ways to most
other antiseptics, that the very pertinent question arises, Do
they act by virtue of their antiseptic properties, or is there some
other explanation of their success ? It is a matter of common
knowledge amongst those who have employed such " antiseptics "
as eusol, Dakin's solution or chloramine-T, that under their
influence sloughs separate readily. Dakin,7 in one of his papers,
states that " the solvent action of hypochlorites on necrotic tissue
is a great advantage when contrasted with the coagulating effect
of many antiseptics on blood-serum and wound exudates. The
former action of hypochlorites permits the wound surface to
remain moist and so removes obstacles to the outward flow of
lymph, which is so readily checked by antiseptics which are
protein precipitants."

In another place 8 he says, with reference to chloramine, that
" the results were clinically similar to those observed in the early
treatment of infected wounds with sodium hypochlorite, with the
exception that the sloughs are dissolved somewhat more readily
by the hypochlorite than by the chloramine." Again, in the
course of a discussion following a paper on the "Secondary
Closure of War "Wounds," read at a meeting held at the Paris
Academy of Medicine, M. Dastre9 and others expressed the
opinion that " the beneficial effect of hypochlorite was due to its

16 Robert Donaldson

ability to clear away damaged and necrotic tissue and to destroy
toxins rather than to its antiseptic action." I shall refer at a
later stage to the question of toxin destruction.

Similarly, Fleet-Surgeon Dalton,10 R.N., quotes as one of the
advantages of the use of sodium hypochlorite solution, "the
rapidity with which sloughs separate and clear granulation tissue
is formed in a wound under its influence," while, in a still more
recent paper,11 the very decided view is expressed that " eusol as an
antiseptic is quite unimportant, but that its great and undoubted
value lies in its power to destroy dead tissue, so depriving the
infecting organisms of their pabulum." Exactly the same theory
had been put forward to explain the action of the Reading
bacillus in a paper12 published some months before the above
statement appeared.

The claim of eusol to be regarded not as an antiseptic merely
is still further strengthened by the extraordinary results obtained
by Professors Lorrain Smith, Ritchie, and Dr. Rettie in certain
cases treated by the intravenous injection of eusol — a full account
of which has already appeared in this Journal.™

The hypochlorites certainly differ from other antiseptics in so
far as the former possess the power to disintegrate dead tissues,
and there is reasonable ground for supposing that their virtue in
wound treatment depends almost entirely on this power. The
similarity between this and the method of treatment which I
advocate in these pages will be at once apparent. Treatment by
means of the Reading bacillus differs, however, in certain points
from the hypochlorite method. The former, for instance, effects
its results entirely by virtue of its proteolytic powers, with this
very important difference — that it is a living catalyst as distinct
from an inorganic one, and it is precisely on this account that the
biological method possesses an advantage over the use of hypo-
chlorites. The value of the latter depends on bulk chemical
action, and this necessitates the observance of a direct ratio
between the quantity of dead tissue to be destroyed and the
amount of chemical necessary to effect that change. This
involves considerably more in the way of technique than does
treatment with the Reading bacillus. For the chemical to be
efficient there must be frequent manipulation of the wound — a
proceeding bad for the patient, since it breaks the cardinal rule
that a part which is injured demands rest. In the second place,
the application of hypochlorites seems to provoke unnecessary
bleeding, which, although in many cases unimportant, may,

A New Method of Wound Treatment 17

nevertheless, in some be a matter for concern. Their use is,
moreover, not altogether free from the charge that they may even
act injuriously on the living tissues, and in this feature they
resemble the action of antiseptics. The Beading bacillus, on the
other hand, once introduced with the appropriate dressing, goes on
automatically proliferating till its work is complete, and, what is-
of vital importance, it appears unable to damage living healthy
tissue. It is entirely non-pathogenic, and does not in the course
of its attack on the dead tissues give rise to degradation products
of a toxic nature. This, however, is not its whole action.
Certainly, at first, I was inclined to attribute the success of the-
treatment entirely to the destruction of the dead tissue base by
the proteoclastie activities of the bacillus, but this theory did not
quite explain all the clinical phenomena observed in cases so
treated. Where the organism happens to be present or is
purposely sown and the conditions are favourable to its growth,
improvement in the patient's general condition usually begins by
the third day at latest, and sometimes earlier. This clinical
observation has been recorded by all who have described cases
treated by the salt-pack method. If this improvement depended
entirely on the destruction and disintegration of the dead tissue-
by the Beading bacillus, one would scarcely expect it to begin till
the disintegration process was completed or at least well advanced.
At the time when constitutional improvement begins, however,
proteolysis is far from complete, and even at the end of seven days
there may still be a few threadbare sloughs left. While still
convinced that proteolysis was the key to the explanation, it
became necessary to take a wider view of the organism's range
of activity. As the main point still awaiting adequate explana-
tion was the reason for the rapid improvement in the con-
stitutional symptoms, and as the latter were, in my opinion,
probably caused by toxic substances constantly finding their way
into the patient's system as a result of the activity of pathogenic
organisms, two explanations occurred to my mind. The first of
these was the possibility of an inhibitory action on the growth of
the pathogenic organisms present by the formation on the part of
the Beading bacillus of some organic acid or acids. Investigation,
however, in this direction failed to furnish any evidence of such
action.

The second explanation was based on the supposition that
just as the Beading bacillus was able to disintegrate gross protein
matter, so in the same way it might also be able to split up the-

2

18 Robert Donaldson

toxic degradation products of pathogenic organisms. In other
words, what time the Reading bacillus was busy destroying by
proteolysis the base from which the pathogenic organisms derived
their supplies, it was also actively engaged, by virtue of the same
property, in splitting up the toxins formed by these organisms.
In this way, pending complete removal of the dead tissue, further
absorption of toxins by the body was being prevented. There
were obvious difficulties, however, in the way of testing experi-
mentally whether all the toxins elaborated in infected wound
tissues are really so split up, and, in order to acquire some experi-
mental proof of this, I had perforce to choose powerful toxins
which lent themselves to accurate measurement and whose effects
could at the same time be experimentally demonstrated. To this
end I carried out an extensive series of experiments with tetanus
toxin, diphtheria toxin, and with toxic filtrates obtained from
cultures of B. perfringens, using guinea-pigs for purposes of
inoculation. At the same time the ability of various other
organisms to modify these toxins was investigated and careful
controls were kept. For details of these experiments reference
must be made to my original thesis. It is sufficient to state here
that, of all the organisms investigated, the Heading bacillus alone,
and, to a less extent, B. sporogenes (Metehnikoff) yielded evidence
of ability to destroy these toxins. For instance, a guinea-pig was
able to withstand nearly 150 times the M. L. D. of tetanus toxin
in which the Reading bacillus had previously been grown. In
other words, this bacillus was able to exercise on the toxins
investigated a somewhat similar effect to that which it produced
on the dead tissue in wounds. It does not necessarily follow
•of course that because these three toxins can be rendered com-
paratively harmless by the proteoclastic powers of the Reading
bacillus, all toxins produced by pathogenic organisms will be
similarly modified. Sufficient, however, has been done to justify
the assumption that probably all toxins of a protein character or
dependent on protein elements may similarly be split up and
robbed of their toxicity. It is, at all events, a reasoned attempt,
based partly on clinical, but mainly on experimental, grounds,
to explain the working of an organism whose power to cleanse
wounds and hasten convalescence is an undoubted clinical fact.
Such a conception of the organism's activity opens up new possi-
bilities in the treatment of such toxaemias as are dependent on
toxins of protein structure, and suggests that means may be found
along similar lines to reduce them to non-poisonous elements.

A New Method of Wound Treatment 19

In connection with the experimental work and the theories
built thereon, it is a matter of some considerable interest to find
that support is forthcoming from other quarters, although I was
ignorant of it at the time when I began my investigations. In
the hands of Dean and Adamson,14 for instance, eusol — one of
the so-called antiseptics whose success probably depends mainly
on their protein-splitting power — has been found capable of
destroying the toxic bodies formed by B. dysenteric (Shiga) in
the course of the latter's growth on culture media. A similar
conception of the possible role played by hypochlorite solutions
in relation to their toxin-splitting powers has been referred to in
another quotation9 already given. Indeed, the possible ability
of eusol, introduced intravenously, to destroy toxins in cases of
toxaemia is actually one of the theories advanced by the advocates
of this treatment to explain its modus operandi.

This ability, then, to disintegrate not only sloughs but also
toxins of protein composition is due to an enzyme or enzymes
produced by the Reading bacillus. The enzyme is of the nature
of a protease and can be demonstrated in filtrates obtained from
broth cultures of the organism. While most bacteria possess the
power of attacking protein, only a few possess the power of form-
ing proteases in any appreciable amount, and probably still fewer
possess the power of hydrolysing proteins in such a way that their
destruction products are themselves non-toxic. That the Heading
bacillus appears to belong to this select group seems proved by
the clinical and experimental observations which I have made.
The difference between pathogenic organisms and the Eeading
bacillus is this — that the former, in the course of their attack on
the protein pabulum, split off bodies — degradation products — which
are highly injurious to the body cells. These degradation products
are the toxins, and their presence in the blood constitutes toxaemia.
As these are themselves probably protein in composition, they are
capable of being split up, or still further hydrolysed, into elements
devoid of toxicity under the influence of some catalytic agent.
The Reading bacillus appears to be such an agent. The end
products of its enzymic action on proteins are, so far as all clinical
and experimental proof goes, absolutely devoid of toxicity. The
organism is, in short, entirely without pathogenicity, and is there-
fore unique as an instrument of treatment. It may be regarded
as a permanent manufactory of a proteoolastic enzyme whose
initial velocity will be more or less maintained throughout owing
to constant removal by the wound discharges of the products

20 Robert Donaldson

of its hydrolysis. It is a living catalyst as distinct from such
inorganic catalysts as eusol, and, because of this, it possesses, as
I have already mentioned, inherent advantages over the hypo-
chlorites. In a way it may be said to resemble trypsin, which, be
it noted in passing, is also able, to a certain extent, to detoxicate
the toxin of tetanus. It is even possible that the application to a
wound of a solution of a ferment like trypsin might act in a some-
what similar manner to that of the enzymes produced by the
Beading bacillus. As a matter of fact, there exists a reference in
one of the journals 15 to the use, by a German surgeon, of artificial
gastric juice in the treatment of gangrenous wounds, while, as an
empirical attempt in a similar direction, may be instanced the
immemorial use of the leaves of Pinguicula (butterwort) by
shepherds in the Alps as a cure for ulcers on the udders of
cows.16 The therapeutic value of these leaves appears to depend
on a vegetable trypsin, by means of which the plant is able to
proteolyse the bodies of insects caught in the leaves. The Beading
bacillus, however, possesses well-defined advantages over ferments
such as these. The latter, to be of any value, must be kept con-
stantly renewed, since much of them will speedily be carried away
in wound discharges, whereas the Eeading bacillus, once implanted
and given suitable conditions for its growth, will go on auto-
matically supplying fresh enzyme so long as there is necrotic
material to be hydrolysed. In the one case there are limits to the
enzyme's range of action, so that, as in the case of eusol, it needs
constant renewal, whereas in the other the manufactory is on the
spot, and is able to turn out all the enzyme that may be needed.
Before leaving this subject, it is perhaps worth mentioning that
not every organism endowed with proteoclastic properties is able
equally to hydrolyse toxins. For instance, B. histolyticus, a much
more actively proteolytic agent than the Eeading bacillus, is
nevertheless quite unable to modify the toxins of tetanus or of
diphtheria.

If the Eeading bacillus acts in the way described, why had its
activities been manifested only in successful salt-bag cases ? Why
not in wounds dressed otherwise ? A study of its cultural
characters supplies a probable answer. It is a strict anaerobe,
and as such will only grow in the absence of air, provided oxygen
is supplied to it in a form which it is able to utilise. This suggests
that the salt-pack acts more or less as an anaerobic plug. The
latter fills the wound completely, and, when it becomes saturated
with fluid, forms a plug capable of preventing the access of air to-

A New Method of Wound Treatment 21

the wound tissues in which the organism is present, while not so
impermeable that the gases generated by the activities of the
Beading bacillus cannot escape. These gases probably accumulate
at the site of organismal growth, and, as their pressure rises, must
gradually displace any air that may have been imprisoned at the
time of packing. The slight pressure thus formed will also prevent
further entry of air into the wound. Without such an anaerobic
plug, growth of the organism does not occur. This is proved by
the fact that the Beading bacillus odour is absent from wounds
treated by the more usual type of dressings, whereas many cases,
long treated by the ordinary methods, begin within a few days of
employing salt-packs to develop the characteristic smell. In such
cases the organism in its active form can be demonstrated in large
numbers, indicating that it must have been present in the wound
in the dormant form of spores which only became active when the
necessary anaerobic conditions had been established. Where the
spores are not already present, the salt-packed wound emits no
characteristic odour, and the clinical progress of the case presents
an entirely different picture.

As success or non-success seemed to depend on the presence
or absence of the specific bacillus, the question arose, Was the
salt an essential factor for the growth of the organism ? Those
who have practised the salt-bag method of treatment have for
the most part been under the dominance of Wright's hypertonic
theories. It was obvious, however, that whatever truth there
might be in those theories, salt could not be regarded as essential,
in view of the fact that some cases absolutely failed to respond
to this form of treatment. Cultures made from such invariably
failed to grow the Beading organism, which, as I have elsewhere
indicated, can always be recovered from successful salt-packed
wounds.

Experimental work undertaken to corroborate this supposition
of mine showed that salt in the strength used was not only
unnecessary but even inimical to the growth of the bacillus,
which refused to proliferate in a concentration greater than 5 per
cent. Why, then, does it grow at all in wounds packed with salt
in this way ? Probably the answer to this question is, that if the
initial concentration of salt could be maintained, no growth would
take place.

As a matter of fact, however, it is easy to see that the original
concentration must steadily diminish — rapidly at first, especially
during the first twenty-four hours, when there is a tremendous

22 Robert Donaldson

outflow of fluid from the wound, carrying away in solution much*
of the salt into the cotton- wool coverings.

Girling Ball 3 indeed has investigated the content of salt
packs after the latter have been in situ for four days. After
soaking such packs and expressing the fluid contained in them,
he has only been able to recover 2 per cent, of the salt ! This
seems to show that in four days a very considerable reduction
must have taken place in the initial salt concentration. Hence
in salt-packed wounds the Reading bacillus is probably only able
to grow out when the salt concentration has become sufficiently
reduced. These considerations seemed to indicate that the salt
was merely an accident, that it constituted in the wounds, as I
have said, merely an anaerobic plug. To test this hypothesis
further, I suggested to my surgical colleague that he substitute
for salt a comparatively inert substance, such as sterilised
sphagnum moss. As pus and fluids accumulated, the moss, I
conjectured, would swell, and so mould itself more closely to the
shape of the wound. The interstices and chambers would become
filled with fluid and the whole thing would then form a most
efficient anaerobic dressing. The technique of its application was
the same as for salt packing, the moss being contained in small
gauze bags. In the cases so treated the salt factor was thus
completely eliminated. As I anticipated, these cases followed
exactly the same course as did those in which salt bags had been
successfully employed. I wish therefore to make it clear that the
new method of treatment put forward does not depend on the
use of salt packs, which are a mere accident, and that therefore it
is not synonymous with salt-pack treatment as that was originally
conceived. Whatever can be relied upon to provide an anaerobic
environment will serve just as well as salt, provided the Reading
bacillus is present. The latter is the essential factor, but, in order
that it may become active, suitable conditions for its growth must
be provided, and these may be attained in a number of ways.
Where, on the other hand, the Reading bacillus is absent from
the wound, the salt pack, in spite of the salt and all its lymphagogic
action, will fail as an agent for cleansing the wound or for
improving the condition of the patient.

Having determined from the cases at my disposal that the
Reading bacillus was present in its active form in all successful
salt- or sphagnum-moss-packed wounds, while it could not be
grown from similar wounds which had failed to respond to this
treatment, it still remained to apply a crucial test to prove the-

A New Method of Wound Treatment 2$

causal connection between the activities of this organism and the
successful cleansing of the wound.

To do this involved the deliberate introduction of living
cultures of the Beading bacillus into a wound which had previously
failed to clear up under salt-pack treatment and from which
the Beading bacillus was known to be absent. As a preliminary
to such an experiment it was of the utmost importance to>
ascertain whether the bacillus was pathogenic or not. To this
end I inoculated a long series of animals — rabbits, mice, and
guinea-pigs — intravenously, intraperitoneally, subcutaneously, and
intramuscularly. Cultures of all ages and grown on various
types of media were injected on different occasions, using a range-
of doses. On none of these animals was there the slightest ill-
effect, nor was there ever any evidence that the degradation
products of its growth in culture media possessed the slightest
toxicity. No oedema and no gangrene ever resulted. Experi-
ments were carried out to show the fate of the organisms so
introduced, and it was found that they provoked a polymorph
leucocytosis, the polymorphs more or less rapidly ingesting the
bacilli and their spores. It was therefore evident that in animals,,
at least, the Beading bacillus was unable to attack healthy living
tissue. This has a certain though perhaps a subsidiary bearing
on the treatment of wounds by the new method. Since the
bacillus grows easily and rapidly on dead proteins but will not
attack living tissues, it is necessary to make sure that before
sowing and packing a wound the organism has free access to
every part of it. This necessitates thorough opening up of all
pockets and sinuses and the evacuation of all collections of pus,
etc. The organism will not grow through a barrier of living
tissue.

As a further safeguard, before deliberately sowing the organism
in the wounds of human beings, I investigated, as already men-
tioned, the flora from a series of successful salt-pack wounds and
found in all the Beading bacillus. Therefore, having proved it
by experiment to be non-pathogenic to animals and by investiga-
tion to be present in the wounds of many without producing any
injurious effects, it seemed legitimate to carry out, as indicated
above, a crucial test of the theories formed concerning its mode of
action. My colleague, Major Joyce, was willing and eager to
allow this to be done. A suitable gunshot wound was chosen
fulfilling the above conditions, and this I sowed liberally with a
living culture of the bacillus, after which my colleague immedi-

24 Robert Donaldson

ately re-packed it in the usual way. In three days' time the
patient's temperature had come down, the wound was emitting
the foul characteristic odour associated with the active prolifera-
tion of the Beading bacillus and the patient was comfortable.
The packing was left in situ untouched for some days, and within
a day or two of its removal the wound was found to be absolutely
clean, devoid of all sloughs, a brilliant scarlet colour like fresh
raw beef, and covered with healthy granulations. There was a
striking contrast between the results obtained after the first and
second packings respectively, where the only factor of difference,
on the second occasion, was the assured presence of the Beading
bacillus. The case was its own control, since, as a result of the
first packing, the wound did not develop the characteristic smell,
the patient did not improve, and the Beading organism was found
to be absent.

The crucial test had been passed and it only remained to
prove, by treating other cases in the same way, that the first was
not merely a fortuitous happening. Since then, wounds of various
kinds, such as septic knee-joints, etc., have been sown, always with
successful results and never with any ill-effects. For details of
these reference must be made to my original thesis. The wounds
so treated have not all been of one type, although all agree in
having been the result of gunshot injuries. As such they
practically always involved muscle, parts of which were dead or
dying as a result of the trauma. The tissues were generally dirty,
sloughy, and purulent, while the surrounding areas were frequently
oedematous and almost always inflamed. In many cases the
patient was obviously ill, in pain, and running a temperature.
The wounds were generally five or seven days old at least before
the patients reached Beading, and in some instances they had been
suppurating for weeks. They came with all sorts of wound
dressing. Some had undergone " Bipp " treatment, others had had
a long course of Carrel-Dakin treatment, while others had been
treated in a variety of ways at different times. The fact that
some of them had been suppurating for weeks labelled them at
once antiseptic failures, notwithstanding the fact that the latest
antiseptic methods had been employed. It is true that no acute
cases of gas gangrene were admitted here, so that from my own
personal experience I have not had an opportunity to observe
the effect of the Beading bacillus on such wounds. I can, how-
ever, point to the published experience of certain medical men
who have used salt packs with success in cases of gas infection

A New Method of Wound Treatment 25

occurring in France. Eoberts and Statham 4 give brief details of
seventeen cases treated by means of salt bags. Six of these cases
were examples of gas infection. All improved rapidly under salt-
bag treatment with the exception of one, which at first improved
but later flared up so that recourse was finally had to amputation.
From one at least of the five successful cases B. perfringens was
•easily obtained, affording bacteriological evidence of the presence
of virulent gas-forming bacilli. If, then, salt packs were successful
in these gas infections, and since the efficacy of the treatment
depends not on the salt but on the presence of the Heading
bacillus, it follows that there is likely to be little or no danger
in deliberately sowing such wounds with the Eeading organism.

Certain criticisms, however, have been urged against the
claims which I make on behalf of the bacillus. For instance
it has been suggested that the success which follows treatment
with the Eeading bacillus is due not to the activities of that
organism but to the preliminary free opening up of the wound,
to the evacuation of collections of pus, and to the removal of any
foreign bodies that may be present. This line of argument is not
really a serious one, and very cogent reasons can be advanced by
way of meeting it. If the bacillus be merely an accident and
without any beneficial influence on the condition of the wound,
the question may be asked, Why do some wounds fail to get
better under salt-bag treatment although this has been preceded
by free incisions and removal of pus, fragments of bone, or other
foreign body ? Moreover, the subsequent history of wounds
which have been most thoroughly explored and submitted to
■minor operative interference as well as to subsequent antiseptic
treatment is entirely different from that which is true of wounds
treated with the Eeading bacillus. Every hospital can provide
illustrations of what I mean. In such cases no definite time-
limit can be set to the cessation of the infective process. It may
go on for days, weeks, or months, as a glance at the temperature
chart of almost any severe wound infection will show. In these
cases the morbid process is essentially progressive in character,
while convalescence is at best protracted. Not once only, but
many times, in the course of a wound's history may operative
measures of a minor character be required. The very fact that
they are so often necessary is ample proof that the method
adopted for the cleansing of the wound is to that extent lacking
in efficiency, and furnishes an answer to the objection raised
above. It is precisely for that reason that surgeons find them-

26 Robert Donaldson

selves compelled to adopt a more radical method of treatment in
the shape of complete wound excision. Nor is the insertion of
salt packs, even after thorough exploration and free incisions,
always followed by success. Each minor operation performed
on the wound succeeds simply in removing part of the effect, but
fails to eradicate the cause. The recurring abscesses or the
necrosis of fragments of bone furnish proof of this, for they are
merely the resultant of organismal forces acting on tissue already
dead, as a result, it may be, of the operative interference.

It was precisely to find out the reason for such salt-bag
failures that the present investigation was undertaken, culminating
in the method of treatment now actually in use, and, if further
evidence be required, it may be found in the record of cases
recorded in my thesis. In some of them, as described above,
every possible claimant for the honour of being regarded as the
sole curative agent has been eliminated and only the Reading
bacillus left.

The gunshot wound, then, is to be regarded as a solution of
continuity of the body, produced by violence, and characterised
by a greater or less amount of dead or dying tissue in juxtaposi-
tion to the living and less damaged. This dead tissue is more or
less heavily infected with organisms, most of them pathogenic
and many highly virulent. Trouble, local and constitutional,
arises from the interaction of these pathogenic organisms with
the necrotic tissue. Bacterial enzymes are formed, and, in
addition, leucocytic and other tissue ferments are liberated in
the course of the morbid process. As a result of this multiple
hydrolytic action, degradation products, many probably of a toxic
character, are formed. Some of these act injuriously on partially
damaged or even on undamaged tissues adjacent, so that the
necrotic process goes on gradually involving more and more of
the living structures. Others probably enter the patient's system,
giving rise to toxic symptoms, of which evidence is afforded by
the temperature chart, the pulse, and other constitutional dis-
turbance. In order to counteract these destructive processes,
various methods of attack have been adopted, and these may be
divided into two main categories. The first includes all those
which aim at setting a limit to further breaking down of the
tissues. To this group belong practically all the usual methods
of wound treatment. It embraces all antiseptics with, perhaps,
the notable exception of eusol and similar substances. Omitting
these, the rest may be said to be directed against one factor only

A New Method of Wound Treatment 27

in the morbid process. They aim either at destroying the patho-
genic organisms, or at inhibiting their growth, leaving Nature
to cast off slowly the dead tissue. Such methods overlook the
sinister role played by necrotic tissue in the wound, and for
various reasons even the best of them must be regarded as
crude.

Not only can they not be relied on to render the wound1
sterile or to prevent the continued absorption of toxic products
by the patient, but some of them may actually cause fresh tissue
necrosis. The most that can be claimed for them is that they
keep bacterial activity within reasonable limits, what time Nature
is endeavouring to cast off the dead tissue which the antiseptic
itself is powerless to do. The healing of a gunshot wound under
such circumstances must be at best a tardy process, liable at any
time to be interrupted by renewed organismal activity, and for
that reason requiring the frequent assistance of minor operative
measures. During all this time the patient is probably absorbing
more or less of the toxic products, which in turn may initiate
further morbid changes in his body. Indeed, the absorption of
such toxic substances over a prolonged period may have the same
end-result as an initial overwhelming infection. The comparative
failure of antiseptics has led to the substitution for them of treat-
ment by complete excision of the wound. This method, however,
belongs also to the first category, inasmuch as its aim is, once and'
for all, to put an end to further breaking down of the tissues by
the rapid removal of the organisms, together with their breeding
ground. In other words, although ostensibly intended to rid the
wound of its infecting bacteria, this procedure at the same time
removes the dead tissue, and on this account it is, in my opinion,
superior to antiseptic methods. It possesses, however, certain
limitations, to which reference has already been made.

In the second category I would place all methods which
accelerate proteolysis in the wound. This, I am aware, is in
direct opposition to the tenets of many. To this group, in which
inorganic catalysts like eusol and Dakin's solution should be
placed, belongs the new method now advocated. As it is dependent
upon the vital activities of a living organism, I have called it the
Biological method, to distinguish it from the antiseptic, the physio-
logical, and the surgical respectively. It is not, as I have said
elsewhere, synonymous with the salt-pack method of wound treat-
ment, although the latter certainly depends upon it for success.
The Heading bacillus, however, not only possesses the power of'

-28 Robert Donaldson

accelerating proteolysis so that the dead tissue disappears from the
wound, but it appears to be endowed with the further property of
being able to render non-toxic the degradation products of patho-
genic organisms. Over and above all, its hydrolytic action is
confined to the dead tissue, and does not extend to the living.
This fact must be borne in mind by those to whom anything
calculated to hasten proteolysis is anathema. It is an entirely
new method of treatment, pregnant with possibilities for the
future and full of suggestions for new lines of research.

The employment of the biological method, however, does not
mean that no surgical interference is necessary. Here, as with
every other method, it is essential that the wound be thoroughly
laid open in the first instance, exposing every pocket and sinus,
so that the organism, together with the packing, may be brought
into direct contact with every section of the raw surfaces.

The advantages of its use include simplicity of application,
the avoidance of the necessity for daily dressing and therefore
-daily disturbance of the wound, the rapidity with which a sloughy
wound becomes a healthy granulating surface, the absence of
secondary haemorrhage, together with the remarkable and speedy
improvement which takes place in the general condition of the
patient, all of which mean considerable curtailment of the time
usually spent in hospital. It is, in short, a method essentially
conservative of life and of limb, while at the same time it is
■eminently safe.

In conclusion it may be of interest to outline the chief points
in relation to the technique of wound treatment by this method.
It ought to be a fundamental axiom that all gunshot wounds be
freely opened up to begin with and thoroughly explored. In
order that this may be done efficiently the patient will require
to be anaesthetised. Every pocket should be laid open, so that
the subsequent packing shall come directly into contact with all
parts of the wound surface. As such wounds are frequently of
an irregular and burrowing character, to do so efficiently will
frequently call for ingenuity on the part of the surgeon. All
•foreign bodies ought if possible to be removed, and care should
be taken to ensure that no adjacent collection of pus has been
missed.

The interior of the wound is now irrigated with very hot
sterile water or saline solution to wash away obvious pus or blood
and to assist in checking capillary oozing. By means of a pipette
the whole surface of the wound is liberally sown with a living

A New Method of Wound Treatment 29>

culture of the Reading bacillus, commencing first with the deeper
parts. The cultures which I am in the habit of using have been
grown in cooked meat broth. It is perhaps an advantage for
some reasons to use a three-day-old culture, but one many months
old will serve equally well. Immediately after sowing, the packs,
whether of salt or of sphagnum moss, slightly moistened with
sterile water or saline, are introduced, and so arranged that they
fill up the wound cavity completely, leaving only the tails of the
bags projecting. In some cases it may be found more convenient
to distribute the culture over various parts of the wound in turn,
packing each section as it is sown.

When all the packs are in situ, several layers of plain sterile
gauze, moistened with sterile water or saline, are laid over the
packing, in such a way that they overlap the edges of the wound.
The whole is then enveloped in thick layers of cotton-wool and
firmly bandaged. It is an additional advantage if some form of
splint can be applied to aid in steadying the part.

The surgeon ought always to have a large supply of packs
available before beginning the operation. These packs are really
small gauze bags containing either salt or moss. It is an advan-
tage to have them made in various sizes, from which those most
suitable for packing a given type of wound may be chosen. A
good average size is one measuring about 5 or 6 ins. long and
about 2 fingers'-breadth wide. During the first twenty-four hours
there is a very copious outflow of fluid from the wound. This is
generally ascribed to the hypertonicity of the salt. The same
thing, however, occurs where sphagnum moss has been used instead
of salt. By the end of this period the outflow has very perceptibly
diminished, and thereafter remains small in amount. Where salt
has been used the patient will, for a few hours after packing,
probably complain of slight pain and smarting, due to the irritant
effect of the salt. Where sphagnum moss has been used the
patient does not experience any immediate pain, but after twenty-
four or forty-eight hours may suffer some discomfort owing to
swelling up of the moss by imbibition. This can be obviated to a
large extent by making due allowance at the time of packing for
subsequent increase in bulk.

Whatever form of packing is employed, the temperature will
probably rise higher on the day following than it was before
interference. Towards the end of the second or third day the
temperature usually begins to fall and a very definite improve-
ment takes place in the patient's general condition. This improve-

30 Robert Donaldson

ment ought to be steadily maintained. There is no daily dressing
to worry the patient except, perhaps, the substitution of fresh for
soiled cotton-wool. His appetite improves and he is able to
obtain sound and refreshing sleep. There is only one objection-
able feature and that is the characteristic penetrating odour, whose
presence is not a danger signal, as some have thought, but an
indication that the organism is becoming active. If the odour
fails to develop, there has been some flaw in the technique. The
smell generally begins to manifest itself towards the end of the
second or third day, corresponding roughly to the time found
necessary for active proliferation of the organism in test-tube
experiments. As a matter of interest it is worth noting that it is
about this time also that the temperature begins to alter for the
better. Although in some cases the latter may not come down to
normal, on the third or fourth day or thereabout it will almost
certainly be lower, and will finally fall for good on removal of the
packing at the end of the appointed period. Occasionally a case
may be met with where the temperature is not influenced at all,
and where the patient does not show the progress he ought to do
although the organism is at work. In such it is well to consider
the possibility of there being some other focus of infection which
has been missed, while at the same time one ought carefully to
scrutinise any other wound if such be present. It may be that
a collection of pus requires evacuation, arising from some small
focus shut off and so overlooked at the time of the original explora-
tion, or the treatment adopted for some other wound, considered
too trivial to require the application of the Beading bacillus, may
not be satisfactory.

Just how long the packs require to be left in will probably
depend on the size of the wound and the amount of dead tissue
present, but in human beings the period ought probably to be at
least seven to nine days. In horses and mules, owing to the rapid
growth of healthy granulation tissue, I am given to understand
by a veterinary authority that the period should be somewhat
shorter. At the end of this time the packing may be removed
without the aid of an anaesthetic. The superficial layers of gauze
will be found set hard as if starched, and more or less firmly
adherent to the skin.

After gently detaching the board-like upper dressings, the
actual packing, be it salt or moss, comes out easily en masse,
bathed as a rule in bright yellow pus, from which the Reading
•organism can be recovered if desired.

A New Method of IVonnd Treatment 31

The wound surfaces are then irrigated with eusol or with
Avarm sterile saline to wash away all clinging pus and debris, after
which the wound will be found, as a rule, perfectly clean.

Perhaps one or two somewhat delicate sloughs still remain
slightly adherent, and these the irrigating fluid causes to wave
about like little fragments of transparent seaweed. All oedema
and inflammation, however, have disappeared. The wound is
then lightly dressed with plain sterile gauze wrung out of eusol or
sterile saline solution. Once a day thereafter it is irrigated and
dressed in the same manner. In the course of one, two, or three
days the wound surfaces will present a brilliant red colour, devoid
of sloughs, and covered by firm healthy granulations. Such a
wound heals rapidly or, if deemed necessary, may be covered with
skin grafts, or have its edges approximated in some way. The
end-result is usually a firm, more or less linear, scar.

One point, in conclusion, deserves special notice, viz. that in
no case where this method of treatment has been employed in
Heading has secondary haemorrhage ever occurred.

Indeed, I have copiously sown with this organism a wound in
which the tissues were so rotten that secondary haemorrhage had
just occurred. This particular wound was thereupon packed in
the usual way, and no recurrence of the bleeding took place.
Absence of secondary haemorrhage is a feature remarked upon by
all who have published accounts of salt-bag treatment. Major
A. J. Hull, 17 E.A.M.C., for instance, even goes the length of saying
that in his hands the salt-bag method of treatment lias actually
been one of the most generally applicable of procedures for the
treatment of secondary haemorrhage.

All this is in direct opposition to the published statement
•of Sir A. Wright,18 who has said, with reference to secondary
haemorrhage, that the aim and object of treatment must be to pre-
vent any digestive action in the neighbourhood of the endangered
artery. Basing his conclusions on histological grounds, Bashford w
takes up a similar attitude when he advocates surgical interfer-
ence as the only sure way to prevent further ravages by the
organisms and their products on vessels, etc., in the damaged area.
Yet the whole success of the biological treatment which I here
advocate depends entirely on the active proteolytic power of a
bacillus. The reason for such apparently conflicting statements
is probably due to a failure to discriminate between the various
types of organism present and their resultant action. It does not
follow that because some are to be feared, all are bad. Because

32 Robert Donaldson

many are highly virulent, it must not be taken for granted that
none can be beneficial. That one at least of the organisms
hitherto indiscriminately condemned is not only not virulent but
actually beneficial is proved by the experimental work on which
this new method of treatment is based. Its free use by various
surgeons in various hospitals has always been attended with
success, and has demonstrated that this bacillus at any rate can
be introduced into septic gunshot wounds not only with impunity
but with marked benefit to the patient.

Summary and Conclusions.

1. The preceding pages deal with a new form of treatment

for gunshot wounds, which I have called the biological
method to distinguish it from the antiseptic, the physio-
logical, and the surgical respectively.

2. It is based on revised ideas which I have formed regarding

the relative importance to be attached to the various
factors which prevent wound healing and is the outcome
of work which I undertook with the original intention
of finding an explanation for a clinical observation made
by a surgical colleague.

3. The new method depends on the introduction to the

wound of a spore-bearing anaerobe of a saprophytic
character belonging to the proteolytic group of
organisms. I have named it the Heading bacillus.

4. It is non-pathogenic when introduced into gunshot

wounds and in the course of its activities does not give
rise to toxic products injurious to the patient. Its
morphological and cultural characters, together with the
experimental work which I have carried out in connec-
tion with it, are described in another journal.

5. The Eeading bacillus is probably to be found in the

majority of gunshot wounds, but is unable to exert its
beneficial action except where anaerobic conditions
obtain. Hence the reason for its appearance in salt-
packed wounds, from which I isolated it in the first
instance.

6. The biological method is not synonymous, however, with

the salt-pack method of treatment, although the latter
is dependent upon the Eeading bacillus for success.
Salt is not only not essential but may actually impede
proliferation of the organism. Sphagnum moss or any-

A New Method of IVound Treatment 3S

thing, indeed, that will secure anaerobic conditions in the
wound may be substituted for the salt packs with
equally good results. The rationale of the salt-pack
treatment, therefore, cannot be explained along the lines
suggested by the adherents of the physiological school.

7. All methods of wound treatment hitherto in use have been

directed almost solely towards destruction of the infect-
ing flora and arrest of proteolysis in the wound. Their
relative efficiency actually depends, however, on their
influence, if any, on the necrotic tissue present.

8. Special emphasis is laid on the supreme importance in a

wound of dead and damaged tissue, and I have attempted
to show that this should be the chief point to which
treatment should be directed.

9. The antiseptic and the physiological methods fail to

realise this, and consequently find themselves in process
of being supplanted by the surgical, or method of wound
excision. The superiority of the latter over the two
first-named depends not so much on the speedy removal
of infecting organisms, for which purpose it was
originally intended, but on the fact that it removes
a large part of the dead tissue as well.

10. The surgical method, however, is not always anatomically

possible, may fail to remove all the dead tissue present,
is a mutilating form of treatment, and by its very nature
inflicts a fresh trauma, leaving a zone of death behind
to form the base for fresh organismal activity.

11. The biological method, on the other hand, belongs to quite

a different category, inasmuch as its avowed object is to
hasten proteolysis and, with the possible exception of
eusol and kindred substances, it is the only one in this
class.

12. The Beading bacillus has a twofold action. It not only

disintegrates the dead tissue upon which pathogenic
organisms live and from which as a base they are able
to keep up a continual bombardment of the patient's
body by means of toxic degradation products but, to
judge from my experimental work, it is probably able
also to destroy these toxins so that they are no longer
absorbed.
12. The former action brings about a local improvement in the
wound which is rapidly, automatically and easily freed

8

34 Robert Donaldson

from all necrotic material, while the latter puts a stop
to continued toxaemia as is proved by the rapid con-
stitutional improvement which takes place. Pending
removal of the supply base by the Heading bacillus, the
further absorption of toxins by the patient is prevented.

13. Both results are achieved by reason of a proteoclastic

enzyme produced by the Reading organism. This
enzyme acts as a living catalyst which is able to
hydrolyse not only dead protein but also the toxic
degradation products of other organisms. Once intro-
duced into the wound and given suitable conditions for
development, the Reading bacillus will go on forming
enzyme as long as there is any dead protein to hydrolyse.
For these reasons, therefore, it differs from all other
known methods of wound treatment hitherto employed,
and while opening up new possibilities for the more
efficient treatment of toxic absorption in general, raises
other side issues of considerable importance. It
becomes, in short, a problem in colloid chemistry.

14. The technique of wound treatment by this method is

briefly described.

15. The advantages claimed for it include simplicity of applica-

tion, the avoidance of daily dressing and daily disturb-
ance of the wound, the rapidity with which a sloughy
wound becomes a healthy granulating surface, the
absence of secondary haemorrhage, together with the
remarkable and speedy improvement which takes place
in the general condition of the patient, all of which
mean considerable curtailment of the time generally
spent by a wounded man in hospital.

References. — 1 Gray, Brit. Med. Journ., 1915, ii. 32. 2 Wright, Wound
Infections, Univ. of London Press, 1916, p. 20. 3 Girling Ball, St. Bart.'s
Hosp. Journ., October 1916, p. 3. 4 Roberts and Statham, Brit. Med. Journ.,
1916, ii. 283. 5 Donaldson, Lancet, 1917, i, 821. 6 Donaldson, Journ. of
Path, and Bacteriol.,'1918, xxii. No. 2. 7 Dakin, Brit. Med. Journ., 1917, i.
835. 8 Dakin, Cohen, and Kenyon, ibid., 1916, i. 161. 9 Dastre, ibid., 1916,
i. 212. 10 Dalton, ibid., 1916, i. 126. u Morgan, Saner, and Schlesinger, Brit.
Journ. Surgery, 1918, v. 446. 12 Donaldson and Joyce, Lancet, 1917, ii

13 Lorrain Smith, Ritchie, and Rettie, Edin. Med. Journ., 1916, p. 611.

14 Dean and Adamson, Brit. Med. Journ., 1916, i. 611. 15 Annotations, Lancet,
1915, ii. 683. 16 Von Marilaun, Nat. Hist, of Plants, Blackie & Son, 1894,
i. 143. " Hull, Lancet, 1916, i. 1077. 18 Wright, Brit. Med. Journ., 1916,
i. 793. 19 Bashford, Brit. Journ. of Surgery, 1917, p. 793.

Income Tax Information

35

INCOME TAX INFORMATION.
By JOHN BURNS, W.S., Edinburgh.

II.

Having in the first article set out the leading general rules, we
shall now show how these are brought to a point in the actual
adjustment of the tax payment and repayment.

Bates of Tax.

Considerations of space lead us to confine attention to the
current year, but we may state that the rates during the three
preceding years were lower. The rates for the current tax year,
April 1918 to April 1919, are:—

Total Income from all Sources
(Including Wife's Income) not
Exceeding

£500
1000
1500
2000
2500
over 2500

Rate of Tax on the Part of the Income which is

Earned. Unearned.

S. d. S. d.

2 3 3 0

3 0 3 9

3 9 4 6

4 6 5 3

5 3 6 0

6 0

6 0

Thus, if your total income (as already explained) exceeds £500
"but does not exceed £1000, the true rates are 3s. on the part which
is earned, and 3s. 9d. on the part which is unearned. On the
earned part the true rate will be charged on the direct tax assess-
ment. But in the case of the unearned part (mainly dividends
and interests on investments) there is the difficulty that much of
that income is taxed " at the source " before you receive it. One
way to handle that is to send in a claim for repayment by the
department. But it is better, if possible, to arrange to have the
adjustment made by an allowance from your direct tax assessment.
Thus, suppose the tax on your business profits would be £50, but
your (or your wife's, or both) income from investments is all taxed
at the source at the full 6s. rate, so that in that way £40 will be
deducted from that part of your income, whereas your true
unearned rate is only 3s. 9d., there is a rebate of £15 due to you.
So, to save trouble, that sum will be allowed off the Schedule D
profits tax, which will be thus cut down from £50 to £35.

36 John Burns

Abatements.

We have given the rates of tax, and we have stated how these
rates are arrived at, namely, according to the total income. But
it may have been noticed that we have not said that these rates
are charged on every part of the total income. Thus, a doctor
may have an income of, say, £700, and yet he may be taxed on
only, say, £365. The difference of £335 would be explained by
the various abatements to which he might be entitled. Thus (1)
he gets £70 free simply because his income does not exceed £700,
without any other reason ; and we have further assumed that he
(2) has a wife (£25) and (3) four children under 16 years of age
(£100); (4) maintains an incapacitated dependent relative (£25)
and (5) pays £115 a year for premium of insurance on his life.
But pray note that these abatements do not pull down his " income "
to £365. Not at all, it is still the £700, and so his rates of tax
are 3s. (earned) and 3s. 9d. (unearned) because the income is over
£500, and not 2s. 3d. and 3s., which would be the rates if the
income did not exceed £500. We shall now briefly state the
different abatements.

Small incomes, that is, total incomes not exceeding £700, are
entitled to a certain part free of tax, thus : —

Total Income not Abatement

Exceeding Abatement.

£400 £120

600 100

700 70

Wife. — If the total income does not exceed £800, £25 is
allowed free if the taxpayer is married and husband and wife
live together. This dates only from April 1918.

Widower's Housekeeper. — This is the same as the wife abate-
ment in all respects as just stated. But the housekeeper must be
a relative of the taxpayer or his late wife, and there must be a child
under 16 years of age.

Children. — This abatement is more than four years old, but
during those years the conditions have varied a great deal. Now
the rules are that the abatement is £25 for each child in life and
under 16 years of age at the start (6th April) of the year of
assessment if the total income does not exceed £800 ; or for each
such child after the first two, if the income exceeds £800 but does
not exceed £1000. In both cases adopted children and step-children
count. It is not necessary that the children (except adopted
children) should be living with, or be maintained by, the taxpayer.

Income Tax Information 37

Incapacitated Dependent Relatives. — This dates only from April
1918. The abatement is £25 of income free of tax for each
relative of the taxpayer or of his wife maintained (wholly or partly)
by him, provided the relative is incapacitated by age or infirmity
and has an income, if any, not exceeding £25. This, amongst
other things, enables an abatement to be obtained for an incapaci-
tated child over the age of 16 years.

Life Insurance. — In this case there is no limit of income. The
abatement entitles the taxpayer to total relief from tax on the
amount which he pays for premiums of insurance on the life of
himself or his wife not exceeding one-sixth of the year's income
or (if greater) of the income of 1913-14 — the last pre-war year.
But there are certain restrictions. Thus no premium can be
passed to an extent exceeding 7 per cent, on the original sum
insured. On policies effected after June 1916 there is a limit of
relief to 3s. per £, but that is still total relief to any professional
man whose total income does not exceed £1000. There is more
liberal treatment in regard to war "extra" premiums. The
following kinds of policies qualify for the abatement : — ordinary
life policies, endowments, double endowments, partnership policies
(sometimes not; care is necessary), accident policies if covering
fatal accidents and to the extent of the proportion of premium
corresponding to the death risk; also contributions to widows'
funds whether the taxpayer is married or not.

Operation of Abatements.

The fundamental distinction is between a deduction from
income on the one hand and tax abatement on the other hand.
The one reduces income ; the other does not. And they respec-
tively operate very differently on the amount of tax which is
payable. The rules regulating the operation of tax abatements
are these: —

1. One abatement does not confer, increase, or diminish any
other abatement.

2. No abatement reduces the rate of tax.

3. All abatements come off income chargeable at the lowest
rate of tax in the particular case, except that —

4. War pay, if any, is taken last.

We shall now proceed to illustrate the application of these
rules.

38 John Burns

Rule No. 1. — One abatement does not confer, increase, or
diminish any other abatement.

Illustration No. 1.
Income ....... £900

Life insurance premium ..... 100

£800

The taxpayer is not entitled to take his income as £800, and
so claim (1) wife abatement £25, (2) incapacitated dependant
abatement £25, and (3) for his two children £50, which, if
claimable, would have been paying tax on only £700. His-
income is £900 and so his only abatement is the insurance. He
pays tax on £800. But if he had more than two children under
16, he would receive an abatement of £25 for each after the first
two, because his income does not exceed £1000.

Illustration No. 2.

ticome .....

, .

£700

Wife

. £25

Three children under 16

75

100

£600

The taxpayer is also entitled to a scale abatement. He claims
£100 because £600 is the income limit for the £100 scale abate-
ment. That is wrong. His income is £700, scale abatement £70,
which leaves him paying tax on £530, his full abatements being
£170, namely (1) scale £70 ; (2) wife £25 ; (3) children £75.

Illustration No. 3.
Income ....... £600

Abatements —

Scale £100

Wife . . . . . .25

Three children .... 75

200

£400

The taxpayer pays £100 in life premiums. What is his.
insurance abatement ? One-sixth of what ? It is one-sixth of
his income, which is £600. Therefore the whole £100 passes,
and he pays tax on £300.

Rule No. 2. — No abatement reduces the rate of tax.

This is the enforcement of what we pointed out at the
beginning, namely, that tax abatements do not alter income.

Income Tax Information

m

The income is just the same as it would have been if the law
had not granted those abatements. If a practice yields £100
less, that is one thing; but it is a totally different thing to
receive a concession of the tax on £100, on account of the
payment of life insurance premiums to that amount, the income
remaining stationary.

Illustration.

£650

Abatements —

Scale .

£70

Wife ...

25

Three young children

75

Incapacitated dependant

25

Life insurance

This leaves .

75

270
£380

to pay income tax. At what rate ? We assume that the income
is all earned. The rate is 3 s., which is the earned rate for incomes
over £500 and up to £1000, and not 2s. 3d., the rate for incomes
not over £500. The reason is that while only £380 remains to
be taxed, the rate is fixed by the total income, and that is £650.

Rule No. 3. — With the exception stated in rule 4, all abatements come
off income chargeable at the lowest rate in the particular case.

Suppose an income of £600, half earned and half unearned ;
abatements £300 ; remains taxable £300. The earned rate is 3s.
and the unearned 3s. 9d. If the abatements were given off the
higher taxed unearned income, the tax payable would be 3s.
on the earned £300, which is £45. But they are actually
given off the lower taxed earned income, leaving the taxpayer to
pay tax on the unearned £300 at 3s. 9d., which is £56, 5s. This
rule thus makes him worse by £11, 5s.

Illustration No. 1.

Income from practice ....
Income (including wife's) from investments

Total income,

Abatements— (1) scale £70; (2) wife £25; (3) child
£25 ; (4) life insurance £45 ; in all

Leaves .

£600
100

40 John Burns

The tax payable is —

1. Earned income .

Less abatements

Tax at 3s. on

2. Unearned income

Tax at 3s. 9d. on .

Total tax,

It will be seen that the whole abatement is taken off the lower
3s. rate, leaving only part of the earned but all the unearned
income to pay tax.

Illustration No. 2.
Practice . ... . . . £1500

Investments ...... 300

£600
165

£435

£65 5 0

100

18 15 0

£535

£84 0 0

£1800
Life premiums ...... 300

Taxable, . . £1500

The tax payable is —

1. Earned income £1500 ; less life insurance

£300 ; tax on £1200 at 4s. 6d.

2. Unearned £300 at 5s. 3d.

Total tax, .

Illustration No. 3.
Practice ......

Wife unearned income (liferent under her father's will)

Total income, .
Life insurance premiums

Taxable, .
The tax payable is —

1. Earned £600, cancelled by part of the insurance

abatement, therefore no tax.

2. Unearned £3600 less balance £100 of the insurance

abatement ; tax at 6s. on £3500 . . . £1050

£270 0 0
78 15 0

£348

15 0

01)

£600
3600

•

£4200
700

£3500

Total tax (but super tax in addition), . . £1050

Rule No. 4. — War pay, if any, is taken last.

This rule was new in April 1917. Assuming the possession of
three classes of income — (1) war pay, (2) other earned income, and
(3) unearned income — abatements were, before that date, taken off
in the above order. Now the order is — (1) other earned income,
(2) unearned income, and (3) war pay. If the only income is

Income Tax Information 41

'(1) other earned income and (2) war pay, or (1) unearned income
and (2) war pay, then the abatements are taken off in that order.
But the deduction for officers' uniforms of necessity comes off the
pay, for it is treated as an expense of earning the pay, and is an
actual income deduction, not merely a tax abatement.

It is known that correspondence is at present proceeding with
the Treasury and the War Office regarding the right of doctors
in charge of military hospitals but not holding commissions to the
special low rate of tax on the pay for these services. It is akin
to the question — already raised in Parliament — of the same claim
on behalf of women doctors doing service with the Forces but
holding no commissions, which will on no account be granted to
women. It is probable that the other question also will be
brought up in the House of Commons shortly.

Marginal Eelief.
Enough has been said to show how much one might be pre-
judiced by having an income just a little above some step in the
scale. Thus an income of £700 gets an abatement of £70; an
income of £701 does not. An income of £1000 gets abatement
for children over two in number, and is charged at rates of 3s.
and 3s. 9d. ; an income of £1001 is excluded from that abatement
and pays 3s. 9d. and 4s. 6d. But these absurd results are not in
fact allowed to arise. You pay to the Exchequer the £1 (or other
excess over the scale) and then you are put in the same tax
position as if you had never had what you thus surrender. But
in the case of a partnership this relief is dependent, not on the
firm's income but on the total income of each partner separately.
Thus the firm's profits might be £1001, yet the marginal relief
might not operate at all, for each partner's total income might be,
say, £1200. On the other hand the firm's profits might be £1000,
yet both partners might be entitled to it, for their total incomes
might be, say, £505 and £810 respectively.

Time Limit.
There are exceptions, but the general rule is that repayment
claims are in time if sent in within three years of the end of the
tax year to which the claim relates. That means that up to 5th
April 1919 you may go back to 6th April 1915. The tax year
1915-16 ended on 5th April 1916. Three years from that date
expire on 5th April 1919. But this does not make it less
necessary for you to appeal at once against any assessment notice
served upon you if you consider that it is excessive. Many
mistakes arise in that way.

42 Obituaries

OBITUARIES.

ROBERT ALEXANDER LUNDIE, M.B., CM., F.R.C.S.E.

Many, now far from Edinburgh, who were students here in the
seventies, either in Arts, Science, Divinity, or Medicine, will share the
keen regret with which his professional brethren heard of Dr. R. A.
Lundie's sudden death on 18th December from the results of a bicycle
accident. Among the many brilliant students attending the University
in these years there were few who surpassed him in strength of
character, vigorous intelligence, and width of interests, and not many
who stood so high as he did in the estimation of his fellows and for
whom a career of future eminence was so confidently predicted.

Robert Alexander Lundie was born in Birkenhead in 1855, the
elder son of the Rev. Dr. R. H. Lundie, a well-known minister of the
Presbyterian Church of England, who took a leading part in social
work in Liverpool. His mother, who survives him, is a daughter
of the late Charles Cowan of Westerlea, Member of Parliament for
the City of Edinburgh.

Having received his early education in the Upper School of
Liverpool College, Lundie entered Edinburgh University at the age
of sixteen, and, from that time onward, paid all his expenses out
of the bursaries and scholarships which he gained. In most of his
classes he took a distinguished place ; and, as illustrating his varied
interests, it may be mentioned that, amongst other honours, he gained
in his Arts course the first prize for Latin Verse, the third for Logic,
the first medal in Natural Philosophy, and a medal and prize in
Mathematics. In 1875 he graduated as M.A. with First-Class Honours
in Mathematics.

From the Arts classes he passed to those of Science, and in these
also he was one of the foremost men of his year. He won medals and
other honours in Botany, Chemistry, and Geology, and gained the
Robert Wilson Memorial Prize as the best student in Senior Chemistry
and the Falconer Fellowship in Geology. It was expected by many
of his friends in these days that he would make a career and a name
for himself in science, or possibly as an explorer. In 1877 he took the
degree of B.Sc, qualifying for it doubly — in Mathematics and in the
Natural Sciences.

At this time, like many other sons of the manse who have ultimately
joined the ranks of medicine, he had thoughts of entering the ministry
of the Presbyterian Church, and became a student in the New College.
There he was associated in close companionship with Henry Drummond,
Robert W. Barbour, David Patrick, George Adam Smith, and many
others who became his life-long friends.

Edinburgh Medical Journal, Vol. XXII. \o. 1.

Dr. R. A. Lundie.

Obituaries 4S

After one year spent at the College, however, he felt that his life-
work lay in another direction, and he returned to the University to-
study medicine. Although he did not take quite so distinguished a
place in the medical classes as he had done in those of the other
faculties, he continued to be a very enthusiastic and successful
student.

Having graduated M.B. and CM. in 1880, he acted as House
Physician to Dr. Brakenridge and as House Surgeon to Professor
Chiene in the Koyal Infirmary, and he was also one of the Presidents
of the Royal Medical Society.

In 1881 Lundie decided to devote himself to medical practice in
Edinburgh, but his plans were delayed by a serious attack of typhoid
fever, after which he made two voyages to South Africa as a ship's
surgeon. On his return he settled down in the Grange district of
Edinburgh, in which locality he has spent thirty-seven strenuous years
in general practice. During twenty-two of these years he was associated
with his friend Dr. R. H. Blaikie as Assistant Medical Officer to the
Longmore Hospital for Incurables.

In 1884 he was married to Annie, daughter of Mr. Charles Henry
Moore, who soon became a friend of his friends, and to whose watchful
care and sympathetic comradeship in all his varied interests he owed
his singularly happy home life. In the same year he became a Fellow
of the Royal College of Surgeons of Edinburgh.

During the earlier years of his practice Lundie made a thorough
study of the subject of ophthalmology, to which his scientific attain-
ments specially inclined him. For several years he was private
assistant to Dr. Argyll Robertson, and he acted for some time as
Assistant Ophthalmic Surgeon to the Royal Hospital for Sick Children.
He also wrote at least one valuable paper on an ophthalmological
subject. After Dr. Robertson's death he had some thought of devoting
himself entirely to this branch of medicine, but he finally decided to
continue in general practice, the human interest of which had great
attractions for him, and for which his kind heart and ready sympathy
fitted him in no ordinary degree.

Not many men in large practice are able to keep themselves so well
informed as he did in regard to the recent advances in scientific
medicine. As illustrating his keen insight and enterprise, it may be-
recalled that he was one of the first in Scotland to make use of the
thyroid treatment of myxoedema, and that he discovered for himself (in
July 1892) the important fact that the remedy could be as efficaciously
given by mouth as by subcutaneous injection. This, it was afterwards
found, had been discovered shortly before by Professor Howitz of
Copenhagen, Dr. Hector Mackenzie of London, and Dr. E. L. Fox of
Plymouth, but, at the time when Lundie made his observations, their
experience had not been published — in this country, at least.

44 Obituaries

He was also the first in Edinburgh, and one of the very first in this
country, to perform successfully an emergency operation for perforated
gastric ulcer. This operation, which was performed in 1894 in a
private house on a servant girl who was not able to be removed to
hospital, has frequently been referred to, with good reason, as a very
remarkable achievement for a general practitioner.

Although never a fluent speaker, Lundie frequently took part in
the proceedings of various medical societies, and contributed a number
of papers on medical and surgical subjects which were models of lucid
and logical statement. One of the best of these was the admirable
summary with which he opened the Discussion on the Treatment of
Myxoedema in the Medico-Chirurgical Society on 15th February 1893.

His abounding energy found further outlet in medical politics, and
he was an active and useful member of many committees and associa-
tions. At the beginning of the war he was Chairman of the Edinburgh
and Leith Division of the British Medical Association, and at the time
of his death he was Treasurer and President-Elect of the Edinburgh
branch of the same body.

He always retained his keen interest in pure science, and he con-
tributed two original papers to the Proceedings of the Royal Society of
Edinburgh. One of these (read on 20th December 1897) was "On the
Passage of "Water and Other Substances through India-rubber Films " ;
and the other, written a year later in collaboration with Dr. Cargill
Knott, dealt with the obscure subject of " Dew-Bows." Both of these
communications aroused much interest when they were delivered, and
are still regarded as authoritative. For many years he has acted as
Examiner in Physiology to the Royal College of Surgeons.

In the intervals of his busy practice he found time to write
occasional papers on scientific subjects for lay publications such as
Chambers' Journal. He also was responsible for a large proportion of
the medical articles in Chambers' Encyclopaedia, the editor of which,
Dr. David Patrick, was one of his oldest and most intimate friends.

Lundie was widely read in general literature and had a retentive
memory, especially for poetry. Those of his friends who accompanied
him on botanical and geological excursions or fishing expeditions will
recall how Browning, Lowell, and Bret Harte, the Border Ballads,
and the Ingoldsby Legends shortened many a long day's tramp over
the hills.

Since 1914 he has thrown himself with his usual tireless energy
into all sorts of war work in a way that would have tried the strength
of many a younger man. He acted as Convener of the Edinburgh and
Leith Medical Emergency Committee, as Chairman of the Edinburgh
and Leith Local Medical War Committee, and served on several other
Boards. He also undertook extra hospital work and looked after
many patients for colleagues who had gone on foreign service.

Obituaries 45-

He took a hearty interest in the work of the Grange United Free
Church, of which he was an elder for about thirty years, and also in
many charitable and philanthropic causes. Some years ago he spent
much unavailing energy in endeavouring to persuade the authorities
of some of the Presbyterian Churches in Edinburgh to keep their
doors open on week-days for rest and private prayer.

Only a few weeks before his death he had the great sorrow
of losing his only son, Captain (Acting Major) R. C. Lundie, D.S.O.,
an able and gallant officer in the Royal Engiueers who had won high
distinction in France.

It is not for us to say what Robert Lundie's death means to his
wife, to his only daughter, and to his aged mother, nor is it easy to
write of what it means to the many who had the privilege of knowing
him well. At every stage of his career his strong steadfast character
and eager friendliness drew other men to him, and they remained his
friends for life. Though many of them have latterly seen him but
seldom, they always found the old ties as close as ever in spite of new
interests, new friends, and new associations. Principal Sir George
Adam Smith — a fellow-student of New College days — writes : " He
was dearly loved by his friends ; and on the occasions I have met him
since — alas ! too few — I have never failed to be profited by our inter-
course. . . . We shall always remember him as one devoted to the
service of his fellow-men from his earliest days till his death, as a very
hard, thorough, accurate, and unselfish worker, and as the kindest and
most gentle of friends."

Robert Lundie was a man of strong and unselfish character, who
warmly appreciated the good in others and ever thought little of him-
self. He has left behind a host of friends who will always feel that
tbey are better men for having known him.

How happy is he born and taught

That serveth not another's will ;
Whose armour is his honest thought,

And simple truth his utmost skill !

This man is freed from servile bands
Of hope to rise or fear to fall ;

Lord of himself, though not of lands,
And having nothing, yet hath all.

J. T.

CAPTAIN DENIS COTTERILL, R.A.M.G, F.R.C.S.

There is no armistice with Death. Three weeks after hostilities had
ceased, and when we at home were beginning to look to the future
with lighter hearts and clearer vision, the sad news came through that
Denis Cotterill had died at Bohain on 2nd December. Cotterill was

46 Obituaries

among the first of our younger surgeons to volunteer for service with
the Army ; he joined the staff of No. 11 Stationary Hospital at Rouen
in November 1914, and was actively engaged on military duty till the
end. The long-continued strain of arduous work had not been without
its effect even on his wiry constitution, as his friends regretfully noticed
when he was home on what proved to be his last leave ; and when he
was stricken down with an attack of virulent influenza, followed by
pneumonia, it was more than he could withstand.

Denis Cotterill was born at Edinburgh in 1881, and after passing
through the Edinburgh Academy he commenced his medical studies
at Cambridge, where he was a member of Christ's College. After
two years at Cambridge he returned to Edinburgh and graduated
M.B., Ch.B. at this University in 1906.

From his school-days onwards he was keenly interested in out-
door games and field sports, and in every branch he took up he excelled.
But he had other interests ; he was fond of music and was an excellent
draughtsman. Although he was of a modest and gentle disposition,
his general all-roundness gave him affinities with a wide circle of
companions, who valued his friendship and appreciated his sterling
qualities.

On the completion of his university course he elected to take up
surgery, for which he had inherited a natural aptitude. He was
specially attracted to the department of orthopaedics, before it had
become a cult, and studied the subject at various continental and
English schools before he obtained the Fellowship of the Royal College
of Surgeons in 1910. Three years later he was appointed an Assistant
Surgeon to the Royal Infirmary.

Those who worked with him in Edinburgh soon came to recognise
his ability as a surgeon, and even in the short time that was given him
to prove his powers he had shown that the school had enlisted one
who would maintain its best traditions. Much was expected of him
when he went to France, and that even the highest hopes of his friends
were justified is abundantly borne out by the testimony of those in
authority with whom he was associated there, and who had the best
means of assessing his achievements. Lieutenant-Colonel Tabuteau,
Officer Commanding No. 11 Stationary Hospital, said of him in the
beginning of 1918: "Nothing I can say can express my appreciation
of his work. A more hard-working, conscientious, and loyal officer
I have never served with. His surgical technique and attention to
detail are excellent. He is full of initiative and keen on anything new
in his profession. Captain Cotterill, by his skill and attention to his
patients, inspired confidence in all those with whom he came in
contact." Referring to the two and a half years during which Cotterill
was in charge of and responsible for the work of the surgical division
of the Scottish section of No. 1 1 Hospital, Lieutenant-Colonel Jameson,

Edinburgh Medical Journal, Vol. XXII. No. 1.

Photo, by Moffat.]

Captain Denis Cotterill, R.A.M.C.

Obituaries 47

his 0. 0.| says, "His surgical work was of an exceptionally high
standard " ; and he, too, makes special reference to his keenness and hard
work. Colonel Pilcher, Consulting Surgeon, Rouen Base, writes : " He
has had a very large experience of war surgery, and has done excellent
service in times of great stress, as, for example, in the Somme fighting
in 1916. I wish to bear cordial testimony to his dexterity in manipu-
lative surgery ; to his mechanical genius, as shown in adapting splints
and apparatus to the needs of individual cases ; to the tact, unwearied
patience, and kindness he showed to his patients ; to his great zeal and
industry, and to the many admirable social qualities which endeared
him to his brother officers." Another consultant surgeon bears testi-
mony to the high standard of his surgical work, and to the tactful
manner in which he had performed duties of unusual responsibility.

After serving at No. 11 Stationary Hospital for over three years,
Captain Cotterill resigned his appointment, and was transferred to
No. 50 Casualty Clearing Station. At the time he took up duty at
the C. C. S. place names were not mentioned, but field-cards were
signed, and from these his friends learned that in the perilous days
when the fate of Paris was still in doubt and the Montagne de Rheims
was the centre of our anxious thoughts, he was on one of the most
vital fronts.

With the turn of the tide he moved further north till he reached
the St. Quentin-Le Cateau section of the line. On the way much
was required of him, and how he met the call his Commanding Officer,
•Colonel Simpson, records : " He displayed an energy and devotion
to duty which were the admiration of us all. During the early days
of the Allied push on the Marne, in July, when this unit worked
almost without cessation day and night for several days, he displayed
untiring energy. Later, when the attack was being carried out against
the Hindenburg line and the unit was again called upon to work at full
pressure, Captain Cotterill showed the same perseverance and devotion
to duty." On the 4th of December his brother officers carried him
to rest in the British Military Cemetery at Premont, about five
kilometres north-west of Bohain.

Many of those who knew Denis Cotterill and were cognisant
of his work in the war have testified in the most emphatic and
generous terms to the excellence of his surgical work, to his self-
sacrificing devotion to duty, and to the great affection and regard
which he inspired in his patients, his fellow-officers, and in all with
whom he was associated in his work. His many friends at home will
feel that they have lost one who by his character and by his sweet
and gentle disposition was specially endeared to them. We can but
mourn his loss, and offer our heartfelt sympathy to his widow and
children, and to his father, Lieutenant-Colonel J. M. Cotterill, C.M.G.,
and his family, in this their culminating sorrow. A. M.

48 E. Treacher Collins

THE TKAINING OF THE STUDENT OF MEDICINE.

An Inquiry Conducted under the Auspices of the
Edinburgh Pathological Club.

LX.— ON THE TEACHING OF OPHTHALMOLOGY TO
MEDICAL STUDENTS.

By E. TREACHER COLLINS, F.R.C.S.

The advantages to be derived from instruction in ophthalmology
by medical students may be discussed under three headings: —
I. The assistance which it affords them in the diagnosis and
prognosis of general diseases. II. The capacity which they acquire
of recognising and treating the commoner local affections of the eye,
and in avoiding mistakes, which are not only disastrous in themselves,
but which may add to the burdens of the community. III. The
training which they receive in attention to detail and exactness of
observation.

I. It is now nearly seventy years since Helmholtz invented the
ophthalmoscope — since Graefe for the first time saw the background
of the eye, with its nerve entrance and its blood-vessels, and jumped
up, with flushed cheeks, exclaiming, " Helmholtz has unfolded to us
a new world." This new world has, by the labours of many careful
observers, been thoroughly explored and charted ; yet it is a remark-
able fact that for the majority of medical practitioners it is still a terra
incognita.

Every medical student provides himself with a stethoscope, and
devotes much time and patience to training his auditory faculties for
its use. Comparatively few purchase an ophthalmoscope or make
attempts to train their eyes to see the wonders which it reveals. For
purposes of diagnosis the latter instrument is, in its way, just as
valuable as the former. In proof of this I would put before you the
following brief statement of information which may be obtained from
an ophthalmoscopic examination apart from anything else : —

(a) That a patient has suffered from syphilis, or that a child has
descended from parents who have suffered from that disease ; (b) that
a patient is suffering from tubercle, or that a meningitis of doubtful
origin is due to tubercle ; (c) that a patient complaining of headache
and sickness has intracranial pressure, and is probably suffering from
a cerebral tumour ; (d) that a patient apparently in good health has
"contracted granular kidneys," and will probably not live for more
than a year ; (e) that a patient is suffering from arteriosclerosis, and
will probably die of cerebral haemorrhage ; (/) that an individual,
apparently robust and well nourished, is suffering from glycosuria;
(g) that a patient has aortic regurgitation, and has probably suffered

The Teaching of Ophthalmology 49

from rheumatic fever ; (h) that a patient who complains only of dim*
ness of sight will ultimately develop locomotor ataxy or general
paralysis ; (i) that a child who has weakness of the back and who is
thought to be rickety or marasmic is of Jewish extraction, and will
shortly die of an affection of the ganglion cells of the brain and spinal
cord ; (j ) that a man who has been passed for military service and
graded for the fighting line is unable to see at night, and if put into
the trenches, or on sentry duty, will be a source of danger to his
fellows; (Jc) that a patient has an enlarged spleen and is suffering
from leucocytbsemia.

II. Medical practitioners of good standing often remark "that
they do not dabble in eyes, but send at once any of their patients
suffering from eye symptoms to a specialist." One is, moreover,
bound to admit that, under the circumstances in which they are
placed, it is wiser for them thus to confess their incapacity rather
than to profess to deal with what they do not understand. This is
not a position, however, which the rising generation of practitioners
should be encouraged to adopt. The General Medical Council
advocate, and many universities and other licensing bodies insist, on
the attendance of a medical student at a course of instruction in
ophthalmology before he presents himself for his Final Examination.
After three months' diligent attendance in an ophthalmic out-patient
department an average student, provided he has a good teacher,
should be able to recognise and treat many of the commoner and less
severe forms of eye disease. Knowledge so obtained will not only
add largely to his reputation, and be of benefit to his pocket, but
will also tend to decrease the overcrowding of ophthalmic out-patient
departments.

There are some eye affections about which it is a medical prac-
titioner's duty to be well acquainted. Anyone who practises
obstetrics should know how to prevent, recognise, and treat ophthalmia
neonatorum. It is a disease which is preventable and curable without
loss of sight if taken in time, and yet it is the commonest cause of
loss of sight amongst the inmates of blind asylums. This deplorable loss
of sight, dating from infancy, which renders those affected a burden on
the community for the whole of their life, is generally attributed to
the ignorance of mid wives. My own observations, extending now over
several years, show that the culpable person is more often a medical
practitioner.

The general and local symptoms of acute glaucoma cannot be too
often dinned into the minds of medical students, so frequently is the
eye affection, as the cause of the general disturbance in these cases,
overlooked, and the time when active interference would save sight
and relieve suffering allowed to drift away, hopeless blindness
resulting.

4

r>o E. Treacher Collins

III. Subjects are often included in an educational curriculum
not only for their intrinsic worth but also for some ulterior object
which their study is likely to effect. Thus the study of classics is
advocated because it improves the student's powers of expression, and
the study of Euclid because it stimulates the reasoning faculties. In
the same way the study of ophthalmology is of value to a medical
student, apart from its intrinsic worth, because it affords such an
excellent training in precision and accuracy of observation. In this
respect I claim it to be superior to that of any other branch of medicine.
As, however, my opinion on this matter may be thought to be a
prejudiced one, I will quote as an authority Dr. Hughlings Jackson,
who said that " he regarded it as the luckiest thing in his medical life
that he began the scientific study of his profession at an ophthalmic
hospital, because he had there the opportunity of being well disciplined
in exact observation."

Having thus summarised the advantages of a training in ophthal-
mology for medical students, I propose next to consider how best it
may be carried out. The methods usually adopted are, as in other
branches of medicine, by lectures and clinical demonstrations. Both
as a teacher and examiner I have always considered the capacity for
observation of greater merit than the mere remembrance of facts. For
the training of the capacity for observation practical demonstrations
and quizzing classes are far away better than systematic lectures. The
former are indispensable to the study of ophthalmology ; the reading
of a good text-book may well replace the latter. Indeed, the reading
of a good text-book is often preferable to listening to a bad lecturer.
With regard to text-books, some American students at Moorfields'
were much impressed when, on asking one of my former colleagues
"which was the best text-book for them to read," he turned round,
and with a dramatic wave of the arm to the crowd of out-patients
behind him, said, "There, that is the best text-book."

What is most desirable in teaching is to show typical cases, and
get their characteristic features firmly fixed in the students' visual
memory, so that they recognise them at once when they see them
again, recalling also associated facts which they have been told in
connection with them respecting treatment, etc.

The value of clinical teaching, like the value of a course of lectures,
largely depends on the teacher. No better judges exist of a teacher's
capacities than the students themselves. Some years ago, at a large
medical school, where the ophthalmic teaching was not all that it
might have been, the students were in the habit of publishing
in their journal facetious examination papers. One of the questions
which they set was, " Write all you learnt in the eye department on
the back of your visiting card."

All students should be encouraged to learn the use of the ophthal-

The Teaching of Ophthalmology 51

moscope, for the reasons already stated. For this purpose every
student should be advised to purchase an instrument of his own. The
mere possession of an ophthalmoscope excites a desire to be able to use
it, more especially if the expense to acquire it has been incurred by
the owner himself. When I examined at the Queen's University at
Belfast, we expected all the candidates for the M.B. to show their
capacity of seeing the fundus of the eye with the ophthalmoscope.
For this purpose we asked them to draw the arrangement of the
retinal blood-vessels as they saw them emerge from the optic disc.

To attempt to teach medical students, as a body, to correct errors
of refraction with spectacles is, I think, a hopeless waste of time.
Some students show special aptitude for this class of work — I reckon
about one in five. These should be encouraged and have facilities
afforded them. The capacity to correct errors of refraction is a very
valuable asset to a medical practitioner's capabilities. There is any
amount of it to be done, and the only raison d'itre for a "sight-testing
optician " is the inability of the medical profession to undertake the
whole of it. Uncorrected errors of refraction give rise to many aches
and pains, for which much physic is prescribed, their real cause being
overlooked. An old-fashioned general practitioner once remarked
"he did not think much of this astigmatism which was so largely
talked about nowadays. He had been in practice for twenty years
and had never met with a case."

In conclusion, I would strongly urge that an examination in
ophthalmology, conducted by those who have special knowledge of the
subject, should be made part of the Final Examination for a medical
qualification at all Universities and other licensing bodies. This has
been the custom at the Irish universities and colleges for several
years, and has more recently been adopted at Birmingham and
Liverpool. For three years I examined in ophthalmology at the
final M.B. at Queen's University, Belfast, and thereby came to realise
what an additional stimulus such an examination was to students
to work at the subject. In London no special examinations are held
at its University or at the College of Surgeons. An ophthalmological
question is occasionally set in the surgery paper. I know as a fact
that the surgeons who are examiners have sometimes had to cram up
the subject themselves before they are able to cope with the answers.
Nothing is so unfair and unsatisfactory for candidates as to be examined
by those who are imperfectly acquainted with their subject.

52 Freeland Fergus

LXL— THE PLACE OF OPHTHALMOLOGY IN THE
MEDICAL CURRICULUM.

By FREELAND FERGUS, M.D.

For about thirty years I have been engaged in teaching medical
students the elements of ophthalmology, and indeed I believe that I
have taught more students the elements of that subject than any man
who has ever lived in the West of Scotland. I do not think that any
part of my strictly professional work has been more interesting to me,
and therefore I hope I am not presumptuous in thinking that I am
entitled to say something about the place which ophthalmology should
have in the training of the present-day medical student. The time
at the disposal of the modern medical student is far too short to teach
him ophthalmology. No attempt should be made to go beyond those
beggarly elements which are essential if he is to be made a reliable and,
from the point of view of the public, a safe practitioner of the healing
art. The attempt to teach everything in a very limited space of
time only succeeds in making quite certain that the student learns
nothing. Any attempt to overload the ophthalmic course, which at
present is confined to twenty meetings, will be not only foolish but
disastrous. A teacher of the subject ought to make an endeavour
to instruct the pupil in those parts of the subject which are essential
to every practitioner. The student ought not to be taught so much
the treatment of ophthalmic cases as he ought to be made familiar
with the light which ophthalmic methods of examination throw upon
other conditions. You cannot teach much of such a huge subject in
a matter of twenty lessons. No doubt this limitation is a very absurd
arrangement — nearly as absurd as the syllabus of the Triple Qualifica-
tion Board in Physics. There has recently been a re-issue of that
document, and I venture to say that no man of average ability could
master the subjects therein specified in a shorter course than one of
two years.

When I was a student in Holland I found that ophthalmic studies
were very much more prominent in the training of medical students
in that country than they were or are in our own. During three
years of his course the Dutch medical student had at that time to
attend a certain amount of ophthalmic instruction which was very
largely clinical. Personally, when I was teaching large classes I
regarded the twenty meetings as totally inadequate, and as a matter
of fact the class met on four days a week during a ten weeks' session,
giving, roughly, about forty meetings, or twice the amount demanded
by the Regulations. Of that course one-half at any rate was devoted
to clinical work and the other half to lectures. The first half was

Ophthalmology in the Medical Curriculum 53

almost entirely a clinical course and included diseases of the con-
junctiva and cornea ; diseases of the eyelids and lachrymal passages ;
diseases of the uveal tract, including iritis, choroiditis, glaucoma (at
that time I thought I had some idea as to the pathology of glaucoma,
at present I have got rid of any such notion) ; cataract ; diseases of
the retina and optic nerves. Every effort was made to illustrate the
relationship between local conditions of the eye and systemic disease.
I have never conducted a clinic without laying special stress on the
study of diplopia, for I regard this subject as being of very great
importance to all classes of practitioners. Every student was also
trained in the examination of pupillary reflexes.

The second half of the course, which half formed the subject of
lectures chiefly, with, of course, a little clinical practice as opportunity
afforded, included the following: — First, white and coloured light,
with a fairly extensive description of the phenomena of reflection and
refraction, and a discussion of lenses and prisms as remedial agents.
Second, the refraction of the eye. Third, range of accommodation,
both absolute and relative. Under this last heading was also given
a short account of the metric angle and of the relationships of the
range of accommodation to convergence in emmetropia, hypermetropia,
and myopia. Fourth, the sense of sight divided into (a) the sense of
form and visual acuteness ; (b) the sense of colour ; (c) the sense of
light; (d) the sense of projection; (e) the estimation of distance.
Fifth, the field of vision for white and coloured lights. In this section
perimetry and hemianopia were both discussed. Lastly, the affections
of the extrinsic ocular muscles, including squint. That may seem a
very ambitious course to be undertaken in forty meetings — twenty
clinical and twenty lectures. In addition to that, numerous exercises
were always prescribed on the physical part of the subject, and a very
large number of the students took part in this voluntary work. Now
I do not argue that a course of this kind, limited though it be, is one
adapted for all medical students ; I know it is not. You cannot make
ophthalmic specialists in twenty meetings of a class — the minimum
number required by the present ordinances; and the question then
comes to be, What information in a short course can you give that
will be of advantage in after-life1? And here let me once and for all
enter my protest against two things. The first is that the student
should receive only twenty lessons in such a very important branch
of his training. It is far too short. The Dutch limit is a much better
one. I wish also to enter a very firm protest against an abuse which
has in some places crept in, namely, the substitution of pictorial
representations, either by diagrams or by lantern projection, for actual
clinical work. The ordinances have shown a development in the right
direction. At least fourteen of the twenty meetings of any qualifying
class must be clinical, that is to say, I presume, they must be held in

54 Freeland Fergus

a hospital or in an ophthalmic clinic, for the purpose of examining
patients, and not in a lecture-room. If a student has attended lectures
these will, to the extent of six, count in making up the twenty
attendances. Thus the ordinances give prominence to the idea that
the courses for general practitioners as distinguished from specialists
must he essentially clinical, and therein I think they are quite right.
I wish, however, that they had gone much further and made the
clinical training in ophthalmology a more extensive one. I imagine
that if it were found that a particular course was largely or pre-
dominatingly a lecture course and not actual clinical work that that
course would, if the question were raised, be found not to qualify for
medical graduation. Not long ago I came upon some students who
had passed through their ophthalmic course but had never used an
ophthalmoscope and had never even seen it employed by anybody
else. They had, on one or two occasions, been shown pictures of the
fundus, but that was all. Such a course seems to me a farce. It is a
pure contradiction in terms to call a performance of that kind clinical
work. So much for the negative side, and now for the positive.

What, going on my own experience, such as it is, do I regard as
the subjects which should be taught in a clinical class of ophthalmology
to men and women who are going to undertake the responsibilities
of the profession of medicine in general practice % Tuition in ophthal-
mology I think has a twofold object. In the first place the student
ought to learn the signs and symptoms of the more important
ophthalmic diseases. He ought also, so far as is practicable, to study
those which are symptomatic of diseases of the general system; and
lastly, and very importantly, he ought to be able on leaving his
ophthalmic course to use such instruments as are of special value in
investigating diseases of the eye, particularly of those diseases which
are related to systemic ailments. To speak quite plainly, I would
not let a man enter the medical profession unless he could use an
ophthalmoscope almost with the same facility as he uses a clinical
thermometer. These are the ends and objects which I steadily kept
in view in dealing with students, and the rest of this short communica-
tion will simply be an elaboration of this aspect of the subject.

Personally, I would not regard a man as fitted to enter the pro-
fession of medicine unless he could use an ophthalmoscope to examine
the fundus. And here again I would limit my ambition. It is the
use of the ophthalmoscope as an instrument of medical research rather
than of ophthalmic investigation that is of importance. I think an
effort should be made to teach the student to recognise the healthy
optic nerve and to know optic nerve hyperemia, optic neuritis, and
optic nerve atrophy when he sees them. I would also make quite sure
that he could recognise retinal haemorrhages and the various features
which are characteristic of retinitis albuminurica. It would be well

Ophthalmology in the Medical Curriculum 55

also that he were able to recognise a case of choroiditis. Further than
that, I would not insist on his knowing much of the ophthalmoscope.
He ought, of course, to be able to examine the crystalline lens as
to its transparency. It must be remembered, however, that as the
ophthalmoscope is an optical instrument a student will be at a great
advantage if when using it he has a certain knowledge of physiological
optics. It is not a very difficult matter to impart to him the required
amount. Just start with a statement, as I| generally do, that when
a person sees a portion of the fundus of an eye which he may be
examining, that portion and its image on his retina must be conjugate
foci. A few minutes with a blackboard and a piece of chalk in a
lecture-room some morning will teach a student all that he needs to
know of this matter. Incidentally there will be brought before his
notice the various conditions under which the patient's retina and his
own may not be conjugate foci, and the student will be gradually led
to see how these hindrances may be removed by the use of appropriate
lenses. And thus the teacher incidentally gives the student all the
elementary instruction which I think should be imparted as to the
essential nature of emmetropia, hypermetropia, and myopia. I always
introduced the study of the refraction of the eye in connection with
ophthalmoscopic examinations. The definitions which I have given
for many years are as follows : — If a portion of the retina be the source
of light, luminous by reflection, the pencils emergent from the cornea
are approximately parallel in emmetropia. Under the same circum-
stances, in myopia, the emergent pencils are convergent, while in hyper-
metropia the emergent pencils are divergent. At once the student
sees what is required to overcome the divergivity in hypermetropia
and the convergivity in myopia. No attempt should be made in the
ordinary clinical course qualifying for graduation to endeavour to
make the pupil an expert refractionist. It cannot be done in the time
at his disposal, and all that you will manage is to take his attention
away from work which concerns general practice much more closely.
I have had special courses for instruction in refraction-testing and in
the making of other physical measurements, but these matters, I think,
should be rigidly excluded from a course specially destined for those
who are going to be general practitioners. A mere indication of the
methods employed should be all that is given. I regard it as entirely
wrong to make any considerable portion of the clinical work which
the student must do, under the present ordinances, refraction-testing.

As indicated above, I always take care both in the lectures and in
the clinic, particularly in the latter if suitable material be available,
to instruct students as to the examination of persons suffering from
diplopia. It would certainly in an elementary course be a mistake to
dwell on the binocular field of fixation. I do not think that it is even
justifiable to treat at any length, if at all, of the measurement of the

36 Freeland Fergus

positive and negative ranges of convergence, but I do say that a man
would be failing in part of his duty if he did not teach a student the
differential diagnosis of diplopia so that the muscle, or group of
muscles, affected by the lesion may be well ascertained. I have never
found any difficulty in teaching students the study of diplopia in terms
of rectangular co-ordinates. Modern medical students all but invari-
ably have some acquaintance with the elements of co-ordinate geometry.
It lightens a student's work immensely if he is told that the fixation
point is the intersection of the abscissa with the ordinate and that
the position of the false image may be resolved into horizontal and
vertical components. Moreover, such a method of presenting a case
allows the observer to estimate from time to time what progress is
being made by the patient, for at a constant distance the value of the
vertical and horizontal components can of course be ascertained as
often as may be deemed necessary. For my elementary students I
always have divided cases of diplopia into two groups, namely, those
in which there is no vertical component, or, at any rate, one that is
negligible, and those having a marked vertical in addition to a
horizontal component.

I think it is also necessary to detail the chief facts as regards the
development of strabismus. There can be no doubt whatever that in
most cases of ordinary concomitant squint occurring in young children
the onset of amblyopia in the squinting eye can be prevented and good
vision insured for both eyes by rational and timely treatment. I
imagine there is no ophthalmic surgeon of any experience who has not
often met cases hopelessly and permanently amblyopic in which the
patient, when a young child, was taken to a general practitioner and
his parents or guardians told that it would come right as the child
grew older. The intelligent exposition of a fallacy such as that cannot
but be of service to the public. I have always found it most easy to
explain squint, for I start with the definition that when the visual
axes do not intersect at the point of fixation then there is squint.
From that it is very easy to detail the factors which may cause a
want of intersection. I think it would be improper to elaborate to
any extent the study of muscular anomalies in a course specially
destined for general practitioners, but a careful explanation of the
damage that will inevitably be done by neglect in the case of con-
comitant squint in a young child would lead all conscientious general
practitioners to take proper measures when they are brought face to
face with such a contingency.

It goes without saying that all medical practitioners should be
taught carefully and well how to test pupilary reflexes.

It is equally true that every medical student should be taught how
to take the visual acuteness. Personally, I think Landolt's test is
much the best, but it does not seem to have caught on either in this

Ophthalmology in the Medical Curriculum 57

country or in the United States of America. It has many advantages,
an especial one being that it is equally useful for the literate and
illiterate, for those who know the lioman characters, for those who
only know the Hebrew or Teutonic characters, and for those who
know none. It is a universal test suited for every intelligent member
of the human race. It is almost absurd to have to say it, but every
medical student should be warned that in stating a visual acuteness
he should invariably say, visual acuteness admitted is so and so.
That is all that he or anybody else, apart from the examinee, knows
of the matter.

I would not, in an elementary course, give any attention to the
various methods of testing the light sense. No doubt that is a matter
of considerable importance, but I do not think that any general
practitioner is likely to have the apparatus necessary to carry out
such an investigation. Probably, although not so certainly, the same
line of argument applies to the testing of the colour sense. That is
a very special part of ophthalmic work. Investigations of the colour
sense, however, do not as a rule throw much light upon disease, except
perhaps in the well-known case of central colour scotoma occurring
in such conditions as tobacco amblyopia, and the occasional case of
transposition in the field of vision of some of the colours in cerebral
tumour. These are matters which may, however, very properly be
discussed under the heading of perimetry.

There can be no doubt whatever that every medical student should
be fully instructed in the methods of using a perimeter both for white
and coloured lights. It is an instrument which gives valuable aid to
the physician, to the surgeon, to the ophthalmic surgeon, and to the
general practitioner. I do not perhaps lay the same stress upon
teaching a student the use of the perimeter as I do upon teaching
him the use of the ophthalmoscope, but it is an important instrument,
with the use of which students should be made thoroughly familiar.
It is perhaps quite true to say that there is no modern text-book on
medicine where the perimeter is not mentioned. The same is largely
true of text-books on surgery, which facts are tantamount to an
admission that the instrument is of extreme importance in the
examination of a large variety of diseases.

In the public interest I would lay special stress on a student
acquiring a competent knowledge of the appearances and symptoms
characteristic of glaucoma, both acute and chronic. Many an eye has
been lost because a young practitioner has failed to realise what he is
dealing with. There is no ophthalmic surgeon of the older school
who has not seen that again and again. A case may be, by a prac-
titioner who has been ill trained, carelessly diagnosed as incipient
cataract, and special advice may not be sought till it is much too
late to be of any practical value. On the other hand, an intimate

58 Freeland Fergus

knowledge of the particular features of glaucoma would often lead a
practitioner to hold his hand before using a mydriatic. I, for one,
think that every student should be warned of its danger and should
be sufficiently instructed by the practical examination of actual cases
to know the disease when he sees it. No doubt there are many
interesting points in the discussion of the pathology and treatment of
glaucoma, but surely that is scarcely the thing to give to an under-
graduate in medicine.

Wounds of the eyeball will certainly be seen by the student during
a good clinical course. He ought to be informed as to the danger
of wounds of the eyeball in their connection with the possibility of
sympathetic ophthalmitis. He ought to be taught the treatment of
simple wounds of the eyeball which are not complicated by the
presence of a foreign body in the eye, and he should also be carefully
instructed as to the diagnosis of foreign bodies in the eyeball.
Certainly, wounds of the eyeball should be properly brought to his
attention, but unquestionably the best way of doing it is to let him
see them as they occur in the ordinary clinic. A student will learn
far more in a clinic where several cases of eyeball wounds may be
seen daily than by spending a month or two in reading or in hearing
lectures about them. Lectures as a method of teaching a clinical
subject are an entire mistake.

Little remains to be said except regarding those diseases which are
usually called externals. I refer to the various forms of conjunctivitis,,
diseases of the cornea, iritis, and diseases of the lachrymal passages
and to those of the annexa of the eye.

Thirty years ago, acting, as I believed, in the best interests of the
public, I wrote a letter to Dr. J. B. Russell, then Medical Officer of
Health for the City of Glasgow, saying that both ophthalmia neo-
natorum and trachoma should be made notifiable diseases. I got
back a letter to say that he saw no occasion for any such action.
Within recent years they have very properly come under the auspices
of the Public Health Authorities. That means that they are both a
danger to the public health. Students should, in the public interest,
unquestionably be taught the diagnosis of such diseases, and that from
the actual inspection of cases and not from text-books or pictures.
Further, the other common forms of conjunctivitis should be illustrated
by suitable cases. I do not say accurately diagnosed, for the diagnosis
of most cases of conjunctivitis depends on the oil-immersion lens. In
1891 I introduced into my own clinic the rule of having all cases on
which it was proposed to operate competently investigated by a
bacteriologist. Since that day I have not seen a suppuration after
cataract extraction. I have seen one after a needling. Shortly
thereafter, my colleague and friend, Dr. Lewis M'Millan, took up
the subject in the ordinary everyday clinic, and thus from 1891 the

Ophthalmology in the Medical Ctirriculum 5&

oil-immersion lens has been used daily for all cases of conjunctivitis.
You cannot possibly expect a general practitioner to examine con-
junctival secretion, notwithstanding the fact that it is a vastly
important investigation. That is no reason, however, why he should
not be taught to recognise ordinary conjunctivitis and the differentia-
tion of that condition from ophthalmia neonatorum, from trachoma,
and even from that special form which is still, for the most part, called
phlyctenular. I always insist that a student shall realise that a con-
junctivitis is a septic infection of the conjunctival membrane. The
microscope or cultures may show him, if he has time to apply such
methods of research, what particular organism he is dealing with, and
it may well be worth his while to take pains to make such inquiries,
or to have them made for him, but not for a moment should he lose
sight of the fact that an inflamed conjunctiva, like inflammation of any
other mucous membrane, is most frequently micro-organic in origin
and must be treated on precisely the same principles and from the
same point of view as any other inflamed mucous membrane. No
application of a so-called antiseptic is of the slightest avail, for, up.
till now, we have not found anything which may be said in general
terms to kill the organism without at the same time killing the corneal
or conjunctival tissue. The only exception to this general rule which
occurs to me just now is the influence which zinc sulphate undoubtedly
has in the removal of the Morax diplobacillus. One point should
always be emphasised, and that is that a case of iritis is apt to be
mistaken for acute conjunctivitis. I invariably make students, in the
presence of a case of ordinary catarrhal conjunctivitis, examine the
pupilary reflexes. Most cases of iritis can be treated perfectly well
by a general practitioner, excepting those in which there are great
oscillations in tension ; such cases should be in the hands of an
ophthalmic surgeon.

Regarding iritis, the important point to get the student to realise
is that it is not primarily a disease of the iris but is the expression of
an infection. The first duty of the practitioner in charge of such cases,
be he a general practitioner or an ophthalmic surgeon, is to find out
the nature of the infection. That is the first step towards treatment.
Thus inflammation of the iris while forming a condition which
requires the closest attention of the practitioner who may be attending,
the patient, sometimes throws considerable light on other diseases of
which the patient is the victim.

As regards the cornea, there are some conditions which I would
insist upon a student knowing — ulceration with or without hypopyon,
suppuration, interstitial keratitis and cicatrices, such as nebulae or
leucomata resulting from local diseases of the membrane. A student
certainly ought to be instructed as to how to diagnose ulceration of the
cornea and interstitial keratitis. Here, again, the oil-immersion lens

•60 JVilliam George Sym

may come into use. On one thing I am quite clear, and it is that the
oil-immersion lens is sometimes of particular use in prognosis. Given
a pneumococcal infection, the prognosis is much more grave than in
many other conditions. The plain fact is that the practising physician
can, if he likes, get the greatest possible assistance in the way of
accuracy of work from modern pathology. I do not say that I would
insist on every student who is going to be a general practitioner going
through a special course of ophthalmic bacteriology : certainly not. It
would be wrong to occupy any large proportion of the time at the
student's disposal with any such study, but if a student attends a
good clinic for some months he cannot but pick up some knowledge
of ophthalmic bacteriology from the everyday practice which he sees,
and, further, it is satisfactory to know that the present-day medical
student receives competent training in bacteriological work in his
pathological course and therefore has little, if any, need of special
training in ophthalmic bacteriology.

No lasting or definite progress is likely to be made on anything
else than a strictly scientific basis. Ophthalmology in its true sense
ought to be the practical application of physics, pathology, and
-physiology, with something also of the therapeutic art.

LXII.—THE TEACHING OF EYE DISEASES IN THE
CURRICULUM.

By WILLIAM GEORGE SYM, M.D., F.R.C.S.

As the matter presents itself to my mind, the principal danger to be
avoided is the tendency to teach the subject of diseases of the eye
(and all such special subjects) as separate entities and not as depart-
ments of medicine and surgery, and to inculcate in the student a
specialist's knowledge rather than a general practitioner's knowledge
of the subject. Notice that I speak meantime of the student
proper. I ought — I wish to speak for myself, not to preach to others
— to regard my class-teaching as a portion of the class-teaching of
surgery ; the general surgeon cannot overtake all the branches of
surgery (for more reasons than one), and to him is relegated general
surgery, to me the ophthalmic aspect of surgery, to another the
gynecological, to another the aural. I am not expected to teach the
more erudite developments of ophthalmology to the student, nor is it
desirable that I should endeavour to transform him into an oculist
before he has even become a licensed practitioner of medicine and
surgery. That, in brief, is what I look upon as my duty from the
negative point of view; from the positive, it is to teach him such
portions of the subject as he is likely to require to know in any circum-
stances, such as he might meet with on the day on which he goes into

The Teaching of Eye Diseases 61

general practice, leaving for further study the more precise and
intimate details of examination, of work, and of investigation. Let
me give a simple example : I endeavour to instil into the student an
understanding of what the expression "error of refraction " signifies,
of the reasons for which such error is of high importance in the
economy of the eye itself and in that of the general health, of the
signs and symptoms which point to such a condition, and of the more
ordinary means by which such error may be recognised, measured,
and treated ; but I do not bamboozle a man who has still to pass his
Final Examination in Medicine with details as to the first principal
point of the eye, or the theory of the ophthalmoscope, nor do I expect
him to be able to estimate with precision the degree of fault in a
given case.

I therefore agree in the main with the sound good sense of the
authorities who have restricted the various teachers in regard to the
frequency of attendance on lectures and demonstrations, and to the
scope of the teaching — that they may make sure that on the shoulders
of an already heavily-weighted student a burden is not laid which he
is unfit to carry. The course of twenty-four lectures and demonstra-
tions, with a little tutorial instruction in the ophthalmoscope, is,
I think, neither too short nor too long for the purpose. As to
the ophthalmoscope — using that instrument as an example of several,
the mode of employment of which ought to be more or less familiar
to the student — what is the right course? It is obvious that to
become an expert a man would require a great deal more instruc-
tion than it would be right to inflict upon him in a class adapted to
the needs of every student. The average practitioner, even one in
general practice, rarely, I think one might say almost never, uses
an ophthalmoscope, but I do not consider that when one has said that
one has closed the question, for if he were better able to employ it
perhaps he would more frequently do so. Still, when all is said and
done, the ophthalmoscope will remain, nineteen times out of twenty, a
specialist's instrument, simply because the efficient use of it demands
incessant practice, and that is what the family practitioner cannot
give to it. I consider our present plan quite a suitable one : we teach
the student how to use the instrument, to do so sufficiently to under-
stand how the tool is worked : its more intimate manipulation he
must postpone till after graduation.

The weak point about the present teaching arrangements is this :
I consider that with the class recurring during each of three sessions
per annum, one is so kept at the grindstone that there is neither time
nor strength for higher teaching in the subject. (Of course during
war time there are no post-graduates to teach.) I wish it could be
arranged that during two of the sessions one of the colleagues lectured
and he was set free for senior work in the third, and similarly that

•32 IVilliam George Sym

the other had senior teaching during one session (not the same session
as his fellow), and taught students in the other two. That plan would
give quite sufficient facilities, I should suppose, for the students, and
yet would afford some relief, some variety, some encouragement to the
teachers themselves.

Another point on which I must dwell for a moment is that of the
examination. No teaching of ophthalmology can be satisfactory unless
the student is subject to examination.

The fear o' hell 's a hangman's whip
To haud the wretch in order.

We have allowed some other universities to get before us in this
matter; for years I have been examiner in ophthalmology for the
Final Examination in Medicine, first in the Royal and now in the
National University of Ireland. At one time it was considered
sufficient in our own university that when he was passing through the
sieve of clinical surgery the candidate should be shown a patient from
the eye department and asked for a diagnosis by the ordinary
examiner in clinical surgery. When I became university lecturer I
declined to have any dealings with so palpable a fraud, and refused
to supply from my wards patients for the surgeon to employ in the
examination of students. These, probably, being fresh from a class on
diseases of the eye, knew a good deal more about the matter than
the examiner, who never dealt with such cases in his practice from
year's end to year's end. I consider it eminently desirable that the
student should be examined in the subject, but the examination should
be a fair and honest one.

The plan which has been hit upon for the avoidance of the difficulty
is that our class certificates are held to indicate that the student's
knowledge has been found to be sufficient to allow him to escape
further examination in that particular subject. I consider this plan
quite unsatisfactory, first because it violates the principle that no
candidate should be rejected in any subject except by the agreement
of two examiners, since it throws upon the teacher alone the
responsibility of passing or rejecting; and secondly, because that
mode of dealing with class certificates is limited to these subjects.
Would the physicians, may I ask, be satisfied that a class certificate
(popularly known as a " D. P.") of attendance at Dr. Z.'s class should
clear a man from any examination on practice of phj^sic as an integral
part of his Final Examination'? Why then should this be done as
regards diseases of the eye and of the ear?

I have suggested before, and now suggest again, a method by
which the difficulty may be got over ; that to examine every student
in diseases of the eye, the ear and throat, and in diseases of children,
would entail a heavy strain on the candidates, and a serious

The Teaching of Eye Diseases 63

increase in the cost of the Final Examination. My plan is this :
Let it be assumed for the moment that each candidate is at pre-
sent examined on three patients in clinical surgery. Divide the
candidates into five groups of equal numbers — A, B, C, D, E — by lot,
or in any other manner which would completely obviate any candidate
knowing until the day of his examination into which group he fell.
Every candidate would now have two cases in clinical surgery, and
those in sections A and B would have three, and they would have no
"special " subject; those in section C would have two clinical surgery
cases and be sent to the eye department for their third ; those in
sections D and E similarly with diseases of the ear and throat and
children's diseases. Thus every candidate would require to be ready
in every subject, yet the actual examination of any one would be
limited, the labour curtailed, and the examination be conducted by a
person really familiar with the subject in which he was an examiner.

What value, for examination purposes, ought to be placed upon the
special subject? I do not suppose that anyone would suggest that,
should a candidate do well in clinical and systematic surgery he should
be stopped altogether if he came down badly in eyes or in throats, but
such a contingency very rarely happens in my experience elsewhere.
If a man is good in surgery he is at least fair in ophthalmology ; if he
is bad in ophthalmology he is no better than very moderate in surgery.
In the university in which I examine, the value of ophthalmology,
relatively to surgery, is (I must not give away secrets) in the pro-
portion of something like one to four or so. It is so adjusted that the
risk of a good surgeon being stopped because he is a bad ophthal-
mologist is reduced nearly to zero when the values are added, and also
that a good ophthalmologist may have a figure or two to spare to help
to keep his feet clear of the bar in the larger subject. In practical
experience it is not found to be true that that favourite bugbear of the
general surgeon is of any real importance, the danger, namely, that
the specialist may rate a knowledge of his subject too high and expect
too much of the candidate. Such an error is not found to exist. In
speaking thus of numerical values I speak in complete ignorance of the
methods used in the Final Examinations here ; that is a matter regard-
ing which I have never made any inquiry, and I have no information
whatever. But in the estimate of a man's position in reference to
knowledge of his work, to justify his receiving or being refused
licence to practise, a moderate acquaintance with these two branches
of surgery, eye and ear, ought to have a definite value, and to have
it because they are parts of a big subject, parts which in point of fact
■are excluded unless they are in some such way included. For one must
recognise that the so-called general surgeon is a specialist in his own
portion of surgery just as I am in mine ; his scope may be wider, but
the essential fact is the same in both instances.

64 J. V. Paterson

LXIIL— THE TEACHING OF DISEASES OF THE EYE
TO MEDICAL STUDENTS.

By J. V. PATERSON, F.R.C.S., Ophthalmic Surgeon, Royal Infirmary.

Speaking as a teacher of considerable experience I would consider the-
following points of special importance : —

1. When should the students attend the class on eye diseases'?

2. How much of the subject should they be taught, and what time
is adequate for the proposed instruction 1

3. Should the student require to pass a qualifying examination,
and what should be the type of examination if such a test is made
compulsory ?

As to 1, I am very strongly of opinion that the students ought to
be as far advanced as possible in their study of general medicine and
surgery before they begin the study of eye diseases. If they have not
a reasonable knowledge of these subjects the teacher is necessarily at a
great disadvantage and many of the most important clinical facts in
ophthalmology cannot be seen in their proper bearing and perspective,
e.g. changes in the pupils, optic nerve and retinal changes depending
on diseases of the nervous system or on circulatory or renal trouble.
Diseases of children should also be studied before eye diseases, as eye
conditions of great importance occur so frequently in children and local
treatment is so often of secondary value when compared to general
re-establishment of the child's health.

2. What should students be taught1? They must be taught to
recognise the commoner eye ailments, to know what cases they can
safely and efficiently treat and those which they ought to send
promptly to an eye hospital, or to a specialist for consultation. The
making of a diagnosis implies thorough training in how to examine
an eye and how to note the points on which diagnosis is based and
estimate their value.

The anatomy and physiology of the parts have usually to be
re-stated from the clinical point of view. Teaching must be mainly
clinical and the students must closely examine a large number of cases
so that they have a good opportunity of becoming really familiar with
the common external eye diseases, as, for example, conjunctivitis, hypo-
pyon ulcer, phlyctenular keratitis in a child, interstitial keratitis, iritis,
cataract, glaucoma, squint. Injuries of the eye form an important
group of cases and must be dealt with in considerable detail.

In dealing with the question of defective vision after injury the
teacher should, in my opinion, do his best to enlighten the student on
the question of visual efficiency in workmen.

Certain of the more abstruse conditions on which great stress is

The Teaching of Diseases of the Eye 65

laid in many of the text-books should, in my opinion, not bo discussed
in any great detail. A good example of this is the differential diagnosis
of the various muscular palsies.

In the case of medical students it is enough to demonstrate a case
of diplopia and to call their attention to the significance of diplopia in
medical diagnosis.

With so little time at his disposal I do not think the wise teacher
will show his students a large number of the major eye operations, but
a few typical operations should be shown in order to indicate to the
students the scope and therapeutic result of operative treatment on the
eye. Minor operations on the lids, tear passages, etc., will be of daily
occurrence in the out-patient room, and with the technique of these
the student should have the opportunity of becoming thoroughly
familiar. A certain amount of systematic instruction must be given
in order that the student may be able to piece together what he has
learned from the cases demonstrated and so obtain a clear idea of the
subject as a whole.

The programme of teaching so far indicated seems varied and
somewhat lengthy, but, given plenty of material, the teacher should be
able to overtake his subject in a single term with meetings three times
a week, i.e. about twenty-seven meetings in all.

The size of class that can be efficiently dealt with when so much
of the teaching is done by demonstration of actual cases will, in my
opinion, be limited to forty at most.

So far I have not spoken of a part of the teaching quite as essential
as that which I have been discussing. I refer to the training in the
use of the ophthalmoscope. For this training the students attend
tutorial classes in the evening in sections of eight to twelve. Each
section meets six or seven times, but the number of meetings might
with advantage be increased to eight or nine.

No part of the body affords so good a field for accurate clinical
study as the fundus of the eye, and training in the use of the ophthal-
moscope has, in my opinion, a very special educational value for the
student apart from the help in diagnosis which it may afford him in
his work as a practitioner.

In these tutorial classes the students also receive elementary lessons
on errors of refraction and in the method of estimating and recording
the amount of a patient's vision. The methods of taking and recording
the field of vision are also demonstrated.

No attempt whatever should, in my opinion, be made to teach the
students how to prescribe glasses, as this can only be learnt by long
practice in an eye clinic.

This tutorial instruction should be made compulsory.

With regard to the special conditions prevailing in Edinburgh,
there is no doubt that the teaching in the eye department would be

5

66

New Book

improved if freer use were made of the help of the assistant surgeons.
In the absence of the clinical tutors on war service, Dr. Traquair has
been good enough to undertake the tutorial teaching, at great personal
inconvenience. In normal times, when the number of medical students
is much greater than at present, the assistant surgeon should certainly
have a share in the teaching of the students, more especially in the
demonstration of cases to the students in smaller groups.

3. With regard to the question of examination, I would be content
if the students were made to realise that they cannot be granted a
class certificate by the teacher unless they really have a satisfactory
knowledge of diseases of the eye.

The present method of demanding 30 per cent, on a class examina-
tion paper seems to me to be something of a farce and a higher standard
should be required. An adequate test of a student's knowledge would,
I think, be best made by a written paper followed by a short oral
examination.

NEW BOOK.

By Lewis E. Yealland,
Macmillan & Co. 1918.

M.D.
Price

Hysterical Disorders of Warfare.
Pp. xii. + 252. London :
7s. 6d. net.

With Boswellian frankness Dr. Yealland has laid bare his method of
removing gross hysterical manifestations ; and if the end of the treat-
ment of these patients be to terminate the paralysis, tremor, contracture,
or other obvious symptom, his success has been considerable. He has
shown that the one thing necessary is unlimited self-confidence on the
part of the physician, and that, granted this, it matters not what means
are employed. This confidence he communicated to the patient through
the medium of an electric battery and of a somewhat pompous method
of speech, the details of which have been set out with a candour that
is probably without parallel in medical literature. The result has
been that every patient has been cured of his main symptom at one
sitting. Almost nothing, however, is said about the subjective symptoms
from which these patients suffer — the insomnia, headache, depression,
etc. — except that the removal of the physical disabilities produced an
improvement in the mental condition — a statement often made, but of
more than doubtful truth. From the experience at other hospitals it
seems clear that the cure of an hysterical symptom is not the same
thing as the cure of the patient. Apart from this we cannot think that
the methods described in this book are to be commended. Surely at
this stage of knowledge of hysteria it is indefensible to push electrical
treatment to the length of throwing the patient into convulsions or
causing him to faint (pp. 135 and 200). The use, too, of the wire

New Editions 67

brush as an instrument of persuasion might well be dropped. That
every hysterical disability can be removed at once without torture has
been demonstrated at most neurological hospitals, and it almost seems
that an official pronouncement on the subject might be given with
advantage. Neither do we think it commendable that pomposity of
speech, if necessary at all, should be employed deliberately to bamboozle
the patient. " ' Do you understand what I mean % ' ' Yes, sir,' he said,
' I think I do ' — apparently confused. He began to demonstrate to me
that he understood. ' That is splendid,' I said ; • flex your right thigh
— flex it ; flex it.' He became confused at such an order." He did
not, in short, understand at the time that he began to demonstrate
that he did understand, and Dr. Yealland knew that he did not, and
the whole incident was designed to show the patient how much inferior
he was to Dr. Yealland intellectually. This is not psychotherapy.
These patients are anxious to learn and can be taught much that will
be useful to them in after life ; but if this is the idea of psychotherapy
that obtains at Queen Square it is small wonder that Colonel Farquhar
Buzzard should write in a preface to this volume : " There seems no
good evidence forthcoming to support the view that any therapeutic
measures can alter the temperamental instability of these patients."
Assuredly the methods, physical and psychical, pursued at this hospital
in the treatment of hysterics are not likely to make them less unstable.

NEW EDITIONS.

Eye, Ear, Nose, and Throat : A Manual for Students and Practitioners.
By H. C. Ballenger, M.D., and A. G. Wippern, M.D. Second
Edition. Pp. vii. + 524. With 188 Engravings. Philadelphia
and New York : Lea & Febiger. Price $3.50.

Our knowledge of the diseases of these organs has progressed so
rapidly since the first edition of this book was issued that it has been
found necessary to rewrite almost every chapter in this volume. Dr.
Wippern, who is responsible for the section on the eye and its affec-
tions, treats his subject very methodically but in too technical a fashion
for either students or practitioners. The different elements which
compose the eye are taken seriatim, their anatomy described, and then
the diseases affecting them gone into. It is curious that no mention
is made of tobacco amblyopia, though this must be a fairly common
condition in a race of smokers like the Americans.

The chapters on the ear, nose, and throat, from the pen of Dr.
Ballenger, are written in an easy, pleasant style and more suited to the
needs of students and practitioners. The book concludes with a series
of prescriptions which the practitioner will find very useful.

68 New Editions

Infection, Immunity, and Specific Theraxry. By John A. KOLMKR, M.D.,
D.P.H., M.Sc, Assistant Professor of Experimental Pathology,
University of Pennsylvania. Second Edition. Pp. xiii. + 978.
With 143 Illustrations. Philadelphia and London : W. B.
Saunders Co. 1917. Price 30s.

In these days of serum and vaccine therapy the enormous amount
of work which has been done on subjects relating to infection and
immunity becomes of very practical interest. Dr. Kolmer has, we
think, been exceptionally successful in providing the student and
practitioner with an admirably clear exposition of the extremely com-
plicated problems with which his book deals. After a very practical
section on the laboratory methods required for immunological work,
the great questions of infection and immunity are discussed in detail,
and plenty of space is devoted to the consideration of vaccines, anti-
toxins, and the agglutinin, precipitin and complement-fixation reactions.
The chapters on anaphylaxis strike us as particularly good, and here,
as elsewhere in the volume, Dr. Kolmer moves easily among conflict-
ing theories, preserving a judicial mind himself and leaving a clear
idea of the subject in the mind of the reader. The section on specific
therapy is also very well done, and the practitioner, who is most
interested in the practical application to medicine of much of the
scientific research work described in the volume, will find many useful
hints regarding the employment and dosage of serum and vaccines,
and also a chapter on chemotherapy chiefly devoted to salvarsan.
The book ends with the syllabus of an interesting experimental course
in infection and immunity, which will be found of value by teachers of
the subject, and which is so arranged that it could be probably carried
out by an industrious and conscientious student with very little help
or supervision. A word of praise is due to the illustrations, all of
which are appropriate and helpful. We consider that Dr. Kolmer's
book cannot fail to be of great assistance to all laboratory workers,
that it is worthy of the careful study of all practitioners interested in
specific therapy, and that it is an absolutely necessary addition to the
library of all fever hospitals.

Foods and their Adulteration. By Harvey W. Wiley, M.D. Third
Edition. Pp. xiv. + 644. London: J. & A. Churchill. 1917.
24s. net.

Although not intended specially for medical men, and in no way a
guide to clinical dietetics, Dr. Wiley's book on Food Adulteration is
full of interest. It is a very complete and exhaustive account of its
subject, and, especially at the present time, when camouflage has
extended from howitzers and sea-going ships to pastry, butter, and

New Editions 69

puddings, a great many useful hints can be gleaned from it by those
who are incurious about food adulteration on the commercial scale.
There are chapters on infants' and invalid foods and on vitamines
which have a more strictly medical bearing than the rest of the
volume, and the book as a whole will be found as trustworthy and
complete an exposition of the subject of foods and their composition as
any available.

A Text-Book of Obstetrics. By Barton Cooke Hirst, M.D., Professor
of Obstetrics in the University of Pennsylvania. Eighth
Edition. Pp. 863. With 715 Illustrations. Philadelphia and
London: W. B. Saunders Co. 1918. Cloth, 21s.

A work which has reached its eighth edition may be said to have so
established its reputation as to require little recommendation. One
notices that Simpson's forceps is "the best modern instrument for
ordinary use," and yet it is the old form (without axis-traction rods)
which is shown in the illustration. The use of the "binder" is
distinctly advised, while early getting up after childbirth is a " passing
fad which will soon be given up." Surely the author's teaching that
perineal suture (where necessary) should not be performed till the end
of the first week after delivery is undesirable. The advantages
claimed for this procedure are outweighed by its drawbacks in
ordinary class practice.

Diseases of Children. By George M. Tuttle and Phelps G. Hurford.
Third Edition. Pp. 599. With 50 Illustrations. Philadelphia
and New York : Lea & Febiger. 1917. Price $3.50.

This volume is intended to be a manual for students and practitioners,
and in their endeavours the authors have succeeded well. The book
is compact and at the same time comprehensive. There is much
advantage to be gained by including the acute infective fevers in a
manual dealing with the medical diseases of children, but apart from
such inclusion it is perhaps hardly necessary to introduce into the
book so many conditions which are not peculiar in childhood, which
would seem to be more properly discussed in a book on general
medicine, and some of which are extremely rare in childhood. In the
section dealing with the artificial feeding of infants we are glad to
read : — " Simple Dilution of Whole Milk. — This is manifestly the
simplest of all methods. More than that, it is perfectly satisfactory
in the majority of healthy babies, and is coming gradually into
greater favour all the time."

70 New Editions

A Text-Book on Gonorrlma and Us Complications. By Gkok<;ks Li vs.
Second Edition. Translated and Edited by Arthur Foerster.
Pp. xxi. + 386. With 204 Illustrations. London: Bailliere,
Tindall&Cox. 1917. Price 21s.

The first edition of Dr. Georges Luys' TraitS de la Blennorrhagie
appeared in 1912, and was promptly translated into several other
languages. The present volume represents the second revised English
translation. As there has been no radical advance in the treatment of
gonorrhoea in recent years, only minor alterations and additions have
been made in the new edition.

Dr. Georges Luys rightly emphasises the importance of educating
both the medical profession and the public in regard to the seriousness
of gonorrhoea. Much physical and mental distress is undoubtedly
due to chronic and latent infections, and it is incumbent on medical
men to treat their cases more effectively than is often done at present,
and to caution their patients against the risks of marrying before cure
is complete.

The first chapters of the book deal with the history of gonorrhoea,
and with the social and legal aspects of the disease. A full account of
the gonococcus and of the other causal organisms of urethritis is given.
The pathology, symptomatology, and diagnosis of urethritis are fully
discussed, and special chapters are devoted to gonorrhoea in women
and children. Dr. Luys is a great believer in the value of the
urethroscope, both as a means of diagnosis and of treatment, and one
of the most valuable chapters deals with the use of this instrument.
Finally, the treatment of acute and of chronic gonorrhoea, and of its
numerous complications, is exhaustively discussed. It is impossible in
a short review to mention even a few of the many excellent methods
of treatment which are recommended. It is sufficient to state that in
this text-book we have the subject of gonorrhoea described by one of
the first authorities of the day, and that there is no detail of diagnosis,
or of treatment, which is not fully and satisfactorily explained. The
value of the text is enhanced by numerous excellent illustrations.

Handbook of Operative Surgery. By William Ireland de C.
Wheeler. Third Edition. Pp. viii. + 364. With 226
Illustrations. London : Bailliere, Tindall & Cox. 1918.
Price 10s. 6d. net.

This book was originally written for students attending a course of
operative surgery. Its scope has been extended in the present edition,
and it should now prove useful to young surgeons, with limited
experience, who have to operate either in civil or in military hospitals.
Although almost a third of the volume is devoted to ligature of

Notes on Books 71

arteries and to amputations, the remaining chapters are wonderfully
complete. By the conciseness and clearness of his descriptions the
author has succeeded in giving a satisfactory introduction to operative
surgery. The illustrations are numerous and are well designed to
assist the reader in understanding the technique described in the text.

NOTES ON BOOKS.

Mr. Kutherford Morison has given us a most readable and
useful account of the Bipp Treatment of War Wounds (Henry Frowde
and Hodder & Stoughton) in one of the latest volumes of the
Oxford War Primers. Those who have seen many wounds coming
from France after treatment by this method do not require further
evidence of its efficacy. Mr. Morison's brochure indicates how the use
of the method may be extended to other than recent wounds, and
gives clear and definite instructions as to its application. It should
be carefully studied by all who have to deal with war wounds.

The Medical Annual for 1918 (John Wright & Sons) maintains the
reputation of this publication as a reliable and complete summary of
the recent progress made in all departments of medicine. The able
staff of contributors has spared no pains to bring before the reader all
that is of value in the current literature of the year. The editor's
review of the year's work shows at a glance the trend of medical
thought in all directions, and particularly how the war has influenced
it in many ways. It is unnecessary for us to praise a work which has
become indispensable to every practitioner who desires to keep abreast
of the times.

The President — Joseph L. Goodale — in his thoughtful address
calls attention to the frequency of lesions of the upper air-passages in
the present war, on account of (1) the use of asphyxiating gases,
(2) the rapid spread of inflammations of the nose and throat among
the troops, and (3) the dampness, darkness, and want of ventilation
of the dug-outs. In another portion of his address Goodale emphasises
the importance of science in general education, and recommends that
the natural sciences should be made an integral part of the educa-
tional course in all the great schools. He holds that the medical
profession in America runs the risk of being outstripped unless
it rests upon a secure foundation of scientific training.

The Transactions also contain interesting papers by Delavan and
Watson on " Radium Treatment," by Ingals on " Intranasal Operations
on the Frontal Sinus," by Loeb on " Infection Due to Incompletely
Removed Tonsils," on "Accessory Nasal Sinusitis in Children" by

72 Books Received

Coffin, and lastly on " Foci of Infection in the Nose and Throat " by
Joseph B. Greene.

As usual, The Transactions of the American Pcediatric Society, of which
vol. xxix. lies on our table, yields a harvest of interesting papers on
the diseases of childhood. Papers on metabolism and physiology
are this year rather fewer than is the rule, while those dealing with
interesting and rare diseases preponderate.

BOOKS RECEIVED.

Barrett, J. W., and P. E. Deane. The Australian Army Medical Corps in Egypt

(H. K. Lewie & Co., LU1.) 12s. 6d.
Bruce, J. Mitchell, and W. J. Dillixo. Materia Medica and Therapeutics. Eleventh

Edition (CasseU & Co., Ltd.) 9s.

Chandhuri, Tarini Charan. Modern Chemistry and Chemical Industry of Starch and

Cellulose (Bidterworth & Co. (India), Ltd.) Rs. 3.12

Cobb, Ivo Geikib. The Organs of Internal Secretion. Second Edition

(Bailliere, TindaU & Cox) 7s. 6d.
Hewer, Mrs. J. Lasgton. Our Baby : For Mothers and Nurses. Sixteenth Edition

(John Wright & Sons, Ltd.) 2s. Od.
Hirschfelder, Arthur Douglas. Diseases of the Heart and Aorta. Third Edition

(/. B. Lippincott Co.) 30s.

Johnstone, R. W. A Text-Book of Midwifery. Second Edition . (A. & C. Black) I2s. 6d.

Lane, Sir W. Arbuthnot. The Operative Treatment of Chronic Intestinal Stasis.

Fourth Edition (Henry Frowde, Hodder & Stoughton) 20s.

Loeb, Jacques. Forced Movements, Tropisms, and Animal Conduct

(/. B. Lippincott Co.) dols. 2.50
Luff, Arthur P., and Hugh O. II. Candy. A Manual of Chemistry. Sixth Edition

(CasseU £ Co.) 12s.

Macdonald, R. St. J. Field Sanitation . . (Henry Frowde, Hodder & Stoxtghton) Gs.

Muir, Ernest. Kala-Azar: Its Diagnosis and Treatment

(Butter worth & Co. (India), Ltd.) Rs. 2

Porter, Charles. The Future Citizen and his Mother . . (Constable £ Co., Ltd.) 3s. 6d.
Report of the Scientific Work of the Surgical Staff of the Women's Hospital in the State

of New York, 1018 —

St. Thomas' Hospital Reports. Vol. XLIV (J. & A. Churchill) Ss. 6d.

Sdhryver, S. B. Biological Chemistry .... (Thomas Nelson £ Sons, Ltd.) Ss.

"Twilight Sleep" (Scopolamine-Morphine Narcosis). Report by a Special Committee

(Longmans, Green <£ Co.) 3s.

Wallace, Cuthbert, and John Fraser. Surgery at a Casualty Clearing Station

(A. £ C. Black) 10s. 6d.
Wood, R. C. The Soldier's First Aid (MacmUlan & Co., Ltd.) 2s. 6d.

FEBRUARY 1919.

EDINBURGH
MEDICAL JOURNAL.

EDITORIAL NOTES.

CASUALTIES.

Died at Bagdad, on 7th December, Colonel Harry George Melville,
CLE., I.M.S.

Colonel Melville was educated in Edinburgh, where he graduated M.B.,
CM. in 1890. After acting as Demonstrator in Anatomy and as Resident
Physician to the Royal Infirmary, Edinburgh, he entered the I.M.S. in
1892. Prior to the present war he had seen much service on the North-
West Frontier of India. He received the CLE. on 26th August 1918.

Died on service on 5th December, Captain James Donaldson,
R.A.M.C.

Captain Donaldson took the degree of M.A. at the University of
St. Andrews in 1899, and of M.B., Ch.B. at Edinburgh in 1903.

Died of influenza on 6th December, Captain George Elphinstone
Keith, R.A.M.C.

Captain Keith was educated at Edinburgh, where he graduated M.B.,
CM. in 1887.

Died on service on 2nd December, Captain David Paton Lindsay,
R.A.M.C.

Captain Lindsay was educated at Edinburgh, where he graduated M.B.,
Ch.B. in 1912.

Died of influenza in December 1918, Captain Joseph Vincent
Duffy, R.A.M.C.

Captain Duffy was educated at Glasgow and took the Scottish Triple
Qualification in 1914.

E. M. J. VOL. XXII. NO. II. 6

74 - Editorial Notes

Died on service on 14th December, Captain Henry Ruthvkn
Lawrence, M.C., S.A.M.C.

Captain Lawrence was educated at Edinburgh, where he graduated
M.B., Ch.B. in 1908, and M.D. in 1910.

Died on service on 14th November 1918, Captain J. Johnston
Sinclair, R.A.M.C.

Captain Sinclair graduated M.B., Ch.B. at Glasgow University in 1909.

Died on service, Captain John Fortune, R.A.M.C.

Captain Fortune was educated at the Universities of Edinburgh and
Manchester, and graduated M.B., Ch.B.(Edin.) in 1903 and MD.(Edin.)
in 1907.

Died on service in Palestine on 30th December 1918, Captain John
Wilson, R.A.M.C.

Captain Wilson, who was educated at Glasgow University, took the
Scottish Triple Qualification in 1903.

At the examinations of the Board of the Royal

Triple Qualification College of physicians of Edinburgh, Royal College

of Surgeons of Edinburgh, and Royal Faculty of

Physicians and Surgeons of Glasgow, held at Edinburgh in January, the

following candidates passed the First Examination: — James Kirkness and

Joseph A. H. Sykes.

The following passed the Second Examination : — Adriaan V. Bergh.

The following passed the Third Examination : — Douglas C. Scotland,
James F. Cook, L. S. Ahluwalia, Arthur H. Jacobs, Ronald MacKinnon, and
Bernard M'Laughlin.

The following candidates, having passed the Final Examination, were
admitted L.R.C.P.E., L.R.C.S.E., L.R.F.P.&S.G. :— Lazarus Samuels, England ;
William Francis Gawne, England ; Lachman Singh Ahluwalia, India ;
Arthur Kinsey Towers, England ; Victor Albert Rankin, Lamington ; John
Vaughan Griffith, Wigan ; George Alexander Grandsoult, British Guiana ;
Quintin Stewart, Edinburgh ; William Brownlee Watson, Edinburgh ; Ben
Cheifitz, South Africa ; and Richard Irving Duggle, Liverpool.

Fracture of the Cervix Femoris in Children 75

FRACTURE OF THE CERVIX FEMORIS IN CHILDREN.

By DAVID M. GREIG, CM, F.R.C.S.(Edin.).

Amongst Sir John Bland-Sutton's " Spolia opima " in the British
Medical Journal of 30th November 1918 he refers to two instances
of intracapsular fracture of the neck of the femur in children.
One was a specimen from the Middlesex Hospital museum, a
femur of a young person of about 15 years of age, and the other
a personal observation of his own in a boy of 12 years. Sir
John concludes that paragraph by saying: "I doubt if five
examples obtained from boys or girls exist in all the museums
of the United Kingdom." His doubt is probably well founded,
and this for two reasons. First, this fracture is not common in
children, and second, it is not a fatal occurrence. Indeed it is to
radiographic collections and not to museums, that one must look
for even the existence of this fracture. Nor is it safe to estimate
yet the relative frequency, for this fracture was not recognised
before the introduction of X-rays. The possibility of fracture of
the neck of the femur in children was not overlooked altogether
by the older writers, but they were misled by the absence of
crepitus, and where injury to the bone was admitted it seems to
have been considered a separation at the epiphysis, if displacement
took place. In this respect radiography has also altered our
opinions to some extent in that in many cases where, clinically,
a separation at an epiphysis is diagnosed, radiography shows that
there is really a fracture close to the epiphyseal line.

Fracture of the femur is vastly more common in children than
in adults, and this is a well-known fact. Out of 310 consecutive
cases of fracture of the femur of which I have notes, 193 occurred
in children below the age of 10 years and 34 between the ages of.
10 and 20. All the other ages from 20 upwards only yielded 83
cases. But when fractures of the neck are considered the relative
frequency is reversed. Three cases occur below the age of 20,
none between 20 and 30, only one between 30 and 40, while over
that age no less than 35 are fracture of the neck of the femur.

The three cases of fracture of the nqck of the femur in children
are as follows : —

Case I. — A female child, a3t. 5 years, was admitted to my care in
the Dundee Royal Infirmary in 1910, having fallen from a stair a height
of 12 ft. on the previous day. The child was unable to put her foot

76 David M, Greig

to the ground and complained of pain on manipulation. There was no
crepitus. A radiogram showed an intracapsular fracture of the neck
of the femur with no displacement.

Case II. — A male child, set. 2 years, fell while climbing and com-
plained of pain in the hip and inability to walk. He was kept in bed
a month but freely handled and encouraged to try to stand. It was
after that that I saw him and a radiogram showed fracture of the
neck of the femur with some displacement upwards of the lateral
portion of the neck. There was, of course, shortening.

Case III. — A girl, set. 15 years, came under my observation last
year, a fortnight after having fallen and hurt her left hip. She had
slipped on a stair and fallen, but was able to rise again without assist-
ance and walk home. She continued to walk carefully, with some pain
and some lameness that evening and the following day, but since therv
had been in bed. She had pain in the joint, inability to fully extend,
but no crepitus. Radiography showed an intracapsular fracture of the
neck of the femur without any displacement.

The diagnosis must be confirmed by radiography or by dis-
section, for a mere contusion to the hip may very closely simulate
fracture, as the following case shows : —

Case IV. — A boy, set. 4 years, fell from an outhouse roof on to
the ground. He was unable to rise. His mother picked him up and
he complained of pain in the right knee, which was skinned, and he
had a contusion of the forehead. He continued unable to walk during
the three weeks which elapsed before I saw him. He had then inability
to stand, inability to fully extend the thigh, pain at the hip, no dis-
placement and no crepitus. I had him repeatedly radiographed but no
fracture was found. Yet it was six weeks before the child was again
able to run about. Since then he has had no complaints.

In my first and third cases the accident was recent and the
salient symptoms were lameness and pain. In neither was there
displacement at the hip nor eversion of the limb, and there was no-
crepitus. In my second case displacement had doubtless followed
on account of the attempts to make the child bear its weight on
the injured hip. The absence from children of those signs which
are characteristic of fracture of the neck of the femur in adults
must be accounted for by the physical differences between the
periosteum of infancy and age, by the relative difference of the
weight and size of the lower limb to the trunk in children as
compared with adults, and by the ease with which a child carx
be moved and transported.

Fracture of the Cervix Femoris in Children 77

I am not sure that this is the whole story of fractures of the
neck of the femur in children, for I have had two interesting cases
of trouble in the hip during adult life which I think must be
ascribed to an injury in childhood or adolescence. These I give
in some detail: —

Case V. — A street porter, set. 40, came under my observation first
in 1910, complaining of pain in the left hip and lameness therefrom.
He was of a healthy family and his personal history, apart from the
hip condition, was unexceptionable. When 11 years old he was romp-
ing at a Sunday-school picnic and was running forward carrying a
wicket when the point caught in the ground and he violently projected
himself against the other end, which struck him in the region of
the left hip, inflicting a slight abrasion and causing immediate and
great pain. He remained lying on the ground until assisted home by
others, as he was unable to put his left foot to the ground. A fortnight
later he was admitted to hospital, where it was noted that he had pain
and swelling about the joint but no dislocation and no shortening.
Extension and a long splint were applied, and he was discharged a
month later, the diagnosis entered on the case-sheet being " Synovitis,
hip." That happened in 1881 and he maintains that he had full and
free use of his left hip from then during many years. Gradually,
however, some stiffness manifested itself, but it was not until 1907 that
pain, added to increasing stiffness, interfered with his work. In 1909
he went into hospital where, after a month's residence, his case was
labelled " Insular sclerosis." Later in the same year a surgeon diagnosed
the condition as sciatica and stretched his sciatic nerve. Neither this
nor previous electrical treatment produced any beneficial result. In
the following year he was radiographed and told he had a tumour
of the hip which would necessitate disarticulation. It was after that
when I saw him. I did a cheilotomy, removing many osteophytic
growths from the joint, giving him good movement and freedom from
pain and enabling him to carry on his work as hotel porter during
the four years that followed. Since then I have lost touch with
the patient.

Case VI. — A domestic servant, 45 years of age, I saw in 1917.
■She complained of lameness in the left hip, which had been increasing
during at least five years. Her personal history was good, and her
family history no obvious bearing on her present condition. When
about 18 years of age she was walking on the street when she " twisted
her leg, or something caught her foot," but something gave a " click " in
the left hip and she was immediately incapacitated from further move-
ment. She did not fall, but stood balancing herself till a passer-by
called a cab and helped her into it. She was put to bed and condition

78 David M. Greig

gradually passed off. It was supposed to be rheumatic. Her life-
thereafter was a quiet and, to a great extent, a sedentary one, and she
was not aware of any inconvenience from her hip till some five years
ago when her friends called her attention to how lame she was. When
I saw her there was much fixation at the hip and some fulness, and a
radiogram demonstrated many osteophy tic growths. As in the previous-
case I did a cheilotomy, but the osteophy tic growths did not lend them-
selves to removal, and the operation was of but limited and, I fear,
temporary benefit.

In considering these two cases it is of course open to say that
they were merely cases of monarticular osteo-arthritis, the first
manifestation of what would one day become a generalised articular
affection. But in how many osteo-arthritic cases is a definite-
traumatism found ? I submit that it is a possibility that the osteo-
arthritis was a reaction following a traumatism of a growing joint,,
and it is likely that that traumatism was a fracture.

Notes on Radium Treatment 7£

NOTES ON RADIUM TREATMENT.

By DAWSON TURNER.

One of the conditions for which in recent years radium has been
found consistently useful is that of exophthalmic goitre. The writer
has now treated upwards of fifty cases with radium, and with one
exception all of those patients derived more or less benefit. The
exception was a woman of 22 years of age, who suffered from
extreme nervousness, and who died, within a fortnight of the
treatment, of hyperthyroidism and toxic phenomena. The benefit
that patients with exophthalmic goitre derive from the expert
application of radium is in their general condition and in their
special symptoms. Thus they regain strength, lose the tired
feeling and put on weight, and at the same time the tachycardia,
tremor, and breathlessness are diminished and may disappear,
altogether. The thyroid gland becomes harder, denser, but usually
does not diminish in size, and the exophthalmos is but little
affected. It is well to warn patients of this, lest they suffer dis-
appointment at the neck swelling remaining the same. Operative
measures to reduce the size of the gland might now be considered,
both because the vascularity is diminished, and because the patient
is better able to stand an operation. The writer is in the habit of
treating each lobe, and the isthmus of the thyroid, and the thymus.
A dose of from 200 to 400 milligram hours, properly screened so
as to avoid injury to the skin, may be given over each of these
areas, and the patient may then be sent home for some three
months, when more treatment may, if necessary, be given. As
the skin over the front of the throat appears to be very sensitive
to radium rays, great care should be taken to avoid over-exposing
it. As compared with X-rays in the treatment of this condition,
radium has the following advantages : — (1) Absolutely constant
emission of rays and therefore exact dosage possible. (2) Far
greater penetration of its rays, so that the deeper parts of the
gland are reached. (3) No noisy, exciting apparatus, so that the
treatment can be applied at the bedside without in any way dis-
turbing the patient. The words cito, tuto, et jucunde can fairly be
applied to the radium treatment of exophthalmic goitre.

Malignant Disease.

One can say generally that radium is of benefit in malignant
disease — in suitable cases of great benefit, even to bringing about

SO Dawson Turner

an apparent cure. It is sometimes objected by surgeons — " In what
way is radium superior to a hot iron or to arsenic paste ? " The
answer is that these caustics only have effect locally on the actual
tissues they are in contact with, and that they destroy impartially
both healthy and diseased parts ; further, they occasion great pain.
It is quite otherwise with radium rays. Owing to their penetrative
power they attack the deeper parts of the growth — the very roots
-of the disease, as well as the superficial (the gamma rays can
be detected through the armour plating of a Dreadnought). In
proper doses they have a selective action upon the diseased tissues.
Lastly, they relieve pain instead of occasioning it. As to the
variety of malignant disease most susceptible to radium, it is
admitted that sarcomas are more easily dispersed than carcinomas,
and of sarcomas, lymphosarcomas, in the writer's experience, are
the most amenable. As to position, those on the surface of the
body and those affecting the cervix are the most favourably
situated. The buccal cavity, respiratory and digestive passages,
and internal organs are unfavourable positions. An exception
may perhaps be made in the case of accessible sarcomas of the
nasal region. 0. J. Stein {Pract. Med. Ser., 1918, iii. 275) reports
a case of a nasal sarcoma which entirely blocked the right nostril,
and which was accompanied by pain and haemorrhage. A dose of
6200 milligram hours of radium was followed by brilliant results.
The pain and haemorrhage ceased within a week, and the tumour
quickly disappeared.

Case I. — The writer treated a case of chondro-fibro-sarcoma
in a boy, aged 6, for Dr. J. S. Eraser in May 1916. The
disease affected the left maxillary antrum, causing protrusion of
the cheek, diplopia, and proptosis. Dr. J. S. Fraser removed as
much as was possible of the growth by scraping, but, fearing that
he had not eradicated it, consulted with Mr. Dowden with a view
to the removal of the left superior maxillary bone. Mr. Dowden,
however, was of opinion that the case was more suitable for radium.
Tubes of radium were introduced through an opening into the
mouth, and a dose of 1440 milligram hours administered. The
patient was examined eight months later on 3rd January 1917,
and no trace of the disease could be detected. Two years and
three months after the treatment, on 8th August 1918, the boy's
mother wrote to say that he was quite well, that there was no
sign of a tumour, or of blockage of the nose or swelling of the face.

But the dose must be a sufficient one for the particular case, as
the following report shows : —

Notes on Radium Treatment 81

Case II. — Myeloma in a female of 23, recommended by Mr.
Dowden. Two years ago patient complained of a gumboil on the
right side of the superior maxillary bone. Her dentist found a
growth present, and sent her to Mr. Dowden. The latter scraped
out the cavity and the pathologist reported the growth to be a
myeloma. As a prophylactic, a tube of radium was attached to a
wire and passed up into the cavity, and a dose of 1920 milligram
hours given. This was in October 1915. The patient remained
well until June 1916, when a recurrence was detected. On 27th
June Mr. Dowden again scraped out the cavity and inserted tubes
of radium. A dose of 4400 milligram hours was now given, being
more than double the previous dose. Precautions were also taken
to maintain the radium in a more effective position. Very severe
reaction followed, with swelling and pain, requiring the use of
opiates, the tongue and mucous membrane of the cheek being
burned. In December the patient was better, and there has been
no recurrence during the last two years and four months. This
patient is a nurse and she is able to work steadily at her profession.
There can be little doubt but that the radium, when it was given
in a sufficient dose, has so far preserved this patient's life.

In order that a malignant growth may be successfully treated
by radium, the growth must be localised and accessible; further,
the whole of the growth must be given a sufficient dose — the
periphery as well as the centre. Now, in the majority of cases
recommended for radium treatment these conditions are impossible
•of attainment, because the growth is a recurrence and is wide-
spread. Take the cases of cervical cancer in which the broad
ligaments are involved before the aid of radium is called in. The
cervical part of the disease can be given a sufficient dose so as to
cause its disappearance, but how can the outlying cancer cells be
efficiently radiated ? Further, as Dr. 11. Knox states {Radioihera-
leutics, p. 528), " The important point in all cases is, that to be
successful in the treatment of any diseased condition by radium,
the dose must be accurately estimated, and the maximum dose
fiven at the first treatment. Many cases receive no benefit at all
because the dose is either too strong or too weak. In either case
lost untoward results may follow." It is the writer's experience
that the majority of more or less suitable cases of malignant
lisease treated by a radium expert get well (are temporarily cured),
)ut in the course of time recurrences and metastases carry the
mtient off. These can be again subjected to treatment, but, as a
rule, less successfully than the primary growth, and this for two

82 Dawson Turner

chief reasons: the one that the recurrence is probably situate!
in a less accessible position, the other that after a course of raying
only those cells survive which are refractory to the rays, and a
recurrence consisting of such cells, or daughter cells, is less sus-
ceptible to attack. There is a tendency by natural selection to
breed cells which are immune. As cases which remain well for
more than three years after the primary treatment are relatively
rare, I quote the following : —

Case III. — Recurrent sarcoma in a female of 49, recommended
by Dr. Maclagan of Ayton. Duration, four years. Several opera-
tions for the removal of the growth were unsuccessful. Admitted
by Mr. Miles, 15th July 1915. Now a large nodular mass project-
ing in the left suborbital region, so as to interfere with vision and
adherent to the maxilla. Pathological report, large spindle-celled
sarcoma. As Mr. Miles considered the tumour inoperable, radium
treatment was recommended. By internal and external applica-
tions a dose of 5180 milligram hours was given. In November

1915 an external dose of 5180 milligram hours was given. During
the applications the growth diminished markedly. In February

1916 the tumour had greatly shrunk and was movable; it had
been fixed before. Patient better, stronger, and can see normally.
The condition had so much improved that Mr. Miles removed
what was left of the growth, and this was followed by a prophy-
lactic dose of 4120 milligram hours. In November 1916 the growth
had disappeared, and Mr. Miles could detect no sign of recurrence.
In July 1918 the patient was examined by Dr. Maclagan and the
writer, and found to be perfectly well and strong.

The following is a good case which has been under observation
for two years : —

Cask IV. — Parotid mixed-cell tumour, by pathological report,
in a female, aged 34, recommended by Professor Caird. Two years
ago a warty growth succeeded a mole on the left side of the face.
This was removed by Dr. Eeid of Inverness in January 1916. In
March a recurrence, with stiffness of the jaw. In June Professor
Caird removed this and a gland. In August the swelling
reappeared. In September 1916 there were three swellings, the
larger one, the size of a small egg, beneath the left ear, the smallest
one on the left side of the face, a larger one higher up. Kadium
was now buried in each of these and a dose of 6125 milligram hours
given. In two months' time the swellings had gone. In January

1917 Mr. Jardine wrote, "The condition is perfect." In June

Notes on Radium Treatment 8&

1917 Dr. Gillies of Inverness wrote, "There is no trace of a
recurrence. I should like Professor Caird to know, as he had said
a year ago that he regarded the case as hopeless." On 17th
October 1918 Dr. Gillies wrote, " Delighted to tell you the patient
is, so far, quite free from any recurrence. She reports to me
regularly. It has been a great success and I am quite sure she-
owes her life to the radium treatment."

Sometimes a growth will disappear rapidly and completely, even
when only part of it has been efficiently radiated ; the dissolution
started in one part by radium rays spreads through the whole mass.

Case V. — Sarcoma of the Sacrum. — A male, aged 16 years,
was admitted to Professor Alexis Thomson's wards in July 1917.
He complained of pain and of difficulty in defecation. On
examination a large swelling was found to be projecting principally
from the left side of the sacrum, but also involving the other side.
The swelling was firmly adherent to the bone, which was hollowed
out. Per rectum a projecting mass could be felt encroaching on
the lumen of the passage. The duration of the disease was about
four years. The growth was a sarcoma with a tendency to be
hemorrhagic. As it was inoperable, Professor Thomson suggested
the employment of radium. Accordingly, on 6th July 1917, two-
tubes containing 30 milligrams of pure radium bromide were
introduced through an ulcer into the growth, and at the same time
external radium applications were begun. After a total dose of
12,240 milligram hours internally and 4100 externally the radium
was withdrawn. Within a fortnight the growth was distinctly
smaller, the patient felt better and had no pain. By 16th October
1917 the external swelling had gone, and the growth invading the
bowel had diminished. In September 1918 he was re-examined
by Professor Thomson, who could find no trace whatever of the
tumour either externally or internally. The disease for the time
being is cured. This patient died in Ward 32 of pneumonia
following influenza on the 20th October 1918. No post-mortem
obtained. As only portions of this large growth were efficiently
radiated, the retrogressive process must have spread from these
to the more distant parts.

Case VI. — Recurrent Adenoma. — A male, aged 27, suffering
from this disease was recommended by Dr. Boyd Jamieson and
Mr. Miles for radium treatment on 12th June 1916. History. —
In December 1915 the patient injured his nose in a motor bicycle
accident. This got well, but three months later a papule appeared

84 Dawson Turner

a,t the site of the injury and grew fairly rapidly. Patient consulted
Dr. Boyd Jamieson, who cauterised the papule. It recurred and
Mr. Miles excised it on 5th April 1916. It started again from
the wound and grew all around until there were five separate
adenomatous nodules. On 30th May 1916 Mr. Miles again
removed it, but within a week it reappeared, and during a space of
four days visibly increased. When radium treatment was begun
on 12th June 1916 there was a nodule the size of a nut and about
the diameter of a shilling to the right of the healing wound. By
external applications a dose of 3600 milligram hours of radium was
given. There was a severe reaction, but the result was successful
in completely checking the tumour, for there has been no recurrence
during a period of more than two years. The patient was examined
at the end of October 1918 and there was nothing to be seen
except the cicatrix and a little telangiectasis.

Malignant disease of the cervix is favourably affected by radium
rays, and localised epitheliomas and still more sarcomas can be
confidently expected to disappear temporarily. Eecurrence, after
a longer or shorter interval, is, however, the rule, because of the
difficulty of efficiently raying the more distant portions of the
disease, and few cases are sent for radium treatment which are not
in an advanced condition. Even in these cases, however, some
improvement is observed both locally and generally. Pain is
removed, discharges cease, ulceration heals, and the patient gains
in general health, strength, and weight.

Many cases could be quoted to illustrate this temporary
alleviation, but sometimes the improvement goes further and is
more permanent, as in the following: —

Case VII. — Rapidly Growing Fungating Epithelioma. — A
patient, aged 63, was recommended on 16th October 1916 for
radium treatment by Dr. John Orr and Dr. William Fordyce.
She was suffering from a squamous epithelioma growing from
vaginal roof behind and to left of cervix. There was a soft
fungating gangrenous mass of the size of a Victoria plum in the
above position. This was removed by operation in September
1916, and the base of it thoroughly scraped and pure carbolic acid
applied. Pathological report, squamous epithelium showing marked
necrosis. Ten days later the mass had grown again to half its
previous size, the discharge was very foetid, the same necrosis was
present. The mass was again removed and a dose of 4900 milli-
gram hours of radium applied. Two years later, in November
1918, Dr. John Orr reported that the patient appeared to be quite

Edinburgh Medical Journal, Vol. XXII. No. 2.

Keloid in Cicatrix resulting from Excision of Tuberculous Glands (Case IX.).

Notes on Radium Treatment 85

well. She has not needed a doctor for the last eighteen months, she-
does all her work, and her only symptom is a slight discharge.
As she considers that she is quite well, she refuses to come to the
Eoyal Infirmary to see Dr. William Fordyce.

Case VIII. — Sarcoma of Cervix. — A patient, aged 47, was recom-
mended for radium treatment on 20th July 1916 by Dr. Barbour.
Duration, one year. Complains of a bearing-down pain and some
discharge. On 26th June 1916 the cervix, found to be ulcerated
by Dr. Fordyce, was curetted. Pathological report, sarcoma. Dr.
Barbour examined her on 20th July 1916 and found hard nodules
all round the cervix except posteriorly. The right ligament was
thickened. Body of uterus unaffected. Hysterectomy unsuitable-
A dose of 4300 milligram hours of radium was administered. In
two months' time the nodules had disappeared. In four months
the parts seemed quite healthy ; no discharge ; patient much
stronger. After a lapse of two years and four months, viz. in
November 1918, the patient was examined by Dr. Barbour, whose
report is as follows : — " The cervix is small, nearly flush with vaginal
roof ; firm, almost cartilaginous, but showing no evidence of return
of sarcoma." Owing to the length of time that this patient has
been free from recurrence, Professor Lorrain Smith kindly
re-examined the microscopical specimen taken on 26th June .1916-
and confirmed the diagnosis of sarcoma.

Keloid, Indolent Ulcers, Persistent Simis, etc. — Radium radiations
are of benefit in these and other lesions associated with local
malnutrition and chronic sepsis (vide an article by Professor Cole
in B. Knox's Eadiotherapeutics, p. 563). The following case
illustrates the value of radium in keloid : —

Case IX. — A female, aged 18, was admitted by Professor Alexis
Thomson in August 1917. Round the left semi-circumference of
the neck of the patient there was a large keloid sticking out like
a collar or ruff of Queen Elizabeth's period. The history was that
when she was 7 years old some enlarged glands were removed from
the left cervical region by Dr. J. MacLennan of Thurso. A year
later Dr. MacLennan had to operate again to remove a keloid
which had developed in the scar. Three years later Sir Harold
Stiles operated on a recurrence. Four years later Mr. David
"Wallace, assisted by Mr. Henry Wade, removed another recurrence.

On being consulted by Professor A. Thomson as to the use of
radium, it appeared to the writer that, as the growth was too large-
to be readily removed by radium alone, it would be better to-

36 Dawson Turner

remove it again by the knife, and then to treat the roots with
radium. Accordingly, a few days after Professor Thomson had
excised the mass, radium was applied externally. Further, to test
the efficacy of radium in preventing a recurrence, only the posterior
3 ins. of the wound were treated, the anterior half being left alone.
•One month later a recurrence was observed in front, in the part
untreated by radium, but the posterior half which had received
radium treatment remained free. The recurrence was now given
some radium exposures, which resulted in its disappearance. The
total dose, well distributed over theposition from which the keloid
arose, was 4780 milligram hours screened by 2 mm. of silver.

In September 1918 Dr. John MacLennan, in reply to an
inquiry, wrote, " I am glad to say the keloid has not given any
further trouble, and it has remained quiescent, as when you dis-
charged her from the hospital."

In December 1918 this patient was readmitted with a slight
recurrence, consisting principally in a downward growth of two
<;law-like projections below the level of the original keloid.
These are now receiving radium treatment.

Case X. — Indolent X-Bay Ulcer. — The writer suffered from an
indolent X-ray ulcer on dorsum of the middle finger of the right
hand. It had followed the breaking down of a warty mass, and
had resisted treatment for six months. This ulcer was removed
by one application of 20 milligram hours of radium made by Sir
-James Mackenzie Davidson, to whom the writer is much indebted.

Scopolamine- Morphine Narcosis 87

SCOPOLAMINE-MORPHINE NARCOSIS Oil
TWILIGHT SLEEP.

By ROBERT WALLACE, M.B., Ch.B.

As the value of the induction of scopolamine-morphine narcosis
in women in labour has been a good deal debated of late in the
medical press, it may be of interest to give the results of observa-
tions recently made on 104 cases at the Maternity Hospital,
Edinburgh.

The drugs were given in each case with a view to the produc-
tion of a painless labour by inducing a peculiar light degree of
narcosis, to which Gauss gave the name of twilight sleep. In this
condition, when perfectly induced, there is both amnesia or loss of
memory of present events, and analgesia or freedom from pain.

As the result of our observations we heartily endorse Gauss'
claims as to the merits of twilight sleep. We found that in nearly
every case the narcosis reduced the pain and shock of childbirth,
and in 50 per cent, of cases entirely abolished both, as well as
erasing from consciousness all memory of the lying-in process.
Indeed, in many cases after delivery, instead of being exhausted
in consequence of pain and shock, the mother seemed rather to
have been stimulated and even exhilarated by the experience.
The child itself is occasionally born in a state of twilight sleep,
a condition sometimes so closely simulating white asphyxia as to
create alarm in the inexperienced, but this condition soon passes
off' and usually requires no treatment whatever.

As a routine practice, before putting any patient under the
influence of scopolamine-morphine, we first obtained her history
and then made a thorough examination of her condition. We
examined her heart, lungs, and kidneys, took her pelvic measure-
ment, noted the presentation and position of the child, the state
of the os, the condition of the fcetal heart, and finally registered
the mother's pulse and temperature. We then put her under the
best possible conditions for the induction of twilight sleep. She
is given a quiet room free from all noises. The blinds are drawn
down to avoid distractions and assist in producing a drowsy, restful
state of mind, and her ears are plugged with cotton-wool to damp
all unavoidable noises. She is put in charge of a competent nurse
trained to give hypodermic injections and with instructions on no
account to leave the patient unless relieved by another nurse.
The bowels and bladder having been emptied and the pains

88 Robert Wallace

having become regular and strong, she is now ready for the-
first injection. The first dose, which consists of \ gr. morphia
and TVg. gr. scopolamine, we give as early as possible in the first
stage of labour consistent with the pains being regular and fairly
strong. In a very short time she sinks into a state of light
narcosis, from which she begins to emerge, as a rule, in about
three-quarters of an hour.

The second dose is now given, which consists of -^^ gr. of
scopolamine, and this dose is usually repeated hourly till the
child is born.

In the majority of cases we found this dosage sufficient to
keep her continuously in a condition of twilight sleep. In some
cases, however, where the pains were very strong, we had to-
increase the dose to T£7 gr. or even to 7£7 gr. of scopolamine in
order to maintain the narcosis, and in a few very refractory cases
we had to repeat the morphia more than once, as well as to
administer several whiff's of chloroform in order to keep her
under. And it is worthy of note that the more experience one-
has of the treatment, the better one is able to judge as to proper
dosage in unusual cases, the more favourable the results obtained,
and the greater one's confidence grows in the perfect safety and
value of the narcosis.

And it is an undoubted fact that the mental attitude of both
medical attendant and nurse have a specially powerful influence
upon the patient when she is well under the influence of the
narcotics, for in this condition she is evidently extraordinarily
suggestible. To have perfect faith oneself in the efficacy of the
treatment assists materially in promoting its success. And vice
versd : if the attendant nurse is weak, negative, and easily thrown
off her balance, the patient invariably becomes restless and difficult
to handle.

It is essential that the physician thoroughly understand the
method, and that he be full of the faith and confidence born of
knowledge and understanding. And it is equally essential that
the nurse be thoroughly competent and able to handle the patient
with firmness and confidence. It is a great mistake to imagine
that because the patient is apparently in an unconscious state
that she is unable to sense one's mental attitude, She is in
reality much more amenable to mental influence in this condition
than she is in normal consciousness ; and, of course, patients vary
very greatly in susceptibility to this influence. Personality is a
very important and powerful factor in managing these cases, as,

Scopolamine- Morphine Narcosis 89-

indeed, it is in the case of patients of all kinds, The operation of
this factor in success explains why some men make a brilliant
success of twilight sleep, while others make a miserable failure,,
although using the same drugs and dosage.

By giving small doses of scopolamine, repeated with sufficient
frequency to keep her in that state of amnesia and analgesia to
which the term twilight sleep is applied, one can keep the patient
entirely oblivious to her surroundings. At the acme of her pains
she may arouse herself and make a great outcry, but she relapses
into the twilight as the pains subside.

A few of our patients were very restless, noisy, and obstreperous
throughout the whole of the treatment, and yet, when questioned
afterwards, they had no recollection whatever of anything that
happened.

When the head is on the perineum she is especially liable to
be noisy, but a little chloroform soon puts her under again. After
delivery she usually falls into a deep sleep, lasting, on an average,,
from four to ten hours, from which she awakens refreshed and
without the slightest sign of exhaustion.

The course of the puerperium is uniformly prosperous, for there
is absence of exhaustion ; the lactation is normal, the involution is-
satisfactory, and the recovery is more rapid than in the average
case of natural delivery, because the course has been freed from
shock and fear. In a small minority of cases, however, there-
exists an idiosyncrasy towards scopolamine, and in them the
method fails. In such cases there is no amnesia, and instead of
producing narcosis the drugs may cause excitement and even
delirium. As soon as these indications arise the treatment should
be immediately stopped.

In our early cases we followed rigidly the Freiburg technique,
which necessitates very close watching and involves the use of
the memory test as an indication for a further injection.

An essential requirement for the induction and maintenance of
twilight sleep is that the patient be kept as quiet and undisturbed
as possible. For this reason some obstetricians, who use the
memory test, refrain from vaginal examinations during the treat-
ment so as to avoid arousing the patient. They cannot, however,
apply the memory test without arousing her. We, therefore,
soon came to the conclusion that, on the whole, the application
of the memory test was much more objectionable than frequent
vaginal examinations, for the latter could be made without
awakening the patient, whereas the former could not. Moreover,

7

DO

Robert Wallace

internal examination furnishes valuable information regarding
the state of the membranes, the condition of the os, and the
progress of labour — facts that cannot be obtained in any other
way : whereas the memory test often gave no reliable information,
for we found that a test object may be clearly recognised every
time it is shown and yet there may be complete amnesia. And
furthermore, it is sometimes difficult to extract anything intelli-
gible from a mentally confused and drowsy patient. Therefore
we soon discontinued the memory test, but did not hesitate to
make vaginal examinations when deemed necessary.

Two labours were unduly prolonged owing to the membranes
being so tough that they refused to rupture without interference.
In one ease the first stage of labour would have been shortened
several hours had we made the necessary vaginal examination.
Finally, we resorted to a routine method of hourly injections, as
described in the foregoing pages, and made occasional vaginal
examinations to ascertain the progress of labour.

This routine method of controlling patients under twilight
sleep has been employed by Dr. Haultain at this hospital on
previous occasions and with great success, and it was under his
supervision that the present series were conducted. The results
we obtained in the present series of observations were equally
encouraging, striking examples of which are given in detail later.

This simplified technique allows twilight sleep to be carried
out at home in the case of the better-class patients, and frees the
obstetrician from the necessity of constant attendance, as a com-
petent nurse trained to give injections can be left in charge, and
the physician 'phoned for when complications arise or when the
head is on the perineum.

But, unquestionably, ideal conditions can alone be provided at
a properly staffed and appointed institution, where physicians are
in constant attendance and the supervision is of the closest kind.

During the first quarter of the year 1918, at the Maternity
Hospital, Edinburgh, we gave scopolamine-morphine to 104
patients, of whom 64 were primipara and 40 multipara. The
results obtained in amnesia and analgesia are given in the
following tables: —

Primipara.

Complete amnesia . . .50 per cent.

Partial amnesia
No amnesia

Complete analgesia
Partial analgesia
No analgesia .

39
11

59

38

3

Multipane.
52 \ per cent
40"

57*
40

Scopolamine- Morphine Narcosis §1

The term amnesia is applied to that mental condition in which
there is complete loss of memory of all events occurring after %
•certain injection and lasting until consciousness is regained after
delivery. In this state the patient is utterly unconscious of the
birth of her child. In many cases where the amnesia was incom-
plete, the outstanding impressions recollected were the strong
pains experienced when the head was being born. This con-
stituted an " island of memory," and if previous impressions had
formed other " islands," the series constituted stepping-stones by
which she mentally retraced what she fancied to be the whole
course of her labour. On questioning her, however, one soon
perceived that her mind had been in reality for the most part
a blank while she was undergoing treatment.

It will be observed from the foregoing tables that only 11 per
•cent, among primiparee and 7£ per cent, among multipara remem-
bered the whole course of their labour. Where the treatment was
prolonged there was always some amnesia. The no-amnesia patients
included those having few doses, and cases where treatment was
begun late in the second stage. It was curious to observe that
in some cases where there was great outcry and apparently great
suffering there was nevertheless complete amnesia. One very
uproarious patient stated afterwards that she had a sort of dazed
recollection of having had a nightmare. Only 3 per cent, of
primiparse and 2| per cent, of multipane had no analgesia. Even
in those cases where there was no amnesia, most of them admit
that the injections diminished the pain. In two cases, where the
whole course of labour was clearly remembered, there was no pain
whatever. Notwithstanding that many patients came into hospital
too far advanced in the second stage to derive much benefit from
'the treatment, about 97 per cent, of all cases treated derived some
benefit, which is certainly a remarkable result.

We shall now consider the working and effects of the narcosis
more in detail.

Effects on the Labour. — Pains that are irregular are rendered
'steady and regular by the narcotic. In some cases, however,
where the labour seemed to have been arrested, we found that the
contractions were going on all the time, but gently and imper-
ceptibly, so that an external os dilated one finger would in the
course of a few hours be found fully dilated. Often the lessening
of the contractions is more apparent than real, for they are so
■painless they go on unobserved.

In the first stage the narcotic tends to steady and prolong th,e

92 Robert Wallace

period of contraction, but it affects the length of this part of the
labour very little.

In the second stage labour is prolonged, especially in primipane,.
mainly due to the lack of voluntary expulsive effort, but also
in a measure to the slowing of the uterine contractions. The
resultant easy and gradual dilatation of the maternal passages has
the following advantages : —

It diminishes shock, it lessens the risk of perineal lacerations,
and it gives ample time for head moulding.

Twilight sleep increases the percentage of forceps cases. In
this series of observations it was 24 per cent. Some cases were
accounted for by persistent occipito-posteriors, and others by
varying degrees of pelvic contraction. In two cases forceps was
put on because the patients were so noisy and obstreperous during
pains that we gave chloroform and delivered, although the head
was making fair progress. Some of our forceps cases would very
likely have delivered spontaneously had we given them sufficient
time, but in the latter half of this series we usually interfered
instrumentally if progress was slow as the head approached the
perineum and the external parts were sufficiently dilated to allow
the easy application of forceps.

We have had healthy, vigorous children of normal weight —
one of 6 lbs. 12 ozs. — delivered through a pelvis of conjugata
vera 3| ins. and with contraction throughout, by giving plenty
of time for dilatation of the passages and head moulding.

It has been urged as an objection to twilight sleep that it
greatly increases the number of forceps cases; but when the
passages are fully dilated and the head is down on the perineum,
where is the objection to applying forceps ? With proper care as
to delivering the head between pains, removing the forceps before
the head is completely freed, and pressing it out gently from
behind the anus, perineal tears can, in most cases, be avoided..
Thus the labour may be terminated sooner than otherwise, and
the doctor and nurse liberated for other patients. An experienced
obstetrician can apply low forceps without the slightest danger to
mother or child.

The third stage was very little affected. The placentas in
about half the cases were spontaneously expelled within an hour.
Two were adherent and had to be removed manually. The rest
were expressed from the vagina.

The Puerperium. — The condition of the great majority of the
patients after delivery was good. The period of recovery was-

Scopolamine- Morphine Narcosis 93

shorter than is the case with women who have gone through
labour in the ordinary way. Lactation was not interfered with.
Involution was normal, and there was a general feeling of well-
being that was very encouraging. The following cases, however,
were exceptions to the general rule of restf ulness and uninterrupted
recovery in the puerperium.

1. An elderly priraipara, set. 35, who was admitted with hyperemesis
gravidarum and bronchitis. Nine injections were given, which much
diminished the vomiting. She gave birth to a seven months', very
evil-smelling, macerated foetus. There was a good deal of post-partum
haemorrhage and collapse. She died of broncho-pneumonia within a
fortnight.

2. An elderly primipara, set. 35, justo minor. Breech case. Thirty
injections. Child delivered dead and slightly macerated.

3. Full-time primipara, set. 24. Came in with eclampsia. Three
fits before admission. Os size of half a crown. Two injections. As
fits continued and os fully dilated, we delivered with forceps. Recovered
slowly after delivery of child. Well in four weeks.

4. Multipara, set. 27. Second pregnancy. Conjugata vera less
than 3| ins. Forty-one injections. Dr. Lackie delivered her by
pubiotomy. Died in a few days of tuberculous broncho-pneumonia.
Suffered from phthisis from childhood, and was not expected to live
to maturity. Father, sister, and two uncles died of phthisis.

5 and 6. Two other cases developed puerperal fever, but ultimately
made a good recovery, and were discharged quite well.

In our opinion scopolamine-morphine narcosis cannot be held
accountable for the unsatisfactory puerperal condition of the
foregoing patients.

Our experience goes to show that, after long and trying
labours, patients who undergo treatment make a quicker recovery
than those who have been delivered without it. Most of our
patients we allowed up for an hour on the third day of the
puerperium. We believe that this early rising improves the
circulation, promotes involution, and tends to prevent the possi-
bility of retroversion of the uterus. We noted the blood-pressure
before rising and again in the evening of the same day, and it
was common to find that it had increased 3 or 4 mm. of mercury.
Our twilight patients for the most part availed themselves with
alacrity of the privilege of early rising. It seemed to aid in
banishing the delusion that the lying-in process was a pathological
one, and that the puerperal condition, being one of disease, needed
to be handled with great caution.

The Use of Chloroform. — Some twilight patients are so well

94 Robert Wallace

under control they can easily be delivered without the aid of a
general anaesthetic. In other cases, when the head is on the
perineum, the pains often become so strong that patients come
out of narcosis and an island of memory is formed. In all such
cases it is better to give chloroform, as from such isolated
memories the mind automatically tends to build up a fanciful
picture of the whole course of labour, and such patients will
afterwards declare the treatment gave them no relief whatever.
Giving chloroform when the head is being born will prevent the
patient forming an island of memory and aid in producing
complete amnesia in many cases that would otherwise be only
partial. It also aids in preventing perineal tears by relaxing the-
parts during expulsion.

The use of chloroform at any stage is a great aid in keeping
the patient under, and in quietening her when very restless.
Pregnant women take chloroform very well, and only a small
amount is required to keep her in the twilight condition when
she is taking scopolamine-morphine. In restless and delirious
cases chloroform is invaluable. One physician uses scopolamine-
morphine in the first stage only, and controls the second stage
entirely with chloroform, giving the patient a whiff as often as
may be necessary. With this liberal use of chloroform he claims
to get very good results.

Effects on the Child. — Out of 104 labours conducted under
scopolamine-morphine narcosis, 98 living children were delivered
and 7 were dead. The following is a detailed list of the dead
children : —

We had only one case of twins in this series of twilight cases.
The first of the twins was delivered dead and slightly macerated.
Three patients gave birth to very macerated foetuses, one from a
case of hyperemesis, a second from an eclamptic. One was a
breech case in a primipara, aet. 35. One was from an induced
labour lasting four days in a woman eight months gone. One was
a hydrocephalus whose head had to be punctured before delivery
was possible. There is no evidence that any of these deaths was
due to twilight sleep.

Out of ninety-eight children born alive, twenty-two were in
a state of oligopncea. In this condition the child gives a single
gasp or a cry at the moment of birth and then makes no further
attempt at breathing. It is very limp, and the condition closely
resembles that of blue asphyxia. It is a transient condition,
however, and usually passes off in about twenty minutes.

Scopolamine- Morphine Narcosis 95-

Oligopnoea is likely to occasion anxiety, to the inexperienced,
and death may be caused by too energetic treatment. The child
is simply in a state of twilight sleep like the mother, and will
shortly recover. We observed nothing unusual in the subsequent
history of these children up to the time of discharge from hospital,

Effects on Sleej). — Nearly all the patients slept after the labour
was over and recovered consciousness in from four to ten hours,
for the most part feeling refreshed. Three patients felt somewhat
dazed during the whole of the next day and unusually drowsy for
several days thereafter. *

One woman, a weak negative character, was in a hazy mental
condition and the victim of hallucinations of sight and sound for
six days after delivery. She dozed at intervals but had no con-
tinuous refreshing sleep. Bromidia induced regular sleep and
thus cured her condition. Particulars of her case are given later^

The majority of cases were in twilight sleep in the interval
between pains. Fifteen were asleep the whole time, remaining
apparently in complete unconsciousness even during contractions.
Ten remained awake during all the treatment ; some of these,
however, had only two or three doses, having arrived too far
advanced in labour to be put under a proper course of twilight
sleep.

Four common clinical features of the narcosis are thirst,,
flushing of the face, mental confusion, and restlessness. Thirst
was present in nearly all our cases. Often the restlessness of the
patient drew our attention to the dry and parched condition of
the lips, and when water was offered it was taken greedily and
the restlessness disappeared. When the narcosis lasts longer
than six or eight hours most patients need catheterising. It is
to be remembered that a full bladder will impede the progress
of labour.

Mental confusion was present in the majority of cases. In a
few cases where the treatment was prolonged the patient rambled
disconnectedly the whole time. A few had hallucinations of sight
or sound, or both. This mental derangement passed away during
the after-labour sleep in all cases except two. In one case it per-
sisted for a day ; in the second case for six days after the birth of
the child.

Restlessness. — Marked restlessness occurred in 14 cases out
of the 104 that had the treatment. In some it was continuous
throughout, with periods of exacerbation at the acme of a pain.
Two cases became almost maniacal at the height of their pains.

$6 Robert Wallace

Both were multipara : one with a conjugata vera of Z\ ins., with
strong pains and slow advance and controlled by four whiffs of
•chloroform at different times. (See Case VIIL, p. 98.) The
second had roomy passages but the membranes were tough;
seventeen injections — the last two doses we increased to ^^ gr.
scopolamine — and, finding it made her still more unmanageable, we
made a vaginal examination and found the os fully dilated, the
head nearly down on the perineum and the membranes unruptured.
We ruptured the membranes, put on forceps, and delivered her
in five minutes. She made a good recovery in the puerperium.
After this case we no longer hesitated to make vaginal examina-
tions when necessary. In three cases the restlessness took the
form of the patient trying to get out of bed. These were easily
controlled by being ordered firmly to lie down. As we have
already said, most twilight patients are very suggestible. In two
cases, increasing the dose from T^ gr. scopolamine to 3^ gr.
scopolamine increased the restlessness. All cases of restlessness
were easily brought under control with chloroform. The following
is an abstract of instructive cases : —

Case I. — Three Doses of Morphia. — Multipara, set. 30. Third
pregnancy, abdomen very pendulous, pelvis roomy, pains very strong.
Abdominal binder put on. Seven injections ; first, sixth, and seventh
of \ gr. morphia and -^-^ gr. scopolamine. Very noisy. Child born
an hour after last dose. Cried vigorously as soon as born and thrived
well afterwards. Chloroform was not given as the head was coming
through, as she appeared to be well under the influence of morphia.
Only partial amnesia, as she remembered the birth of the child. Both
mother and child were quite well the next day. A whiff of chloroform
when the head was on the perineum would have produced complete
amnesia.

Some obstetricians assert that the child will be born in a condition
■of oligopncsa if morphia is given within three hours of birth. This is
not our experience.

Case II. — Two Doses of Morphia. Labour could have been much shortened
if a Vaginal Examination had been made earlier. — Primipara, set. 28. Pains
very strong. Forty-one injections. First injection ^ gr. morphia and
Tiiv gr. scopolamine. Last thirteen injections of 4^ gr. scopolamine,
as she began to make an outcry. Twenty-seventh injection of ^ gr.
morphia and T^- gr. scopolamine. This quietened her somewhat, but
she continued to be restless and talked nonsense continuously. As
she was making very slow progress, after the thirty-eighth injection
a vaginal examination was made and the membranes were found
unruptured and very tough. Ruptured them with a stylet. Child

Scopolamine- Morphine Narcosis 97

was born within four hours. Cried vigorously as soon as born. Gave
■chloroform when the head was emerging. Complete amnesia and
analgesia. Mother and child both well the next day.

Case III. — Two Doses of Morphia. Did not give Chlwoform on
Delivery. — Multipara, set. 37. Second pregnancy. Strong pains.
Restless and noisy. Eleven injections. First dose of \ gr. morphia
and yfjj- scopolamine; sixth dose \ gr. morphia and T^ gr. scopol-
amine. The rest = T^TT gr. scopolamine. Pains became very strong
towards the end and the child was delivered so rapidly that there
was not time to give chloroform. Child cried as soon as born. Partial
amnesia and analgesia. She remembered the birth of the child.
Mother and child both well the next day.

Case IV. — Contracted Pelvis. Two Doses of Morphia; Four Whiffs
of Chloroform. — Primipara, set. 20. Conjugata vera 3| ins. Very
strong pains. Thirteen injections. First dose \ gr. morphia and
T3tf Sr- scopolamine; ninth dose £ gr. morphia and ^^ gr. scopol-
amine ; last four doses were 3^ gr. scopolamine. Slept between pains
but made a great outcry at the acme of pains. Quietened her four
times with chloroform. Child born in a state of oligopncea. No tear
of perineum. Child breathing normally in twenty minutes without
any special treatment. Complete amnesia and analgesia. Mother and
child both well the next day.

Case V. — Contracted Pelvis. Two Doses of Morphia; Three Whiffs
■of Chloroform. Her Doctor sent her in for Cesarean. — Primipara, set. 1 9.
Conjugata vera less than 3| ins. Eleven injections. As she was very
noisy during the first three hours we gave her three whiffs of chloro-
form. The head was bobbing at the brim during the first six doses.
Before giving the seventh dose a vaginal examination was made and
the os was found fully dilated. We ruptured the membranes and
gave \ gr. morphia and jfo gr. scopolamine. After this she gave no
further trouble. The head gradually moulded ; the external parts,
which were unusually small, dilated, and the child was delivered
spontaneously without any tear of the perineum. Great moulding of
the head. The mother was not given chloroform as the head emerged.
The head was kept on the perineum for nearly two hours to insure
full dilatation of the parts. Child born in oligopncea ; normal breath-
ing in thirty minutes without treatment. Complete amnesia and
analgesia. Mother and child both well the next day.

Case VI. — Contracted Pelvis. Two Doses of Morphia. Thirty-three
Injections. — Primipara, set. 27. Justo-minor between 3£ ins. and 3| ins.
Thirty-three injections. Second dose of morphia about three hours
jefore birth. After the head was two hours on the perineum, forceps

98 . Robert Wallace

was applied and child delivered. Mother slept a good deal during
treatraent. When awake she incessantly talked nonsense. Much
moulding. Child in oligopnea. Breathed normally in twenty
minutes. Complete amnesia and analgesia. Mother drowsy the next
day. Child quite well.

Case VII. — Inevitable Abortion of Four Months. Two Doses oj
Morphia. — A good deal of bleeding during the night before admission ;
packed cervix and vagina and gave twelve injections. First and fifth
doses of l gr. morphia and y^ gr. scopolamine. Removed packing
in twelve hours and found embryo on top of it. She was curetted
without being aroused. Complete amnesia and analgesia. Felt rested
the next day. Left hospital in a fortnight quite well.

Case VIII. — Maniacal at Height of Pains. Difficult to Control. Four
Whiffs of Chloroform. — Multipara, set. 33. Third pregnancy. Con-
jugata vera 3J ins. The first pregnancy was a three-months' abortion.
The second pregnancy was a six-months' abortion. External parts
very small. Fifteen injections ; the first of | gr. morphia and yi^ gr.
scopolamine, the following eight doses of T^ gr. scopolamine. She
made such an outcry we gave her four whiffs of chloroform and made
the last six doses g^g gr. scopolamine. Baby cried as soon as born.
Great moulding. Complete amnesia and analgesia. Mother and child
quite well the next day. It is doubtful if this child of 6 lbs. 14 ozs.
could have been born spontaneously alive and well and without a tear
of the perineum, through such a small pelvis, without the aid of
twilight sleep.

Case IX. — Sent in for Pubiotomy. Conjugata vera less than 3| ins.
Very Small Woman. Two Doses Morphia; Four Whiffs Chloroform. —
Multipara, set. 31. Second pregnancy. First pregnancy a craniotomy.
Thirty-two injections. Two doses of morphia ; first and twenty-third
dose. Twenty-two doses of T-}^ gr. scopolamine ; nine doses of
3TJU Sr- scopolamine. Chloroform four times. Pains very strong.
Much outcry and restlessness. Head thirteen hours in engaging.
Great moulding. Delivered spontaneously under chloroform. Child
in oligopnoea. Normal breathing in thirty minutes. Mother and child
quite well the next day. She said she never felt better in her life.

Case X. — Conjugata Vera 3 J ins. Two Doses Morphia; Four Doses
Chloroform. — Multipara, set. 21. Third pregnancy. First pregnancy
still-born. Second pregnancy, forceps ; lived ten days. Six injections ;
first and fifth doses of \ gr. morphia and y^ gr. scopolamine. Very
restless and noisy. Kept her under with four whiffs of chloroform
and two doses of morphia. Child born spontaneously while mother
under chloroform. Complete amnesia and analgesia. Mother and

Scopolamine- Morphine Narcosis sift

child both well the next day. The last dose of morphia was given
less than two hours before the birth of the child.

Case XI. — Conjugate/, Vera 3 J ins. Full Breech. Two Doses Morphia ;
Four Whiffs of Chloroform. — Primipara, set. 30. Breech presenting and
half-way down cavity. Labour going on twenty-four hours before
admission. Sent into hospital by her doctor. Sixteen injections ;
first and sixth doses of \ gr. morphia and T^7 gr. scopolamine ; four
doses of T \jj gr. scopolamine ; six doses of ^^ gr. scopolamine. Very
restless and much outcry. Kept her under with aid of four whiffs-
of chloroform. Full breech impacted on perineum. After an hour's-
vigorous manipulation delivered a dead child of 7 lbs. 5 ozs. Mother
next day said she felt well, but tired. Partial amnesia and analgesia.

Case XII. — Mental Confusion lasting for a Week after Delivery. —
Multipara, set. 34. Second pregnancy. First child, set. 8, alive and
well. Twenty-six injections. In a dozing condition the whole of the
time. No evidence whatever of pain. Child born spontaneously
without a tear of the perineum. Very vigorous child. Cried as soon-
as born. The mother persisted in a state of mental confusion, with
hallucinations of sight and sound, for six days after delivery. Fell
into a light doze occasionally but no proper sleep. Under treatment
with bromidia she gradually recovered her mental balance and was
quite normal again at the end of a week. Mother and child left the
hospital quite well a week later.

Case XIII. — Conjugata Vera 3£ ins. Pubiotomy Case. — Multipara,
set. 33. Sixth pregnancy. Three boys craniotomied ; two girls
delivered dead with forceps. With the aid of twilight sleep and
pubiotomy she now delivers a living child. Twenty-three injections.
Head bobbed at the brim for twelve hours before engaging. Foetal
heart regular and normal. Head impacted half-way down cavity. Dr.
James Lackie did a pubiotomy and in less than five minutes delivered
a healthy, vigorous child. Weight 8 lbs. Mother made a splendid
recovery. Next day she said she felt a little sore about the pelvis but
otherwise felt quite well. Mother and child left the hospital in
excellent condition.

Case XIV. — Complete Amnesia and Analgesia with Four Doses. —
Primipara, set. 20. Four injections. First dose put her to sleep.
Unconscious all the time. Child cried as soon as born. Mother and
child quite well the next day.

The Number of Doses. — The number of doses given to each
patient in the present series of observations range from a single
one up to forty-one doses.

100

Robert JVallace

That a large number of injections can be given without injury
to either mother or child is evident from a careful study of the
-cases cited above. Case II., given on page 96, had forty-one
injections. There was complete amnesia and analgesia. Both
mother and child were well the next day and were discharged
from hospital in excellent condition. A difficult primiparous
breech case had twenty-five injections. The child cried vigor-
ously as soon as born, and mother and child were both quite well
the next day. Case IX., given on page 98, had thirty-two injec-
tions. Both mother and child were quite well the next day.
The mother said she never felt better in her life.

In the pubiotomy case, sketched on page 99, twenty-three
injections were given. The child cried as soon as delivered. The
mother's recovery was most satisfactory. Both parent and infant
left hospital in perfect health.

The number of doses given has no direct relation to the degree
of amnesia and analgesia attained. One case was in complete
amnesia and analgesia from the first dose, the total number -oi
doses being only four.

Only three patients out of 104 cases treated had a single dose.
Twelve patients had two doses; twelve patients had four doses,
and nine had six doses. Those having only one, two, or three
doses reached hospital too far advanced in labour to derive full
benefit from twilight treatment.

Hereunder is a complete statement in tabular form of the
number of doses given to each patient: —

Xumber of Doses.

Number of Patients

1 3

2

12

3

7

4

12

5

6

6

9

7

6

8

3

9

5

10

1

11

4

12

4

13

1

14

3

15

4

16

3

C

arry foi

•ward

83

Scopolamine-Morfthine Na r costs

101

Number of Doses.

Number of Patients

Brought forward . 83

17

4

18

3

19

2

23

3

25

2

26

2

32

1

33

1

37

1

41

2

Total

104

Eoutine Treatment Carried Out in the Foregoing
Series of Cases.

1. The patient was thoroughly examined before beginning the-
treatment. The state of the passages was determined and the
pelvic measurements taken. Bladder and bowels were emptied,
and pulse and temperature recorded.

2. She was put into a quiet, darkened room and all visitors
were excluded.

3. The injections were begun as early as possible in the first
stage consistent with the pains being regular and strong. The
first dose consists of \ gr. morphia and T\-^ gr. scopolamine. The
second injection of T^ gr. scopolamine was given three-quarters
of an hour later. Subsequent injections of j^ gr. scopolamine-
were repeated hourly until the child was born.

4. We found that morphia can be safely repeated at intervals
of a few hours if the patient is difficult to keep under.

5. An occasional whiff of chloroform is very helpful in con-
trolling restless patients. We always gave chloroform when the
head was being born, if the pains were strong.

6. Water was given when the patient was thirsty, and she
was catheterised when necessary. The condition of the lips is a
good index of the need for water.

7. We unhesitatingly put on forceps if the head was well
down and the parts well dilated.

8. The baby was removed as soon as born to prevent its cries-
arousing the mother and thus creating an " island of memory."

9. A child born in a state of oligopncea must not be forcibly
treated. We simply cleared the respiratory passages and kept
it warm. In some cases we did a little very gentle artificial
respiration.

102 Robert Wallace

10. As the patient needs to be constantly watched we kept a
competent nurse in constant attendance.

11. It is very important to. get a reliable and constant pre-
paration of scopolamine And morphine. The doses are made up
in tablet form which dissolves very rapidly without residue.

The varying results of different observers are due to four
factors : —

(i) The varying composition of the narcotics used.

(ii) Differences in dosage.

(iii) Personal idiosyncrasy to the drug.

(iv) The personality of the physician and attendants. The
patient must be encouraged to have perfect faith in the treatment.

Conclusions.

Scopolamine-morphine narcosis is a great boon to the lying-in
woman. It is a perfectly safe and efficient means of managing
labour when intelligently used.

It is of special value in primiparae, in whom, as a rule, the
first and second stages are long and painful; and in a prolonged
second stage due to a large head or contracted pelvis, as it allows
head moulding and dilatation of the maternal parts to proceed
easily and gradually, without exhausting the patient. From the
work that has already been done in perfecting this anaesthesia,
there is not the shadow of a doubt that the treatment has come
to stay, and that it will be an unqualified blessing to the
motherhood of the future.

And there are obstetricians even now who would as soon
consider performing a surgical operation without an anaesthetic
as conducting a primiparous labour without scopolamine-morphine
narcosis.

The only contra-indication to the use of twilight sleep is
•personal idiosyncrasy. Idiosyncrasy occurs in a small percentage
•of cases where scopolamine acts as an excitant rather than a
sedative.

Absence of exhaustion after difficult and prolonged labours is
one of its greatest advantages.

As now, more than ever, the importance of motherhood is
being realised by the State, twilight homes should be established
all over the country where lying-in women could have the best
and closest attention.

Clinical Record 103

CLINICAL RECORD.

CARCINOMA OF THE LIVER ASSOCIATED WITH
INFECTION BY CLONOKCHIS SINENSIS.

By H. L. WATSON-WEMYSS, M.D., F.R.C.P.(Edin.),
Captain, R.A.M.C.

I recently had the opportunity of examining, post-mortem, a
•case which, on account of its interest and rarity, seems worthy
of record. I have to thank Dr. V. Mifsud, who was in medical
charge of the patient, for kindly placing the notes of the case at
my disposal.

The patient was a Chinese, a French colonial soldier, and was
admitted to hospital on the 21st July 1918. His age was probably
about 50. No history was obtainable owing to the impossibility of
communicating with him. He was extremely emaciated and com-
plained of pain in the limbs and chest. He lay in bed with his legs
drawn up. His temperature was irregular and frequently reached
100° F., while the pulse-rate was usually about 120. Severe constipa-
tion alternated with bouts of diarrhoea. The liver was slightly enlarged
in both an upward and downward direction and was tender to the
touch.

There were a few crepitations at the right base. The stools were
examined on two occasions by Lieutenant Bentham, protozoologist to
the command, and were found to contain the ova of clonorchis sinensis
in enormous number. No other parasite was found. The patient
gradually became weaker and more cachectic, and died on the 20th
August.

At the autopsy the heart and lungs were found to be free from
disease. There was a little excess of fluid in the pericardium. The
gall-bladder was greatly distended with bile, in which large numbers
of flukes were present. The liver was enlarged and firm and showed
numerous white patches on its surface. It was firmly adherent to the
diaphragm. On the upper surface of the right lobe there was a tumour
the size of a small Tangerine orange, white in colour and densely hard.
A small quantity of pus had formed between it and the diaphragm,
which doubtless caused the physical signs noted during life. Section
of the liver at almost any point resulted in the flukes escaping in
numbers from the cut surfaces. The presence of the worms in the
pancreas could be demonstrated in the same ways. Numerous hard
glands were found in the abdomen, chiefly around the head of the
pancreas. The tumour of the liver itself proved on examination to
be a carcinoma.

104 Clinical Record

During the last eighteen months, infections by many different
worms have been noted in this hospital, but the case under con-
sideration was only the second in which clonorchis sinensis had
been found. The other case also occurred in a Chinese. Clonorchis
sinensis is common in China, Japan, and certain parts of India,
and, with the exception of schistosomum hsematobium, may be said
to be the most important trematode infecting man. The literature
of the subject is at present inaccessible to me, but, according to
text-book descriptions, infection by clonorchis sinensis is a frequent
cause of death in the localities where it is prevalent. The main
interest of this case lies in the presence of a carcinomatous tumour
in the liver, induced, it can hardly be doubted, by the irritating
presence of the worms. Braun x refers to a paper by Askanazy 2
on the relationship of carcinoma of the liver to infection by
opisthorchis felineus, a similar but slightly smaller trematode.
Apart from the actual carcinomatous growth, sections of the liver
tissue showed, when cut and stained, large numbers of ova, and
otherwise very exactly reproduced the picture which Brumpt3
gives in the following words : —

" Les canaux biliaires presentent comme alteration constante,
un epaisissement sclereux de leurs parois ; cette sclerose ne fait
jamais defaut. ... Le plus souvent l'epithelium biliaire irrite
m^caniquement par le ver ou par ses toxines reagit en proliferant
d'une facon intense ; le canal qui l'enserre l'oblige a se plisser et
finalement nous avons un manchon adenomateux visible a l'ceil
nu sur la coupe. En general ces tumeurs restent limitees par la
basale du canal biliaire.

" Dans certain cas [this was the case in the present instance]
la basale est rompue, les productions ad^nomateuses diffusent dans
la parenchyme, la cavite de ces tubes disparait et nous avons des
canaux epitheliaux constituant une tumeur maligne nettement
determined par l'irritation parasitaire."

My best thanks are due to Lieutenant Bentham, without
whose assistance this short record of the case would have been
impossible.

I have also to thank Colonel Price, C.M.G., A.M.S., Officer
Commanding Military Hospital, Imtarfa, Malta, for permission to
publish the case.

References. — J Braun, Max., The Animal Parasites of Man, London, 1906.
8 Askanazy, M., quoted by Braun., loc. cit. 3 Brumpt, E., Precis de parasitologic,
Paris, 1913, p. 337 et seq.

Dental Surgery for Medical Students io5

THE TRAINING OF THE STUDENT OF MEDICINE:

An Inquiry Conducted under the Auspices of the
Edinburgh Pathological Club.

LXIV.— DENTAL SURGERY FOR MEDICAL STUDENTS.

By WILLIAM GUY, F.R.C.S., L.D.S., Dean of the Dental School.

In discussing very briefly the question of including dental surgery in
the medical curriculum, it may be well to narrow it down to the essen-
tial issues. I would state them thus : (1) Is it desirable that medical
students should be taught something of dental surgery1? (2) What
should be the scope and extent of the teaching1? (3) How, when,
and where is the instruction to be obtained 1

To (1) I shall assume that the answer is in the affirmative.

(2) is not so easily answered. I think, however, that prosthetic
dentistry and conservative dentistry must be excluded. For the rest,
the requirements would seem to vary with the many fields of practice
open to the medical practitioner.

A knowledge of dental hygiene and prophylaxis is an indispensable
part of medical and surgical knowledge. The same is true of a know-
ledge of the consequences or possible sequelae of dental disease,
accident, or trauma, and of dental symptoms associated with such
conditions as scurvy, diabetes, plumbism, congenital syphilis, cretinism,
phosphorus poisoning, pregnancy — to name but a few.

The arrest of post-extractional haemorrhage is important. The
administration of suitable anaesthetics for dental operations should be
taught to all general practitioners.

Coming to purely dental work, which, though specially the province
of the dental surgeon, may in emergency be undertaken by the doctor,
I would specify tooth extraction, the treatment of odontalgia from
whatever cause arising, of periodontitis, alveolar abscess, and gingivitis.

All should be instructed in the differential diagnosis of true
pyorrhoea alveolaris, marginal gingivitis due to the presence of tartar
or dirt, and the conditions attendant upon the physiological process
of the shedding of teeth. Some instruction should also be given on
the evils arising from oral sepsis, more especially that associated with
the presence of bridges, crowns, dead teeth, and roots.

The panel doctor and the country doctor must be able to extract
and to give anaesthetics. The pure surgeon or physician and the
practitioner in a large town need not concern themselves with
extraction of teeth.

There remain the medical missionary and the colonial practitioner.
These should be able to do something in the way of first aid dentally

8

106 J , H. Gibbs

— that is, to put in a dressing, devitalise a pulp, and insert a plastic
filling.

(3) If instruction in dental surgery is to be made compulsory for
medical students, further facilities must be afforded : they certainly
do not exist at present.

Neither at the dental hospitals nor the infirmaries is there room
or sufficient clinical material for satisfactory practical teaching. The
dispensaries may be counted out as of little value in this department
of study.

Nevertheless, an effort should be made. The difficulties are-
great. There are very few competent teachers. There are no endow-
ments for dental education, and the dentist who devotes any considerable
part of his time to teaching suffers a pecuniary loss.

In Edinburgh it seems to me that there would have to be co-opera-
tion between the Infirmary and the Dental Hospital. Some extension-
of the dental department of the Infirmary would be needed. The
course of instruction must be compulsory — an optional course would
not survive. It should comprise at least fifty clinical lectures and
demonstrations on dental surgery and medicine spread over the last
two years of the medical course, together with attendance on practical
instruction on extraction of teeth and administration of anaesthetics
for dental operations.

The Scottish universities, with the exception of St. Andrews,
which recently instituted examinations for a dental diploma, have not,
up to the present, taken any interest in dental education or degrees for
dentists. Should they determine to enter on this sphere of educa-
tional activity, the existence of a Chair of Dentistry and university
lectureships would resolve most of the difficulties which at present beset
the teaching of dental surgery and medicine in the medical curriculum.

LXV.— THE TEACHING OF DENTAL SURGERY TO
MEDICAL STUDENTS.

By J. H. GIBBS, F.R.C.S.(Edin.).

Anyone who has regularly attended these discussions upon the train-
ing of the medical student must have been struck by the demand that
almost every teacher has made — that more time should be allotted to-
him for the adequate teaching of his subject — whilst really no one has
complained that he has too much time. As matters stand at present,
the student is undoubtedly overburdened, so that some boldness is
required on the part of anyone who proposes that still another subject
should be added to the curriculum. When one recognises that the
medical student in all the Scottish universities graduates at present
without having had any specific instruction in the two commonest
diseases to which mankind is liable, one is surely justified in demand-

The Teaching of Dental Surgery 107

ing that this state of affairs should be changed. Many universities
have long ago recognised the importance of their medical students
having some definite knowledge of the diseases of the mouth and
teeth, and have required courses of instruction which, personally, I
think are unnecessarily long.

The remedial treatment of dental disease is so specialised that it is
by common consent relegated to the dental surgeon, and the general
practitioner quite wisely sends any patient requiring this treatment
to the specialist. To-day, however, is the day of preventive medicine,
and the future will be so still more. Most dental surgeons are well
aware that the great bulk of dental disease is quite easily prevented
and that remedial measures are comparatively ineffectual, but they can
do very little to help the patient, because the seeds of dental disease
are sown long before they see him — in fact, during the first few years
of life, when the child is so much under the care of the family doctor.
Hence it is to the general medical practitioner that we must look for
the proper upbringing of the infant and young child that these diseases-
may cease to exist. At the present time so ignorant is he of the real
physiological functions of the mouth and its secretions, of the etiology
and pathology of dental disease, and of the ease and success with
which these diseases can be prevented by measures that are wholly
beneficial to the general health of the child, that one has no hesitation
in saying that the prevalence of dental caries and of pyorrhoea alveolaris-
to-day is almost entirely due to the vicious teaching and practice of
the average medical man.

Again, every dentist who attempts to save the children of his-
patients from these diseases by instructing the parents how to bring
them up in accordance with physiological principles, the soundness of
which has been abundantly proved during the last twenty years by
the success that has been attained in preventing not only dental but
other diseases, is met at once by the active opposition of the far more
powerful, but ignorant, general practitioner. It is more than time
that this ignorance on the part of the average doctor of the physio-
logical functions of the mouth and of the barest principles of dietetics
should be remedied, and, provided it is remedied, I do not think it
matters much whether the correct knowledge is imparted to the
student in a special course of dental instruction or in his ordinary
classes. Fortunately the physiologist does not spend much of his
time, either in lectures or in the laboratory, over dietetics, the physio-
logical functions of the mouth and saliva, the nature of mastication,
and of the act of deglutition. It is extraordinary that, after all the
work that has been done along these lines both in this country and
abroad, physiologists should almost without exception still hold and
teach views that have been discredited for many years. Now, inas-
much as the great bulk of dental disease is the outcome of this pernicious-

108 J. H. Gibbs

physiological teaching, the first thing to do seems to be to educate the
physiologist or to protect the student so far as possible by letting him
come under better influences later in his course.

If the medical student is to have a special dental course, as in the
present circumstances I think he should, the instruction should be
made as short as possible and carefully designed to meet the needs of
everyday practice. As a result of my own experience as a teacher
and practitioner, I think that the medical student should be taught
correctly the physiological processes that occur in the oral cavity and
the principles of dietetics, including the proper feeding of infants and
young children. He should also be taught the etiology and gross
pathology of the two commonest diseases — dental caries and pyorrhoea
alveolaris — and the ease with which they may be prevented by
physiological means, and the futility of artificial aids. Because dental
diseases are so rarely a direct cause of death, the general practitioner is
apt to look upon them as of no importance, and it should therefore be
impressed upon the student that they cause more pain, ill-health, and
inefficiency than any other disease, while indirectly they do entail a
large mortality.

Even consulting physicians, teachers of students, habitually pour
good food and medicine into patients who often benefit but little,
because they are absorbing toxins from ulcerated areas in their mouths
that may amount to several square inches. Were ulcers of a tenth
the size to occur in the much-examined rectum or on the skin, they
would be vigorously and promptly treated. Similarly, children are
allowed, with the full knowledge of their doctor, to retain decomposing
teeth, often with abscesses, simply because they may not be causing
actual pain. The student must be impressed with the importance of
his patients having clean mouths at all costs. To-day, even when this
is realised, it is effected by extracting the teeth after they have become
unnecessarily diseased and a menace to the health of the patient, but
the student should be taught that the mouth and teeth must be kept
clean, not by disfiguring mutilation, but by simple and rational
preventive measures.

As regards remedial treatment, he should be taught that neuralgia
is only a symptom and that the cause can nearly always be discovered
and easily removed. He should know simple means of relieving
toothache, and especially how to stop haemorrhage from a socket after
an extraction. He should, of course, be taught such a common
operation as the extraction of teeth. The principles involved can be
explained to a large class, and this should be supplemented by a
demonstration and actual practice.

I think that the minimum instruction necessary could be given in
a'course of seven or eight meetings — it being taken for granted that
the medical practitioner is not to act the part of the dentist, but

Diseases of the Ear, Nose, and Throat ioi>

through putting into practice his knowledge of general principles is
to be an apostle of a much higher standard of personal hygiene and
national health than obtains to-day.

LXVL— THE TEACHING OF DISEASES OF THE EAR, NOSE,
AND THROAT IN THE UNDERGRADUATE CURRICULUM.

By A. LOGAN TURNER, M.D.

The specialty entirely justifies its place in the curriculum of the under-
graduate. It does so on two grounds — first, the progressive import-
ance of the specialty ; secondly, its value as a diagnostic factor in
the recognition of many general diseases.

Let us bring evidence to support both of these points. In 1899'
there was one Ear and Throat Department in the Royal Infirmary and
the number of new patients seeking advice during that year was 1150.
Fifteen years later — I have taken 1914, as the war may have affected
hospital attendance in the immediate past — there are two departments,
and in my own the number of patients attending for the first time
during that year was 3363. If my colleague's patients be added, the
total is considerably increased, probably approaching 5000. The
number of adenoid and tonsil cases alone in 1914 exceeded the total
patients visiting the department in 1899, being 1278 in number. It
is one of the busiest departments in the Infirmary — a striking proof
of its usefulness.

During these fifteen years the specialty has not only increased the
number of its patients but it has greatly extended its boundaries.
We have practically taken over from the general surgeon intracranial
surgery in relation to septic infections from the ear and nose ; we have
come to the assistance of the ophthalmologist in the treatment of
orbital conditions secondary to infections of the nasal accessory sinuses,
and we are prepared to help him in his cases of chronic dacryocystitis.
We have extended our territory to the diaphragm, and in our examina-
tions of the oesophagus and lower air-passages we can assist the surgeon
and the physician in the diagnosis of important conditions, while the
treatment of foreign bodies in these regions has gradually passed into
our hands. The more recent elaboration of the tests in connection
with the eighth cranial nerve has called us to the help of the neurologist
in determining the diagnosis of certain obscure intracranial conditions.
We have thus made our annexations : we have not yet claimed our
indemnities, but this we propose to do after the war. I shall refer to
that presently.

The second argument in favour of its inclusion in the curriculum
is based upon the value of the specialty in the recognition of many
diseases. The ear, nose, and throat are to the body what the outposts

110 A. Logan Turner

are to the army in the field ; they may furnish us with the first signals
of danger and of the presence of the enemy — disease. Vertigo may
herald the advance of arteriosclerosis and epistaxis may prove the first
warning of renal mischief. The discharging ear should keep the
practitioner alive to the possible source of the headache and vomiting
due to a secondary brain abscess or meningitis, and to the origin of
those rigors and varying temperatures accompanying a sinus thrombosis.
The changes in the mucous membranes of the throat and in its
lymphatic tissues may be the first evidence that the patient is the
victim of syphilis, or they will furnish an explanation of some of those
obscure toxic conditions which are often baffling. In hoarseness we
may have a striking danger-signal, giving the first indication of the
presence of deep-seated malignant disease, of pulmonary tubercle, of
aneurysm, or of a central nervous disorder.

And this brings us naturally to the principle which should underlie
the instruction of the undergraduate in this subject, viz. to acquaint
him with the relations which the organs bear to general diseases. The
teacher should approach his class mindful of the fact that his own
training should have made him a surgeon and a physician, provided
with a better knowledge than his colleagues of these special regions.
One is almost inclined to say that while he is teaching he should forget
that he is a specialist. No finicky details : no elaborate description
of operations : no minute account of rare conditions. These must be
reserved for the post-graduate course. This is the principle upon which
I have taught undergraduates for fifteen years, and I believe it to be a
sound one — teach them to recognise the appearances presented by the
common ailments and point out to them the significance of the symptoms
which I have enumerated. The danger which one sees throughout the
whole of this discussion is the lack of a proper perspective — the risk
being that each man attempts to teach too much of his subject. We
teachers spend the best years of our lives in acquiring our own know-
ledge and we never attain perfection : how can we expect more than
the simplest essentials from our pupils %

What are the means at our disposal for conducting such courses 1
Three terms, each of ten weeks, and each student, in his fourth or fifth
year, must attend for one term. There are thirty meetings in a term,
nine or ten for a more or less systematised account of the commoner
conditions and their bearing on general medicine.

Twenty clinical meetings — the whole class is restricted to thirty
or forty members. The clinical meetings are still further limited,
preferably to ten or fifteen. The whole available staff takes part in
the clinical teaching. This is an essential part of the arrangement —
good for the staff and in the best interests of the student. The
teaching staff is encouraged to do scientific and clinical research,
because when teachers are thus engaged, they can then infuse a

Diseases of the Ear, Nose, and Throat ill

scientific spirit into their pupils, while it also improves their manner
of teaching.

As many of the common ailments as possible are shown and the
class handle the patients themselves.

Twenty clinical hours are not sufficient. We ought to have twice
that number. In the medical schools of Canada and the United States
the programme is more ambitious, and facilities are given in some of
them for students attending at two periods in their curriculum. A
short junior course for anatomy, methods of examination, and the
recognition of what is normal in the ear, nose, and throat, and a later
■course, nearer the final term, where diseased conditions are investigated,
would more nearly approach the ideal.

Now I come to the indemnities. I have said that there are two
departments, but both are compelled to work in and share the same
out-patient room, the same theatre, the same wards. This is not
as it should be in a large and progressive specialty. I am conse-
quently forced to teach on certain days, and could not teach on other
days if I would, because my out-patient room is occupied by my
colleague. Some arrangement must be come to between the University
authorities and the Infirmary management to put the Ear and Throat
Department on the same footing as the Eye Department, providing
each surgeon with a distinct and separate department. The money
must be forthcoming. Both on teaching and scientific grounds and in
the best interests of the patients it is necessary, and though the
improvement is unlikely in the immediate future I hope to work for
it for the benefit of my successors. The reputation of a large medical
school cannot rest upon its teaching advantages alone : it is the duty
of every member of the staff to aspire to something more than a routine
and efficient discharge of his obligations to his pupils, and to endeavour
to do something to add to the sum of knowledge of his own particular
branch. We are apt to criticise the waning success of our Alma
Mater. Some of us, I am afraid, are too ready to blame the cur-
riculum and are forgetful of the human factor. Does not some of
the remedy lie in our own increased efforts 1

LXVIL— THE INSTRUCTION OF THE UNDERGRADUATE
IN DISEASES OF THE EAR, NOSE, AND THROAT.

By J. MALCOLM FARQUHARSON, M.B., F.R.C.P.

I have had pleasure in acceding to the request of your secretary to
speak briefly on this subject to-night, and shall make my remarks as
succinct as possible. I shall accordingly enter into no great detail, but
shall indicate the principles which appear to me to be most desirable,
if not essential.

This subject has now become a compulsory one in the course of

112 J. Malcolm Farquharson

medicine, and it will at first probably be difficult for the department
to cope with the number of students presenting themselves for instruc-
tion, and in all probability changes will have to be made to suit require-
ments and altered circumstances. It would appear, however, to be
certain that the size of the class must be kept as small as possible, and
this for various reasons. Comparatively few of the diseases affecting
the ear, nose, and throat are recognisable without the aid of instruments,
and accordingly it is impossible to demonstrate them to numbers at one
time. At first diseases can be shown by the teacher to one student at
a time, but the scope of this elementary instruction must, very soon,
be widened, and the student taught the use of the instruments and to-
train his powers of observation to recognise the disease for himself.
This, of course, occupies much time and is a handicap to the teacher in
aural, nasal, or laryngeal work, and presents a difficulty to him which
is not encountered by teachers of most other subjects. Happily for
teaching purposes, the majority of the diseases which come under
review at out-patient clinics are of a chronic nature, and can therefore
be bandied and demonstrated more or less freely, and to some extent
this is a countervailing advantage to the teacher. It must not be-
forgotten that we are dealing with undergraduates who have necessarily
a comparatively small clinical experience, in contradistinction to the
post-graduate, who is in a position to apply principles in a way
impossible to the former. It is necessary then that the undergraduate
teaching should be confined to a limited field, in which, at any rate in
the first instance, the commoner diseases are fully demonstrated, being
those conditions in fact which he will most frequently encounter in
general practice. Seeing that clinics must be limited in numbers, how
can the students all be instructed adequately % There are at present
two lecturers appointed by the university and the conditions at present
permit of their adequate instruction by the lecturers, assisted by the
assistant surgeon. If, in the future, the numbers applying for instruc-
tion increase, then the university may have to consider whether the
assistant surgeons of the department ought not to be co-opted officially
for assistance in carrying out the obligation of the university to the
student. I can see in such an arrangement an important incentive to
the junior members of the staff, and one which I believe they would
appreciate.

Further, also, I think the student should have the advantage of
clinical lectures, whereby the teacher is enabled to focus attention on
essentials and arrange and systematise the instruction by him. In my
experience the average student does not make much use of text-books,
probably from want of time owing to the pressure of other work, and
from difficulty in selecting what to read ; and if he does, much time and
energy is often dissipated upon the study of diseases of a comparatively
unimportant or abstruse nature. In the lecture such points as the

Discussion 11$

differential diagnosis, avoidance of pitfalls, and the details of treatment
can be more fully elaborated than is possible by the use of text-books
alone ; besides, the personal oral teaching will, in my opinion, be con-
ducive to better results, and in this view I am supported by the
opinion of students, with whom I have frequently discussed this point.
Again, as a- further advantage it is possible to save some time weekly
by teaching a larger number of students collectively, and it is an agree-
able variety in the routine of teaching.

The clinic and the lecture should be supplemented by tutorials,
wherein instruments can be demonstrated, operative proceedings
referred to, and full instruction given in methods of examination. The
employment of models, specimens, and occasionally of patients ir>
tutorial work will, of course, materially assist the student in acquiring
familiarity with diagnostic methods and therapeutic procedures.

Personally, in carrying out the teaching in the department, I have
two clinics and two lectures weekly ; in the latter I take the opportunity
of discussing more fully any important case that has come before us-
in the clinic. In this way I am enabled to have about thirty-five
meetings in the term, with what, I consider, satisfactory results.

With one point of importance I will conclude what I have to say
on this matter, namely, that the teacher should take every opportunity
of showing the bearing which aural, nasal, and laryngeal diseases have
on general medicine and surgery. I would refer to asthma, aneurysm,
thoracic neoplasms, epistaxis, etc. The importance of these inter-
relationships can hardly be over-emphasised, and the future practitioner
should early be taught to take a broad view of such subjects and not to
confine his diagnostic facts to the special region where symptoms appear.

These are the principles which seem to me to underlie the successful
instruction of the undergraduate, and, given their acceptance, I am sure
that it would not be difficult to work out the practical details.

DISCUSSION.

Dr. George Mackay emphasised the importance of teaching ophthalm-
ology clinically, and supported the appeal that had been made for inci'eased
accommodation in the Infirmary for this purpose. As a Manager of the
Infirmary he said that only the lack of funds prevented this being provided.
He also urged the necessity for provision being made for higher teaching and
for research, and for the wider employment of the junior members of the
stall' in teaching.

Dr. Sinclair. — From personal experience in teaching ophthalmoscopy
to undergraduates and graduates, I can say that little or no advantage is
gained from tutorial instruction in ophthalmoscopy, unless the use of the
instrument be continued in the medical wards. The use of the ophthalmo-
scope should be insisted on in the medical wards, and reports and draw-
ings of the optic discs, retinal vessels, etc., attached to the clinical records

114 Discussion

of medical cases taken by clinical clerks, whether there is anything wrong
with the eye or not.

The difficulty in learning to use the ophthalmoscope (indirect and direct
methods) is no doubt a considerable barrier to what I have suggested, and
may be discouraging to the beginner in clinical medicine. If, however, the
jiatient is examined with the pupils dilated, and the student has the
encouragement and guidance of his teacher, this difficulty will be overcome.

The electric ophthalmoscope is much easier to use than the ordinary one
and affords a very attractive picture of the fundus oculi. Each medical
ward should possess an electric ophthalmoscope for the use and convenience
of students in case-taking.

The teaching in the Eye Department will, as in other charges, be under
the entire direction of, and in the main be carried out by, the ophthalmic
surgeon in charge of the department. The assistant ophthalmic surgeon
should, however, take some regular part in the teaching — such as may lie
allotted to him by the surgeon in charge. This is important in the teaching
of practical ophthalmology, where clinical demonstration forms the most
valuable and the largest part of the work.

It is also important that enthusiasm for, and facility in, teaching should
be developed in the assistant surgeon, as he may at any time be called upon
to undertake the whole work of the class, and, in the ordinary course, will
have to do this when his turn comes. It is essential that he should have
practice as a teacher in order that he may be able with the greatest efficiency
to carry out the duties of a teacher of students when his time comes to do so.

Dr. J. S. Fraser said that one of the great difficulties in the teaching
of the ear, nose, and throat is that the student must master the use of reflected
light, and this he finds very difficult, particularly in laryngoscopy. It is
impossible to teach students laryngoscopy in the time available.

In conducting tutorial classes he had found it necessary to devote a large
part of the time to teaching the anatomy and physiology of the organs of
special sense. This should be done in the departments of anatomy and
physiology and so leave the surgical tutor free to devote his time and
attention to clinical teaching.

Diseases of the ear and their complications are attended with such a
mortality that it is essential for the undergraduate to be thoroughly
instructed in this subject. If general practitioners realised the dangers of
*' running ears," and were taught to recognise the onset of serious complica-
tions, there would be a considerable saving of life.

In the teaching of the special subjects it is essential to deal with .small
classes, and this necessitates the employment of every member of the staff in
teaching and the provision of better accommodation in the department.

Dr. Traquair had found it very difficult to teach the students ophthal-
moscopy in tutorial classes. Even in a special class for post-graduates, ex-
tending over thirty hours, the results were only moderately satisfactory.
Their main difficulty seemed to be to learn the management of light. The
use of the ophthalmoscope should be practised more in the medical wards
than it is, and if the electric ophthalmoscope were used the student would
soon learn to see clearly everything that is to be seen in the fundus, and
would appreciate the bearings of the eye changes on general medicine. The

Discussion 115

ophthalmoscope is really a physician's diagnostic instrument and should rank
with the stethoscope and the sphyginograph.

Diseases of the eye should not be presented to the student as a " special
subject" but as a part of clinical medicine and surgery. He was of opinion
that an examination on the subject was a stimulus to the student to master
the subject.

Mr. Wilkie said that at the end of the war an enormous amount of
money will be spent in keeping, up hospitals for assisting those disabled
in the war. That expenditure will fall on the Government. If medical men
are to be adequately trained to staff these hospitals, the Government should
provide money to support the hospitals which are essential for the teaching
of the medical men ; emphasis should therefore be laid on the financial aspect
•of the question.

Dr. Clarkson thought that all a general practitioner requires to know
of dental surgery could be taught in a course of seven or eight meetings.
He was of opinion that there should be no difficulty in teaching the student
enough of the use of the ophthalmoscope and laryngoscope to enable him to
recognise whether the condition present was one he could treat himself or
whether it should be sent to a specialist. The use of these instruments should
be commenced early in the student's training, and should be encouraged in
every way in the wards.

Dr. Norman Walker thought that the rising generation of teachers
was extraordinarily pessimistic about the outlook of things. He remembered
getting instruction in the ophthalmoscope and laryngoscope at the physiology
class, and again from Sir Robert Philip when he was assistant to Sir Thomas
Grainger Stewart, and as a student had in the medical ward quite common
opportunities of using both the laryngoscope and the ophthalmoscope.

Dr. Rainy said that when he was clinical tutor part of his work was
to teach the laryngoscope and ophthalmoscope, and practically every student
drew one or two f unduses and one or two vocal cords before he was allowed
to leave the class-room. When he had charge of the women students they
practically all learned the use of the ophthalmoscope in the medical wards,
and about 50 per cent, of them bought one for themselves before they left
the ward, which showed they appreciated the instrument and were likely
to use it. He thought it desirable to have an examination.

Professor Lorrain Smith. — It is important for us as a committee to
hear the point thoroughly discussed as to how far the students should be
examined in ophthalmology. The Dean is quite in favour of making the
elass certificate as much as possible take the place of the formal examination.
A great many of our discussions have introduced the idea that the term work
should as far as possible relieve the student of the burden of his professional
examinations.

Dr. Logan Turner. — I am in favour of the tendency to build up the
examination during the curriculum and not at certain periods. One of the
first things I tell my class at the beginning of the session is that there will
be a class examination and that all of them who obtain a certain percentage

116 Discussion

will qualify for the Final. I am against the suggestion that there should
he a Special Final Examination in ear, nose, throat, and eye subjects.

Dr. J. V. Paterson. — I hold the same view as Dr. Logan Turner. The
examination could quite well be connected with the class work, and the men
should not have to sit a separate examination in the Final. It should be made
clear to the students, however, that the examination they have to get through
at the end of the course of diseases of the eye or of the ear, nose, and throat
is the qualifying examination for the Final.

Dr. Norman Walker. — I agree with Dr. Logan Turner in this matter.
I have no difficulty about taking the onus of refusing a certificate. At the
first lecture of every course I explain to the students that the responsibility
is laid upon me of seeing that they shall not go out of this university without
such a knowledge of dermatology as shall not do discredit to the university.
If they do not succeed after going up twice, I make them take the class
out again.

Dr. Sim. — I would hesitate to stop a man from passing his Final solely
on the ground of his not being proficient at eyes. I think ophthalmology
ought to be correlated with the other subjects.

Dr. Gibbs suggested that a plan might be adopted by which a certain
percentage in the class examinations entitled the student to a qualifying
certificate, while a higher percentage exempted him from a special examina-
tion in his Final.

Dr. Paterson said in reply. — I am in agreement with those who say
that ophthalmoscopy, from the point of view of general medicine, is only
properly studied in the medical ward. The students would not require much
stimulus if ophthalmoscopes were provided, and there is no difficulty what-
ever in dilating the pupil and no danger attached to it with reasonable care.

I think in the eye ward we are inadequately equipped. This lack of
equipment in Britain tells far more on the training of the teachers than on
the training of the students. The British ophthalmologist has less oppor-
tunity of learning the higher branches of his profession than the ophthalm-
ologist of any of the highly civilised nations of the world. The assistant
in my day was overloaded with routine work at the Infirmary. The senior
assistant should not spend his whole time, and the senior surgeon should not
spend hours after the students have gone, in testing the refractions of school
children. That is the reason why there is not the time for research. The
training in physics and physical optics, for example, is inadequate. The
physiology of the eye has all to be learned from the book. From the scientific
point of view we are behind many of our continental friends and enemies,
because we have not the equipment and the time for the training and because
our energies are completely taken up by the routine work of the hospitals.

Dr. Guy said in reply.— The idea of giving fifty lectures and demonstra-
tions on dental surgery has been rather scoffed at, but I think I am perfectly
justified in taking that as the absolute minimum. I specified, for example,
the administration of anaesthetics for dental operations. I have no hesitation
in making the specific statement that no man knows anything whatever —
as I should understand knowledge of that department — about the administra-

Discussion 117

tion of anaesthetics more particularly for dental operations until he has had
at least fifty opportunities of administering the various anaesthetics under
skilful supervision. I said these meetings should be spread over the last two
years of the course. In that regard, if I may pass from the particular to the
general, it strikes me that what is required in the teaching of the eye
specialities which have been dealt with is co-ordination between surgeons,
physicians, and specialists. The most important part of the medical training,
in my view, so far as the man's life and practice are concerned, is in his
clinical training, which of course should only come after he has had a
sufficient training in the ancillary sciences and in the principles of medicine
and of surgery. Why does not the clinical teacher invite the co-operation
of the specialist ? We all know that there are many medical and surgical
conditions which remain obscure to the ordinary physician or the ordinary
surgeon because he is not a skilled specialist. I think that surgeons and
physicians might select such cases for cliniques, and even for clinical lectures,
and might on- these occasions invite the co-operation of the specialists. In
that way the medical student would have borne in upon him how important
the bearing of a study of the various specialities was upon the general practice
■of his profession.

The other point which has struck me in this discussion is the point which
the chairman, I think, raised as to how far class examinations might be
allowed to supersede Final Professional Examinations. That is perhaps the
most important point which has emerged in this discussion to-night, at any
rate to my mind. On the part of some there appears to be a hesitation to
assume the responsibility for saying that this man is fit and competent or
that he is unfit and incompetent. Of course there are other aspects of that
question. There is the man who is perhaps afraid that if he exacts too high
a standard from his students they will forsake him. All these difficulties
might be overcome, I think, if the class examinations were not confined
simply to the writing of a paper at the end of the course, but were continuous
throughout the course, i.e. at the latter part of every meeting the lecturer
might ask the students to perform some of the procedures which had already
been demonstrated to them, might note the value of their answers and the
skill which they displayed in manipulative processes. Thus at the end of
the course the teacher would be enabled to say quite definitely, " This man
has profited by my instruction, and I therefore have no hesitation in giving
him a certificate to say that he is in this department a fit and competent
person to enter upon practice." How could such an impartial decision be
arrived at ? There might be difficulties in the way, but I think it might
be possible, not always of course, but from time to time, to have an assessor-
present, who might be allowed to put questions and to assist in arriving at
an assessment of the value of the work of a student. Were that done, I feel
quite certain that it would be a step in advance, that it would be of great
assistance to the teacher, and that it would be a very great stimulus to the
student.

118 Robert Knox

LXVIII.— THE PLACE OF RADIOLOGY IN THE MEDICAL
CURRICULUM AND THE NEED FOR CO-ORDINATION
IN TEACHING.

By ROBERT KNOX, M.D.

In by-gone days, when the fame of the Edinburgh school was at it*
height, the value of encouraging initiative and enterprise on the part of
the leaders in the profession was amply demonstrated by the valuable
work carried out by a number of men too numerous to mention
individually, but whose names will readily occur to you since they are
monumental ones in the history of the development of medicine and
honoured in the annals of your school.

Mr. Alexander Miles, in his admirable book Tlie Edinburgh School of
Surgery before Lister, gives an interesting description of the process of
evolution at work which led to the establishment of the Edinburgh
School of Surgery, and clearly shows the value of encouraging
originality and foresight and of giving a free hand to those who show
by their actions that they are capable of doing valuable pioneer
research work.

It is to be hoped that in the near future this valuable book will be
followed by others dealing with the development of the Edinburgh
School of Anatomy, of Medicine, and other useful branches of the
common tree. There can be no doubt that the material is at hand
for the production of a series of valuable books recording the vicarious
fortunes of these many branches.

At this period of its history the Edinburgh school attracted
students and practitioners from all parts of the world, and it was the
privilege of Edinburgh to send out all over the world trained men who
by their subsequent work still further enhanced the prestige of the
school. These were the halcyon days of Edinburgh as a teaching
centre. Some twenty years ago I was interested in the subject of
pathology, an interest I was fortunately imbued with when a student
at Professor Greenfield's lecture-room, and at that time, if my memory
is correct, two-thirds of the leading chairs and lectureships at teaching
centres were occupied by men who had been students at Edinburgh
University. Similarly in anatomy, Edinburgh was turning out men
regularly who were qualified to take high places in the teaching of
the subject.

I could go on for a long time citing instances where the foresight
of your governing bodies has led to the development of new discoveries
and ideas, but no useful object would be served, more particularly as
we are concerned with the present and the future rather than with the
past. A contemplation of the history of the school is, however, useful
when we come to deal with the steps which should be taken to ensure

Radiology in the Medical Curriculum 119

that Edinburgh may occupy in the future that position which her great
past indicates that she should occupy.

It is with the future that I ask you to deal, and particularly with
the future of the important subject of radiology.

The development of the uses of electricity in medicine at Edinburgh
has been somewhat unequal.

The late Dr. Milne Murray, a pioneer worker in medical electricity,
introduced electrical methods and apparatus which at that time gave
Edinburgh an opportunity of placing the subject on a very high level.
That opportunity was allowed to slip away. I remember on one
occasion at a clinical lecture on medicine a simple faradic battery was
required for the demonstration of a nerve or muscle reaction. A
professor, his chief assistant, fifty students, and several sisters and
nurses of the ward were present, the battery was produced, the
patient's skin was duly moistened with salt solution, the switch was
" turned on " ; nothing happened. Believe me, gentlemen, not a single
individual in the room knew what was wrong ; the demonstration was
a complete failure, and that occurred in a hospital at which Dr. Milne
Murray was a teacher — surely a clear indication for the need of
systematic teaching, if ever one could be cited.

The discovery of the X-rays by Professor Rontgen and the speedy
adoption of their use all over the world gave you another opportunity
for pioneer work of which a few men promptly availed themselves.
Very soon after the discovery Dr. Dawson Turner devoted himself to
a study of the actions of the rays and their uses in medicine. I well
remember in 1896 attending a popular lecture at the Queen's Hall
when Dr. Dawson Turner gave to a very large audience a demonstra-
tion of the X-rays in action ; an exposure was made and a plate taken.
I remember how impressed I was at the time, and how I left the hall
convinced of the immense future before the X-rays, and I confess I felt
certain that Edinburgh would hold in the field of radiology a position
second to none, basing my conviction on a knowledge of the past and
the enterprise exhibited by your leaders in fostering new discoveries
and developing them to the utmost.

That conviction has not materialised. Edinburgh does not hold a
position in the front rank, and you at the present time are a long way
behind other centres in this country and the world generally.

Why has this been allowed to happen 1 Your governing body has
not exhibited true foresight guided by experienced minds, and has
failed to take action at the right moment in order to ensure the
development of a most important branch of medicine.

It is not the fault of the men you have had in charge of your
departments. Any one of them, if he had been supported by the
profession and had been given material aid by the management of

120 Robert Knox

the Infirmary and the Senate of the University, could have worked up
the subject and developed a centre of very great importance.

Dr. Dawson Turner is known widely as a pioneer worker in X-rays
and radium. The late Dr. Price was recognised by leading workers as
a prominent radiologist, and the present holders of the position at the
Eoyal Infirmary, Dr. Hope Fowler and Mr. Archibald M'Kendrick, are
known to be workers of sterling value.

There has been a failure on the part of the physicians and
surgeons to recognise the importance of the' subject and its great
future sufficiently early, and a lack of co-operation between radi-
ologists and other experts in other branches of practical medicine. Is it
surprising under these circumstances that the governing bodies should
fail to grasp the opportunity and give the support and encouragement
which the workers in the subject had a right to expect]

This want of foresight and lack of sympathy is not confined to
Edinburgh only. It is and has been prevalent all over, but fortunately
the conditions are changing and the radiologist is, however feebly,
groping for his place in the sun ; and let me assure you, gentlemen,
if I read the signs correctly, he means to get it, and that, I trust, very
soon.

The chief duty of an advocate of any particular line of development
must be to produce proof of the value of the subject and to show that
its proper development will lead to the production of results of
undoubted value.

It seems, therefore, that in order to convince you of the importance
of my subject I must begin by showing that it is worthy of the support
I claim for it.

Taking the subject as a whole, radiology in its applications to
medicine embraces the use of radiations for diagnostic work and in
therapeutics. These two are, to a, large extent, distinct, though, as
I shall show, they cannot be completely separated. A therapeutic
application of X-rays or radium given primarily for therapeutic
purposes may become diagnostic. I refer particularly to the action
upon enlarged glands where, as a result of experience in therapy, it
may be possible to indicate the nature of the lesion by the degree
and the rapidity of the response to the radiations. But, speaking
generally, it may be stated that the diagnostic side can be separated
from the therapeutic. Both are of the greatest importance in the
future development of medicine and surgery. I shall deal with them
separately.

What I want chiefly to point out is the complete interdependence
of radiology with other branches of medicine and science generally,
and the absolute necessity for a close co-operation between men
specialising in this and other branches ; the pathologist, the anatomist,

Radiology in the Medical Currictilum 122

the physician and the surgeon can all learn something from the applica-
tion of radiography to his special subject.

The physicist can help us greatly in our appreciation of the
scientific side of the subject, while he, on his side, may gain immensely
from collaboration with medical men in the joint consideration of
biological processes which may be dependent for their activities upon
purely physical effects.

The anatomist can study the internal structure of bone, the forma-
tion of joints, and the relations of the bones entering into them in a
way which was not possible before. Stereoscopic radiograms of bones
and joints when carefully studied will give a very clear conception of
the real anatom}' of the structure.

In a study of the epiphyses of the bones, radiography will lead ta
the accumulation of evidence which may in the future revolutionise
the teaching of the present day. Every anatomical school should
possess an efficient X-ray installation for the carrying out of research
work, and research must not be confined to the cadaver. Radiograms
of living subjects must contribute largely to the accumulation of
accurate data.

The pathologist will find new fields for investigation, or rather he
will find in X-rays a means of interpretation of the internal structure
of tissues. The value of a sound knowledge of pathological processes
will be appreciated by the physician when he attempts to interpret the
confusing shadows which go to make up a good radiogram.

I could show you a large number of radiograms, all more or less
perplexing to the casual observer, which can be readily interpreted
when the combined knowledge of the pathologist, the physician, and
the radiologist are brought to bear upon them and the facts ascertained
by each are given full weight in their deliberations.

There is practically no field of medical and surgical investigation
in which the use of radiography is not of great value. A due sense of
proportion is, however, necessary if the radiologist is not to become
over-enthusiastic in his claims for his subject. Lack of balance and
knowledge have before now been the causes of failure on his part to
render true service to his colleagues. A complete sympathy and
co-operation is essential if full value is expected from the new aid
to diagnosis.

The surgeon has reaped the full benefit of radiography from its
commencement because early in the development it was applied to the
diagnosis of gross lesions of the bones. As time passed and refine-
ments in technique followed it was possible to go beyond this, and
the use of the rays was directed to the elucidation of obscure
conditions of bones and joints, including the inflammatory diseases,
tumours of bone, and specific infective conditions like tubercle and
syphilis.

•9

122 Robert Knox

Later, the deeper-seated diseases in the interior of the body came
under survey, until at the present time it is possible to investigate
practically any region of the human frame. The investigation of the
skull and brain, the thoracic viscera and the lesions of the gastro-
intestinal tract, the urinary tract and the pelvic organs has led to
the establishment of highly specialised techniques for these regions
and now threatens to create in our midst a number of new specialists
whose activities may be confined to the area limited by their knowledge
of the region they specialise in. Perhaps a later development may lead
to the men practising in special branches of medicine becoming experts
in radiography so far as their special subjects are concerned. There
is even at the present time a tendency in this direction. This will
end in disaster, so far as the value of radiography in diagnosis is
concerned, if steps are not taken to ensure that every man gets a
sufficient amount of knowledge to enable him to understand the
work he carries out. The best results can only be obtained by
co-ordinated teaching in radiology and the branches of medicine
associated with it.

If such an end is to be attained, the subject must come into the
curriculum of the course of study and all students must be taught the
elements of this important work. We must either educate a large
number of expert radiologists or teach all medical students in such a
way that later they may be able to apply their knowledge. It would
be an advantage to do both.

The former plan will naturally give greater value, since an expert
must know more than one who has only a casual knowledge of the
subject.

What has been said of radiography applies with more force to
radiotherapy. In this new development we possess agents whose
activities are great for good or harm. It is more essential than in
radiography that the control of treatment should remain in the hands
of medical men.

The practical application of radiology is not entirely confined to
medicine and its allied subjects : already the rays are being used in
other fields of research and their use is being extended. Thus in the
radiography of metals extensive use is being made of their power to
disclose flaws and faults in shells, while aeroplane parts can also be
scrutinised for the detection of faults. In commerce and engineering
the field for radiography is very large, and in time every engineering
department will be fitted up with an elaborate X-ray installation,
while the departments in teaching schools devoted to these subjects
will also require to install X-ray outfits.

The field of usefulness is rapidly extending and there is room for a
large number of men to engage in research work — physical, pathological,
clinical, and biological. Many interesting problems lie invitingly before

Radiology in the Medical Curriculum 123

us which for their elucidation require the very best skill and intelligence
•at the command of the profession.

In this branch of our work we have to call in specialists in
physics, electricity, chemistry, and electro-techniques. Already we
have profited immensely from the pioneer work of prominent
physicists in this country and throughout the world. We require a
closer collaboration between the physicist and the medical man.

In practical medicine it is only necessary to refer to the great
advances which have been made in the treatment of fibroid and other
tumours of the uterus by X-rays, the use of radium for cancer and
particularly cancer of the uterus, the treatment of lymphadenoma and
sarcoma by X-rays and radium to indicate the future developments
in therapeutics. The further investigation of these agents and their
action upon the tissues calls for a large number of research workers.

The war has been responsible for a great development of radio-
graphy in its application to the investigation of diseases and injuries
of bones and internal organs, and particularly in the localisation and
removal of foreign bodies.

The surgeon has found that he cannot get through his work
without X-rays, and in most instances the services of the radiologist
are thoroughly appreciated. A tendency exists, however, in the minds
of a number of our leading surgeons to disparage the value of the
radiologist even to the extent of stating that any individual can be
quickly trained to do the necessary technical work. He is even
quoted as giving better value than a trained radiologist. That view
might be allowed to pass unchallenged if it were not for the harm it is
likely to do to the subject and to those who practise it.

The analogous condition in surgery is that of the bone-setter, who
in many instances is better qualified to deal with an obscure case than
the average surgeon. Yet what a state of indignation is excited in
surgical circles when a bone-setter ventures to deal with cases which
are regarded as the rightful heritage of the surgeon.

Only trained medical men should deal with diagnostic points in
radiography — only surgeons should deal with injuries or diseases of
bones and joints. The true position of the layman is quite auxiliary
to that of the radiologist and surgeon.

If the surgeon availed himself more frequently of the services of a
trained radiologist and the two considered their cases from all aspects,
surgery would have a very small percentage of failures.

The place of the layman in any scheme for the advancement of
radiology is of some importance. It might be well at the outset to
state that the day when a layman could be placed in charge of an
X-ray department at a hospital or private clinic is gone. The
responsibility, which is a great one, should only be in the hands of a
•qualified medical man. Lay assistance is necessary and ttye layman

124 Robert Knox

must occupy a position in any scheme for the future Assistants
must be trained in the electrical side of the work and in the technique
of radiography. The more thorough the training can be made the
more efficient will be the work turned out in a department. Steps
are being taken to ensure the efficient training of lay assistants, and
it is hoped that an examination of proficiency, followed by the granting
of a certificate, will soon be an established procedure. One of the
conditions of the granting of a certificate will be that the bolder must
only work under the direct control of an experienced radiologist. It
is hoped that in this way the layman will have an acknowledged place
in our departments and that the status will be thereby raised. The
next step will be to ensure that adequate remuneration for the work
done is forthcoming.

The collaboration on an equal footing with the medical men of
physicists, consulting engineers, and others whose work is essential
will also be cordially sought after. In subjects such as radiography
and radio-therapeutics there can be no hard-and-fast line drawn
between the medical and the non-medical.

The endeavour of those of us who realise the growing importance
of our speciality has been to initiate steps which, when materialised,
will raise the status of the subjects and of the men practising in them.
How can this best be done ! The answer is obvious : it can only be
done by recognising that it is necessary to teach adequately the-
subjects at the principal teaching centres throughout the country.

The subjects must be recognised as worthy of a place in the
curriculum of study which students require to take before graduation.
A full recognition of this kind would at once alter the whole position.
It would follow that a chair of radiology and electro-therapeutics
would be established at the university, and in my opinion no half-
measures should be contemplated. The importance of the subject
is sufficiently great to warrant us in approaching the university
authorities in the matter.

Already an association of radiology and physiotherapy has been
initiated. The chief objects of the new association will be to raise-
the status of the subjects and to provide for their adequate teaching.
Cambridge University has been approached with a view to the-
establishment of a diploma in radiology and electrology, and there is-
every prospect that the diploma will materialise.

Teaching will be arranged for at Cambridge and London. It will
be, to begin with, post-graduate, but there is no reason why another
university should not take up the ante-graduate teaching and later
establish a degree in the subjects. Here lies a good opening for
Edinburgh to take the initiative.

The London scheme provides for post-graduate teaching at a
number of the larger hospitals and steps are in progress for the co-

Radiology in the Medical Ctirriculum 125

operation of provincial schools. Edinburgh would form an excellent
centre for the northern part of the kingdom.

In addition, when funds allow, it is proposed to have a large central
institute in London at which the administrative work would be carried
out, a museum established, a library, and demonstration rooms set up.

In a complete scheme for the adequate teaching of radiology and
electro-therapeutics it is essential that the teaching should commence
as early as possible in the career of the student. Physics is, I believe,
-a subject now included in the curriculum of study. The teaching of
this important subject should be on lines which are likely to be useful
in the after-career of the student. Thus it may be advantageous to,
indicate briefly the lines upon which the important subject might be
taught. These briefly include the laws of electrostatics, attraction and
repulsion, frictional electricity, static machines, electrostatic induction,
influence machines, distribution of electrical currents in circuits, Ohm's
law, generation of heat by electricity, Joule's law, production, measure-
ment, and detection of electric currents, primary and secondary cells,
the transmission of electricity through solids, liquids, gases, and animal
tissues.

Electro-Magnetic Induction : the production of induced currents,
relations existing between primary and secondary circuits. The
induction coil, its construction, method of action, and the importance
of the primary and secondary currents, low and high tension electrical
currents.

Radiation : heat, visible rays, ultra-violet rays. Sources and methods
of production.

X-rays : their production, their place in the spectrum. Relation
between wave length and penetrating power. Laws relating to the
absorption of X-rays by various substances, for example, metal, bone,
tissues, fluids.

Secondary X-rays : their production and measurement. Scattering
of X-rays. Conditions under which they may be regularly reflected.

Radium : properties of the different rays emitted by radium and
other radio-active bodies. The laws according to which such rays are
absorbed by different substances. Secondary rays excited by alpha,
beta, and gamma rays.

Electro-technics : direct and alternating currents, their mode of
production and distribution to X-ray departments, methods of utilisa-
tion of electric power — conversion of direct into alternating current,
rectification of alternating current. Motors, dynamos, high tension
currents, transformers, and many other practical points in connection
with these subjects.

It would be possible in the physics course to include all of the
above in a manner profitable to the medical student. He would then
be in a position to appreciate the subject when he came into closer

126 Robert Knox

touch with it in his more advanced course, particularly in the practical
applications of radiology to diagnosis in medicine and surgery and in
radio-therapeutics.

The practical application would be taught in the X-ray department
in the second or third year when he takes the course in surgery.
Every student should spend six months in the department as a clinical
clerk. It would be the duty of the radiologist in charge to arrange
for a course of instruction which would be based on the following
lines : —

Description of apparatus, arrangement of an X-ray and electrical
department, with practical demonstration of technique. Normal radio-
graphy, localisation of foreign bodies, urinary radiology, pulmonary,,
gastro-intestinal, dental radiography, radiography of dislocation*
and fractures, of disease of bones and joints, and radiography of
children.

Radiotherapy — X-rays : treatment of superficial diseases ; deep-
seated therapy.

Radium : treatment of superficial diseases ; deep-seated diseases.

Organisation of X-ray and electro-therapeutic departments.

System of booking cases, filing, etc.

Photography : practical demonstration and lectures.

Electrology : systematic lectures and practical teaching in electro-
diagnosis and electrotherapy.

By the end of the fifth year the student of the future will have-
learned a great deal more than the average specialist of the present
day, and will be in a better position to appreciate the value of the
subjects than the general practitioner of the present.

Advanced classes in physics, electricity, and radiology should be
available for the use of the men who after graduation wish to proceed
to the examination for a diploma or a degree at a university. It
should be on the same footing as the B.Sc. or the D.Ph., and should be
open only to graduates of at least one year's standing.

Research in these subjects should be encouraged by all means
possible. Scholarships should be established. Resident posts at the
hospitals and travelling scholarships would be an additional attraction
to men desirous of specialising in them.

Research work could be as comprehensive as that in other subjects
— in physics, electro-technics, pathology, biology, and experimental work
in connection with the use of radiation in health and disease.

The field is large and will be fruitful of results if the work is gone
into thoroughly. There are many problems in connection with radio-
therapy which might well engage the energies of the very best men
we possess. The subject is full of interest, and important discoveries-
await the ardent investigator.

The short past of radio-activity is full of brilliant research work

Radiology in the Medical Currictilum 127

and important epoch-marking discoveries. In the limitless future
discoveries cannot be less striking.

The subject so far has been chiefly dealt with from the point of
view of teaching the undergraduate, but I should like to see Edinburgh
go far beyond that and venture at once into the establishment of a
large post-graduate centre for the instruction of the numerous men
who after the war will wish to devote a year or more to study. We
in this country must be prepared for the end of the war, and one of
the best ways in which our profession can meet future competition
from our present enemies will be to organise for graduate and for
post-graduate research work in radiology and physiotherapy.

The establishment of a chair in radiology and electrology at the
university would be an important step in that direction.

A properly equipped institute would be required to deal thoroughly
with the subjects. In this building it would be necessary to have a
fully equipped X-ray and radio-therapeutic department, a museum, a
library, lecture rooms and demonstration rooms.

The equipment of such an institute would be a matter for careful
consideration. It would vary with the needs of the institute and the
possibility of linking it up with existing departments at the university
and the Royal Infirmary, collaboration with which would be both
possible and valuable.

It might be necessary to fit up special laboratories for radium and
X-ray research, but that could easily be arranged.

The radium equipment would be a heavy item since two or three
grammes of radium might be required. Eadium is now selling at
£12 per milligramme. Three grammes would cost about £36,000.
Apparatus might run into £2000, and a properly fitted up building
would be necessary. In all about £50,000 would place you on a
footing of equality with other large centres.

The existing radiographic and electro-therapeutic department would
require to be brought thoroughly up to date. A considerable sum
would be required — £6000 to £10,000 would suffice for all practical
purposes. A total sum of about £100,000 would provide for ante-
graduate teaching, post-graduate teaching, the equipment of a radium
institute with the necessary supply of radium, and the endowment of
a chair in the subject.

The business men who look so well after the financial side of your
work might naturally ask : Where is the profit to come from1? Well,
the immediate result would be an increase of prestige. This would in
time attract a large number of post-graduate workers who would expect
to pay for the advantages they would get from a course of study.

Then your fame would be spread abroad and large numbers of
patients would come for treatment.

The advantages of foresightedness combined with shrewd business

128 Discussion

capacity may be instanced in the famous Mayo Clinic of Rochester,
U.S.A., which may be quoted as a thoroughly good business concern
and one which is, from the scientific point of view, equally sound.

The Radium Institute of London, instituted a few years ago, is
another instance of business enterprise. It has had to enlarge its
premises and is daily doing more work, and that with the distinct
limitations imposed by the conditions under which the work is
conducted.

In Edinburgh you could establish a centre which could be unequalled,
for you possess advantages which would all count in your favour. You
have all the academic distinction of a famous university and school.
All the scientific facilities lie at your hand. In physics you have a
distinguished professor whose fame is world-wide. Your surgical fame
is great, and in medicine and its allied specialities you are pre-eminent.
It only requires a centre stone to complete the arch. That centre stone
is radiology. Be bold ; grasp the future in both hands. Establish a
chair and a post-graduate centre, and equip a radium institute, and
you will soon have a world-famous centre to which practitioners and
patients will come in ever-increasing numbers.

It does not require prophetic vision to enable one to predict the
great success which is certain to reward the workers in a school willing
to deal with the subject boldly and thoroughly at the proper time.
Initiative and enterprise must go hand in hand. There is no better
time than the present, when the movement has been initiated elsewhere
and active collaboration is earnestly invited. In this country it should
be possible to establish centres for the teaching of students and post-
graduates in radiology intimately linked up with those in medicine and
surgery, and generally capable of holding their own in competition with
those of other countries. Whatever centres are established, Edinburgh,
with her unexcelled facilities and advantages, must occupy a leading
place. She has occupied a proud position in the past and will
undoubtedly do so in the future. It is my earnest wish to see in the
near future my old school take a place in the developments of radiology
worthy of its great past and establish a guaranteed future in the new
field of practical medicine.

DISCUSSION.

Mr. Archibald M'Kendrick. — Dr. Knox has dealt rather with the
establishment of a school than with the method of teaching medical students.
Although I quite agree that a school such as Dr. Knox suggests might be
established in Edinburgh, I think we would have some difficulty in coming
to an agreement as to what course of lectures should be given in the medical
curriculum on the subject of X-rays. There is no department in the Infirmary
which does not send cases to the X-ray department : the negatives then go to
the wards, where the students are instructed on them. Thus we have a
scattered teaching of X-rays. One would like to see in addition a more

Discussion 129

•centralised teaching. I should leave the teaching of radiology in such a
position that it would be an introduction of the medical practitioner to X-ray
work, rather than to teach him all the minutiae of the subject.

Dr. Hope Fowler said that a place should be found in the curriculum
for the teaching of radiology on a better footing than at present.

Dr. Spence.— Dr. Knox's paper takes a broad outlook on radiology, in
which he is a past master. He has referred to lay radiographers : I hope we
shall never allow the laity to control the purely medical aspect of the subject,
and that electrical treatment will never be taken out of the hands of medical
men. It would be just as unreasonable to do that as it would be to hand
over joints to the bone-setter. At the Sick Children's Hospital next winter
there will be a recognised clinique for the teaching of radiography to fourth-
and fifth-year students.

Professor Robinson.— While I appreciate Dr. Knox's ideal, the problem
before us is how to utilise five years for teaching. To carry out Dr. Knox's
ideal and to keep to the five years' curriculum does not seem possible.
As the anatomist has been referred to so often, I venture to say that everyone
who has spoken seems to forget that the anatomist has to teach in one and a
half years all the terminology, and there are about five thousand terms for
•the ordinary descriptive purposes of the medical man. To demonstrate to the
students the movements of joints, we can only show them radiographs of joints
in different positions.

Mr. Struthers. — I am interested in knowing whether elementary radio-
graphy really ought to be and must be in the hands of a medical man. We
are hampered at present in the use of radiography because our facilities are
so limited. I look forward to the time when a radiographic apparatus will
be part of the equipment of every department in the hospital, and, instead of
having to send the patient to a central department, we shall have our own
X-ray apparatus, just as we have our own microscope and stethoscope. Is it
not possible to train a number of skilled mechanics, who would work our
apparatus for us, and let us use it freely every day and all day ? I would
have radiography taught as a part of ordinary surgical treatment instead of
being too much centralised.

Dr. Rainy. — I would draw a clear line between what Dr. Knox has said
as to post-graduate teaching and what he has said as to the possibilities of
undergraduate teaching. In post-graduate teaching there is no question, if it
is to be done at all, that it must be done in a thorough and efficient way.
Men wishing as post-graduates to get some knowledge of X-rays must be
expected to devote the considerable period of time to the subject that is
necessary before one's diagnosis is worth anything. On the other hand,
taking the practical point of the undergraduate, the question does arise :
What sort of condition is he in when we get him to train ? I take it that Dr.
Knox would expect that he must have a certain knowledge of physics before
he is taught the technique of X-rays. The student who enters for the course
of physics is at present equipped with the following amount of mathematics : —
Arithmetic, up to proportion ; algebra, up to simple equations ; and geometry,
up to the third book of Euclid. He then has three months to build up on this
an adequate acquaintance with physics. I would attempt that if electricity

130 Discussion

were the only branch to be taught. If you remember that there must be taugbt
dynamics, physical optics, and the theory of heat and sound, three months is
inadequate. Then, too, how many of our students are likely to carry out the
practical technique of X-ray work later, either on the diagnostic or the
therapeutic side. As long as the apparatus is such as it is at present, it is not
a business concern for the general practitioner to do more than accept the
findings of a specialist. And therefore I think that the undergraduate's
training in technique should be a minimum. We constantly meet with the
incapacity of the student to interpret simple radiographs or to understand
that he is dealing with shadows and not with solid objects. We must teach
him this. We can also in our ordinary ward work constantly use radiographs.
We should have apparatus for the satisfactory demonstration of radiograms to
our cliniques. But I doubt very much if there is time to do more, either in
the central department or by the specialist who wishes to work by himself,
than to teach the undergraduate the interpretation of the more important
radiograms and the errors he must avoid in sending cases to the X-ray
specialist. It is important that the student should have some knowledge of
the end-pmducts of X-ray work and their interpretation, and I think it is
well that he should be taught the sort of things that with our present know-
ledge are worth asking the radiographers to tackle.

Dr. Chalmers Watson. — I agree as to the necessity of differentiating
between post-graduate and undergraduate teaching. Dr. Knox has discussed
the reforms of the medical school from the larger outlook, not dealing
particularly with the requirements of the undergraduate. I should like to
associate myself with what he has said as to the value of radiology in practical
medicine and the necessity of embarking on some such scheme as he suggests.
I have seen Dr. Knox in his department at Queen's College, with its admirable
facilities for teaching and technique. If his enthusiasm can supply us with
the courage, vision, and initiative which we lack, he will have done us a signal
service. We can and ought to do more for the teaching of the undergraduate.
The university has obligations in this matter which it ought to recognise.

Radiology must remain to a great extent in the hands of medical experts.
The more I see of radiology the more I am dependent on the skilled opinion
of the medical expert, who is doing it every day and all day.

Dr. J. S. Fraser. — We have in the Ear and Throat Department an X-ray
apparatus which Dr. Logan Turner fitted up at his own expense, which we
have found of the greatest value. The late Major Porter studied X-rays for
some time abroad, and on his return he gave us excellent X-ray pictures of
the nose and accessory sinuses, and of the mastoid. Instead of having to
send a patient to the X-ray department, we had both him and the apparatus
on the spot, and the radiograph could be taken at any time. I think there
are certain advantages in this separation from the central department. If we
had an efficient X-ray installation attached to the special departments we
would possibly be able to learn more from it than from perhaps better
skiagrams taken by specialists out of our ken.

If this arrangement works better in regard to our own knowledge of
clinically studied cases, that in itself would have a certain relation to the
teaching of the students. If we had a case for diagnosis, and we could show
the student the method of taking the X-ray plate on the premises, it would
be of value in the teaching.

Discussion 131

Dr. Gardiner. — The question of teaching radiology in relation to derinat-.
ology is very important, as radio-therapeutics occupy a large part in the
treatment of skin diseases. Radiotherapy as regards teaching is of extreme
value to the students, and part of our regular routine is to teach them in our
own X-ray department.

Dr. Traquair suggested that such things as the movements of joints
might be illustrated to a large class by means of the cinematograph. It is-
not necessary to teach students how to take X-ray photographs.

Dr. Knox said in reply. — I consider that no lay person should ever be
put in charge of an X-ray department under any circumstances whatever.
It is quite a different matter when you come to deal with the lay operator
who works under direct medical supervision. That is unavoidable. We
cannot possibly train sufficient medical radiologists to do all the work
individually. At my hospitals I train nurses, and I find I get the work very
well done indeed. The essential point is that we wish to get the interpreta-
tion under our control entirely. I think you cannot have too many X-ray
cliniques or too many X-ray installations in connection with your special
departments, but you want in this case to have an expert to help with the-
interpretation.

I can remember, when I was a student in Edinburgh, we had a bone room,
where I spent many hours ; and I am certain that if there had been radiograms
of these bones I should have learned very much more, as well as something
about radiology. The future teaching of radiography in the anatomical
schools will consist of something in that direction — radiograms placed
stereoscopically where a student can carefully study the structure of the bone
and joints, and so on. I should like to see all the anatomical demonstration
rooms thoroughly well fitted up with even a cinematograph arrangement ;.
but I should not recommend anybody to do too much of it unless the protec-
tion was very thorough. With a properly taken film one could demonstrate
movements quite easily.

If you consider it necessary to teach the student physics, the teaching in-
that subject should be on lines which would carry him on to his later work in
radiology. Physics in the future will play a great part in the treatment of
many medical conditions which at present we really do not know what to
think of. Mr. Struthers has opened up rather a debatable point. I agree
that it is possible to get all your radiograph work done by trained assistants,
but I do think it takes a very long time to learn how to interpret the results..
I have seen some very woeful exhibitions on the part of surgeons and
physicians who ventured to demonstrate X-ray negatives to a class of students
when they did not know the elements of the thing. If surgeons are going to
do their own interpretation, they will have to study radiology very thoroughly,
which is a strong argument for teaching the post-graduate. Does Mr.
Struthers, for instance, do all his blood counts and all his bacteriological
examinations? I would like to rank the radiologist on the level of the
bacteriologist at least. I purposely did not go into the lines on which the
student should be taught radiology. If he understands something about
physics to begin with, he will in a very short time learn sufficient radiology
for his needs, unless he intends to take it up seriously later. The aim of the
radiologist in charge should be to see that the student understands the

132 Discussion

•elements of interpretation thoroughly before he leaves the class : that is quite
sufficient for the practitioner in later life. The post-graduate teaching is quite
another matter. I am certain that after the war we are going to have crowds
of men — Americans, Colonials, Canadians — clamouring for such instruction.
Any school that will prepare for the termination of the war, and get a good
post-graduate school going, will receive these men in hundreds. The men who
aised to go to Germany will come here if you have the post-graduate teaching
in full swing.

Combine and go in for organised teaching, and you break the back of the
thing at once. I would specially like to see co-operation between the surgeon,
and the radiologist.

New Books m

NEW BOOKS.

The Hearts of Man. By R. M. Wilson, M.B. Pp. xx. + 182.
London: Henry Frowde and Hodder & Stoughton. 1918.
Price 6s. net.

Broadly speaking, this book is a study of the physiology of the
emotions, or at least of the one emotion — "starting" from a sudden
fright or excitement. During the reactive stage the author shows
how one of the main results is the driving of blood out of the thorax
and abdomen into the mass of the muscles, and how the suprarenals,.
thyroid, pituitary, and pancreas are compressed and yield their
secretions into the blood. The whole argument appeals to us as-
extremely ingenious, though it is not to be supposed that it is proven
in all details. In a preface Dr. Wilson publishes criticisms of some of
his contentions by Sir James Mackenzie and Dr. Bayliss, and no doubt
other objections may be raised to the correctness or his views. This-
in no way, however, detracts from the originality and suggestiveness
of his work.

Blood Transfusion, Hcsmorrhage, and the Anosmias. By Bertram M„
Bernheim. Pp. 247. With 18 Illustrations. Philadelphia
and London : J. B. Lippincott Co. 1917. Price 18s. net.

The writer of this volume is well known for his contributions to
blood-vessel surgery. The present volume is an elaboration of a
chapter on* transfusion previously published in his book on the
Surgery of the Vascular System. Since the publication of Dr. Crile's
work on HamiorrJiage and Transfusion in 1909 no such complete account
has been presented of the principles and methods of this important
means of treatment. While the theory of the subject is discussed,,
chief stress is laid upon the really practical points. After a short
historical note the author refers in three chapters to the phenomena
of bleeding and its diagnosis. Although it is impossible to state-
definitely the indications for transfusion of blood in preference to the
use of saline in cases of haemorrhage, Bernheim recommends, as a
working rule, that, if the blood-pressure falls to 70 mm. of mercury,
blood transfusion should be performed regardless of all other features
of the case. The indications for transfusion and the methods of test-
ing the donor's blood for haemolysis and agglutination are fully
discussed. All the well-known methods and apparatus employed in
the operations are described and illustrated, and it is interesting to

134 New Books

note that the citrate method is recommended at the moment as the
method of choice.

Five chapters are devoted to the discussion of the results of
treatment by transfusion in the various forms of anaemia, and of rare
conditions, such as gas or benzole poisoning. At the end of each
chapter a useful list of references to the best literature on the subject
is given.

Medical Ophthalmology. By Arnold Knapp, M.D. International
System of Ophthalmic Practice. Edited by Walter L. Pyle.
Pp. xv. + 509. With 32 Illustrations. London: William
Heinemann. 1918. Price 21s. net.

The importance of the relationship between eye diseases and eye
symptoms and the whole field of clinical medicine is not always
thoroughly appreciated even at the present day, and not only justi-
fies, but urgently calls for, the appearance of a work on medical
ophthalmology, more especially one written in the English language.
The present volume, which is designed to supply the needs of physicians
and oculists in this respect, is therefore assured of a hearty welcome.

There are fifteen chapters. The first contains an interesting
account of the anatomy of the optic path from retina to cortex, and
also deals with the topical diagnosis of optic lesions. This is the only
illustrated section, and the diagrams are well done, with the exception
of one or two which might advantageously be modified in accordance
with modern knowledge. The second and longest chapter discusses
fully the eye symptoms in diseases of the nervous system. The ocular
symptoms of neurasthenia are, however, not mentioned — an omission
no doubt intentional on the part of the author, but unfortunate on
account of their frequency and the importance of their proper
appreciation.

Affections of glands with internal secretion are perhaps somewhat
shortly disposed of in fourteen pages, of which seven are devoted to
the pituitary body. The section on infectious diseases is largely
devoted to syphilis and tuberculosis, which are fully discussed. The
remaining chapters deal with poisons, respiratory, digestive, and renal
affections, anaemia, diabetes, the female generative organs, the osseous
system, skin, and hereditary affections. The author is to be con-
gratulated on the way he has brought together a mass of information
covering a very wide field into the compass of a single and not too
bulky volume.

As stated in the preface, a free use has been made of already
existing material, such as the Graefe-Saemisch handbook and other
continental works. This method has the advantage of deriving
information in each case from a specially authoritative source, but

War Books 135

tends to result in a collection of abstracts which sometimes leave the
reader in doubt where he seeks for definite guidance. In several
cases, moreover, the work quoted from has been qualified by more
recent researches.

The author's style is easy and pleasant to read, though occasionally
somewhat condensed, and the type is especially clear and distinct.
Both paper and binding are excellent in quality. Professor Knapp's
book fills a gap in medical literature, and, in spite of the defects
referred to, cannot fail to be of great value to ophthalmic surgeons
and medical practitioners.

WAR BOOKS.

War Surgery. From Firing Line to Base. By Basil Hughes, D.S.O.,
Major, K.A.M.C., and H. Stanley Banks, Captain, R.A.M.C.
Pp. ix. + 623. With 373 Illustrations. London: Bailliere,
Tindall & Cox. 1918. Price 30s. net.

That this work was compiled under active service conditions in the
East, where there was no access to any library of reference, may
account for much of its freshness and force. 1 he authors, who have
had three and a half years' personal experience of surgical work in
every part of the field — from firing line to base — both in the Western
and Eastern theatres of war, have furnished us with a living document
full of original observation and clear, unbiassed deductions. As a
record of sound surgical work carried out under trying and difficult
conditions, it is of great scientific and practical value. How much
has had to be learned by the surgeons of our Army during this war
■comes out, rather than is brought out, by the descriptions the authors
give of the wounds met with in the earlier period, and the general
evolution of the methods of wound treatment which has taken place
since 1914. How well it has been learned is equally evident from the
more recent results. The authors have made no attempt at fine writing,
but some of their descriptions of the conditions in the trenches, and
the wounds that had to be dealt with, literally shock the reader. The
section on gas gangrene, for example, reveals the horror of war more
poignantly than anything we have ever read outside the pages of
Henri Barbusse.

From the purely surgical point of view, which, throughout, is the
writers', we specially commend the sections on antiseptics, on wounds
of joints and of bones. The illustrations, on the whole, are good ;
those in colour by Sergeant-Major Powel, E.A.M.C, strike a new
note in medical art.

136 War Books

Surgery in War. By Alfred J. Hull, F.R.C.S. Second Edition.
Pp. ix. + 624. With 210 Illustrations. London: J. & A.
Churchill. 1918. Price 25s. net.

Lieutenant-Colonel Hull's work differs from that last noticed in
that it reflects the opinions and experiences of many workers, in
addition to those of the author and several collaborators who have
assisted in its preparation. Since the previous edition many advances
have been made in war surgery, and this has necessitated the rewriting
of several chapters and the amplification of all. This book will form
a useful source of reference to young Army surgeons.

The Orthopedic Treatment of Gunshot Injuries. By Leo Mayer, M.D.,
New York. Pp. 250. With 184 Illustrations. Philadelphia
and London: W. B. Saunders Co. 1918. Price 82.50 net.

Dr. Mayer, who is instructor in orthopaedic surgery in the New
York Post-Graduate School, emphasises certain principles and rules
of guidance in the treatment of war injuries from the orthopaedic
point of view, which he naively admits is the point of view of the
general surgeon. The treatment of war injuries is considered under
two main groups — that given at the front and that at the base hospital.
The chapter on injuries to tendons and tendon operations is one of the
most satisfactory and is admirably illustrated. A useful and instruc-
tive section, devoted to artificial limbs, illustrates the extraordinary
ingenuity that has been expended on this most important subject, and
particularly the great share that has been taken in devising prac-
ticable and serviceable appliances by patients who have had the
misfortune to lose their limbs.

War Wounds of the Lung. By Pierre Duval. Authorised English
Translation. Pp. 99. With 27 Plates and Illustrations.
Bristol : John WTright & Sons, Ltd. Price 8s. 6d. net.

In April 1917 this volume was published in the French language
and an authorised translation was made by certain medical officers
of No. 36 British Casualty Clearing Station. Duval may be said to
be the pioneer of the more radical type of chest surgery, and his
views and technique are embodied in the present volume. Shell
wounds of the chest are notoriously associated with a high mortality,
both immediate and late — Duval claims to have materially reduced
the mortality by early and thorough operations. His technique
embraces free exposure of the pleural cavity, deliverance of the lung

War Books 137

on to the body surface, cleansing of the lung wounds, with arrest of
hemorrhage and suture, careful cleansing of the pleural cavity,
accurate repair of the parietal pleura and chest wall, and subsequent
aspiration of the resulting pneumothorax.

While Duval's methods have yielded excellent results, it is, how-
ever, the case that his recommendations have not met with uniform
acceptance. The principal opponent is Hartmann, whose views have
been published in the Presse Mhlicale of February 1917. In addition
to the operative technique the book includes discussion of the various
pathological and bacteriological problems which are associated with
chest surgery.

The translation is, on the whole, a faithful reproduction of the
original. It is exceedingly well illustrated, and a perusal of the
volume is to be recommended to any whose work brings them in
contact with gunshot wounds of the chest.

Gymnastic Treatment for Joint and Muscle Disabilities. By Brevet-
Colonel H. E. Deane, R.A.M.C. Pp. 146. With 26 Illustra-
tions. London : Henry Frowde and Hodder & Stoughton.
1918. Price 5s. net.

The author is at war with nearly all machines for moving joints or
developing muscles, and substitutes for them exercises performed
under skilled direction upon the usual gymnastic appliances. Colonel
Deane writes as an enthusiast, and the excellence of the results
obtained by him at the Croydon War Hospital are vouched for by
Colonels Carless and Mott. The book is well written, but being
very condensed can only be regarded as an introduction to the
subject, and as an incentive to others to further study of the subject.

The Action of Muscles, by Wm. Colin Mackenzie (H. K. Lewis
& Co., price 12s. 6d.) is one of the most illuminating contributions to
the study of muscle action with which we are acquainted. It should
be carefully studied, not only by orthopaedic surgeons, to whom it is
specially addressed, but still more by teachers of anatomy as a stimulus
to infusing into the student an interest in the function of the muscles
rather than in their mere origins and insertions. As a guide to those
who are concerned with the restoration of function in disabled limbs,
whether as orthopaedic surgeons, masseurs, or re-eductors, it will prove
invaluable.

Vaccines and Sera in Military and Civilian Practice, by Captain
A. Geoffrey Shera, is a valuable addition to the Oxford War
Primers issued by Henry Frowde and Hodder & Stoughton, price

10

138 Notes on Books

7s. 6d. It furnishes a very complete summary of present-day know-
ledge of the subject.

A second edition of Colonel Joseph H. Ford's Detail's of Military
Medical Administration (Blakiston's Sons & Co.), published with the
approval of the Surgeon-General, U.S. Army : an authoritative
exposition in 800 pages of military medical administration and the
filling up of forms.

Colonel F. R. Keeper's text-book of Military Hygiene and Sanitation
(W. B. Saunders Co.) also appears in a second edition.

In Field Sanitation (Henry Frowde and Hodder & Stoughton) we
have a series of lectures given by Major R. St. J. Macdonald,
C.A.M.C, at the Divisional Sanitary School in the Field. Based on
prolonged personal experience, they are eminently practical.

Major Arthur C. Christie, U.S. Army, has revised and enlarged
his Manual of X-Ray Technic (J. B. Lippincott Co., price 12s. 6d.).
This, the second edition, will prove useful in military hospitals. It
is clearly written, compact, yet complete, and is well illustrated,
particularly the chapter on " The Examination of the Alimentary
Canal."

NOTES ON BOOKS.

To Edinburgh men who graduated in the seventies the Reminiscences
of a Student's Life in Edinburgh by one of their contemporaries, who
veils his identity under the nom de guerre "Alisma," will afford a
pleasant hour's reading. Writing from memory after a lapse of
nearly half a century — the author began his medical studies in 1871
and graduated in 1875 — the recollections are not always historically
accurate, but they are quite delightful and reflect a genial and
generous nature. To the writer all his teachers appear as heroes and
he cordially worships them. Even in "the youthful student friend-
ships of those days " he " cannot recall a flaw in any of them." It is
most refreshing to find such genuine loyalty and affection for his Alma
Mater in one who, we gather, has had little direct connection with the
school since he left it. The book is published by Messrs. Oliver &
Boyd at the price of 4s.

The Twin Ideals, An Educated Commonwealth (H. K. Lewis & Co.,
price 25s.), is a collection of papers written at different periods by
James W. Barrett, K.B.E., etc., and published in various Australian
journals. In addition to its retrospective interest it throws light on
various aspects of reconstruction.

The second edition of Dr. Whiting's Aids to Medical Diagnosis

Notes on Books 139

(Bailliere, Tindall & Cox, 1918, price 2s. 6d. net) retains all the good
features of the first edition (and, we may add, of most of the other
volumes of this useful series), but the section on "Diseases of the
Heart " has been altered in accord with recent advances.

As a short appreciation of the man and his work Professor
Chandhuri's Sir William Ramsay as a Scientist and a Man (Calcutta :
Butterworth & Co., 1918, Es. 1.8 net) will gratify many who were
acquainted with the subject of the memoir. The monograph was
originally intended as a magazine article ; in its extended form it
will appeal to a larger circle.

A Laboratory Manual and Text-Book of Embryology, by C. W.
Prentice, A.M., Ph.D. (2nd edition, W. B. Saunders Co.), is an excellent
text-book and is written from a modern standpoint. The text and
illustrations can be highly commended.

We have again received the Wellcome — one might almost say ever-
welcome — Photographic Exposure Record and Diary (B. & W., 1918),
which is in reality a good deal more than its name suggests. It is,
in fact, a succinct compendium of photographic processes, and from
personal experience of a good many years we can say that it is a
much-used work of reference. The ingenious calculator has been
improved, and now seems to have reached perfection. It is a good
eighteenpence worth.

140 Books Received

BOOKS RECEIVED.

Anderson, Daniel E. The Epidemics of Mauritius . . (Jf. K. tswIs&Ca., LUL) 6s.

Bm,B. I). Diabetes and its Dietetic Treatment, Ninth Kdition

(The I'anini Office, AlUiliubad) —
I5.wi.iss, W. V. Intravenous Injection in Wound Shock . . (Ismgmans, Green <f 9s.

Borrodaile, L. A. A Manual of Elementary Zoology. Second Edition

{Henry Frowde, Hodder & Stoughton) 16s.

COHSMBBATOH, Elkin P. Essentials of Medical Electricity. Pourth Edition

(.Henry Kimplon) 7s. Od.
Gray, H. M. \V. The Early Treatment of War Wounds

(Henry Frowde, Hodder & Stoughton) 10s.

Hayes, Reginald. The Intensive Treatment of Syphilis and Locomotor Ataxia. Third

Edition (Bailliere, Tindcdl & Cox) 4s. 6d.

Lklkan, P. S. Sanitation in War. Third Edition . . . . (J. & A. Churchill) 7s. 6d.
Lewis, Thomas. Soldier's Heart and the Effort Syndrome . . . . (Shaw & Sons) 7s. <wi.
Lloyd, Ll. Lice and their Menace to Man . . (Henry Frowde, Hodder & Stoughton) 7s. 6d.
Macleod, J. J. R., assisted by Roy G. Pearce and Others. Physiology and

Biochemistry in Modern Medicine (Henry Kimpton) 37s. 6d.

Muir, Robert, and James Ritchie. Manual of Bacteriology. Seventh Edition

(Henry Frowde, Hodder & Stoughton) 16s.

Parsons, J. Herbert. Diseases of the Eye. Third Edition . . (J. & A. Churchill) 10s.

Pennsylvania University. Fourteenth Report of the Henry Phipps Institute . . —
Reoatjd, Cl., Edited by. Lecons de Chirurgie de Guerre . . . (Masson el Cie.) frs. 9+10%
Transactions of the Sixth International Dental Congress, 1914

(The Committee of Organisation) 30s.

Trench Fever. Report of Commission of Medical Research Committee, American Red

Cross (Henry Frowde, Hodder & Stoughton) 21s.

Whittaker, Chas. H. Nerves of the Human Body. Second Edition

(ft & S. Livingstone) 3s. 6d.
Wood, P. The Whole Duty of the Regimental Medical Officer

(Forster, Groom & Co. Ltd.) 2s. 6d.

MARCH 1919.

EDINBURGH
MEDICAL JOURNAL.

EDITORIAL NOTES.

In instituting an inquiry into medical education

The Medical the Edinburgh Pathological Club has done a

Curriculum. ° °

useful piece of work. The Report just issued,

based as it is on papers by well-known teachers from all parts of the
kingdom, is a valuable, and will be a permanent, contribution to a
subject fraught with importance to the well-being of the community.
In this connection it is impossible not to recall the Reports issued in
1910 and 1912 on Medical Education in America and in Europe by
Dr. A. Flexner. Stimulating as these were, they did not materially
influence medical education in this country, and they were the mark
of a good deal of criticism on certain points. A general comparison
of Dr. Flexner's standpoint with that of this Report is not without
interest. Dr. Flexner, in his survey of American and European
schools, collected his evidence from a wider field than the Pathological
Club has done, and his report was not narrowed, as this is, to the con-
sideration of a system of medical education best adapted to local
needs. Notwithstanding this, the Pathological Club's Report takes,
on the whole, a broader view than Dr. Flexner's. A fundamental
proposition in the Flexner report was that medical education is
primarily a pedagogic rather than a medical problem, and it followed
almost naturally from that point of view that the principal change he
foreshadowed was the development of medical schools along purely
academic lines — the creation of whole-time professorships with cliniques
under the jurisdiction of universities or similar academic bodies, and
the evolution of a type of clinicians who were primarily teachers,
divorced from practice. One of the chief criticisms of his system,
from the British standpoint, was that it chiefly contemplated training
professors and teachers, perhaps to the detriment of ordinary prac-
titioners. Apart from this method of raising the general level of
medical education to a university standard, Flexner suggested no radical
change in the curriculum, nor was there any hint of a new orientation
in the teaching of medicine.

The Pathological Club, naturally, approaches the subject from the

E. M. J. VOL. XXII. NO. III. 11

142 Editorial Notes

medical rather than from the educational side, and the new trend of
medicine toward organised prevention of disease has had far more part
in shaping its scheme than any ideals of a purely academic nature.
Several of the contributors, it is true, press for an extension of the
system of whole-time professorships, but though the idea is not strongly
opposed, the impression given by the Report is that the desire for such
was not nearly so widespread as the desire for change in other direc-
tions— notably in the way of co-ordinating the subjects of study, so that
they may form a continuous whole instead of a discontinuous series,
and that at the end of the course the graduate may have a better
working knowledge than at present of the application of physiology,
anatomy, and pathology to clinical medicine, and some appreciation
of his function in the community as a promoter of public health.
Hitherto it has been the universal custom to build one subject on
another — pathology on anatomy and physiology, medicine and surgery
on all these, and to subdivide the course into stages accordingly. The
student begins as an anatomist who knows no medicine, and too often
he ends as a clinician who has forgotten nearly all his physiology.
Nearly every contributor to the Pathological Club's Report asked that
the theory of the present system should be made a reality, and the
suggestion is that this might be done by teaching the preliminary
scientific subjects side by side with, and as far as possible a part of,
clinical medicine and surgery. To admit of this it is proposed, again
with great unanimity, that clinical work should begin early — in the
first and second winter — and that the student's fitness to graduate
should be tested by his record of work less than by periodic examina-
tions. An obvious criticism of such a scheme is that it is a throwback
to the dead and buried " apprenticeship " system and to " walking the
hospitals." But such, in fact, is not the case. In its ultimate analysis
the criticism implies that because clinical medicine is as much farther
from being an exact science than anatomy as that is from, let us say,
astronomy, the teaching of clinical medicine cannot be made so
scientific, and must depend on rule of thumb. This we take leave
to deny. Clinical medicine and clinical surgery are unrivalled as
disciplines for training in observation and in comparison — two funda-
mentals of the scientific method — and if it could be made possible
to conjoin their study throughout with relevant parts of anatomy,
physiology, and pathology, all would gain. To recast the curriculum
in this sense would not be easy, but the Pathological Club's Report
offers strong reasons for the attempt being made.

The Executive Committee of the Post-Graduate

Post-Graduatejeacwng Courses in Edinburgh have decided to re-organise

the post-graduate teaching which has been

suspended during the war. Recognising that young graduates who

Editorial Notes 143

will be released from service with the forces on demobilisation have
the first claim on their attention, the Committee have arranged for
courses in Clinical Medicine, in Clinical Surgery, and in Obstetrics
and Gynecology designed to meet their requirements. The guiding
principle in planning these courses has been to afford facilities for the
graduate studying his subjects in a practical and consecutive manner,
rather than by means of didactic instruction. The professors and
lecturers have arrauged to work together in " teams," so that the
whole of the resources of the school, both in personnel and material,
will be available. The authorities of the various hospitals and other
medical institutions throughout the city also are cordially co-operating
with the Committee in affording facilities for clinical work.

Arrangements have been made by which, in addition to working
in the general and special departments of the hospitals, members of
the courses may take part in the work of the practical classes of
anatomy, physiology, pathology, bacteriology and pharmacology, and
also at the ante-natal and child-welfare centres. It is proposed to
conduct in each of the academic terms a course in Clinical Medicine
and a course in Clinical Surgery ; and during the months of August
and September the obstetric and gynecological course will be held.
As each course will occupy the whole time of the graduate only one
course can be attended in a term. The classes are conducted under
the segis of the University and the Royal Colleges. Further particulars
may be obtained on application to The Secretary, Edinburgh Post-
Graduate Courses, University New Buildings, Edinburgh.

The Edinburgh. University Court have appointed
ChchemSte^iCal Mr. George Barger, M.A., D.Sc, to the newly
instituted Chair of Chemistry in relation to

Medicine.

CASUALTIES.

Died on 1st February of illness contracted during the battle of
Jutland, Surgeon-Lieutenant William Pearson Cowpek, R.N.

Lieutenant Cowper was educated at Edinburgh, taking the Scottish
Triple Qualification in 1903.

Died on service, Captain Robert Aitken, R.A.M.C.

Captain Aitken graduated M.B., Ch.B. at Glasgow University.

Died on service on 1st February, Captain Alexander Graham
Spiers Logie, R.A.M.C.(T.F.).

Captain Logie graduated M.B. and CM. at Edinburgh University in
1887, and before the war was in practice at Kaglan, Newport, Monmouth.

144 Sir Edward Sharpey Schafer

THE POSITION OF PHYSIOLOGY IN MEDICINE.*

By Sir EDWARD SHARPEY SCHAFER.

I daresay you imagine I can have very little to say that you do
not already know about the position of Physiology in your medical
studies, for I have little doubt that you, one and all, look upon
Physiology as one of several sciences which are merely incidental
to the proper study of Medicine and Surgery — subjects which you
are expected to get up to examination point and then to leave
behind you as a fading memory while you pursue those which are
to furnish you with a career and, incidentally, with a means of
livelihood ; enabling you to cure, or, as the case may be, to kill
with impunity. Certainly you are justified in that impression
when one considers the way in which most medical men regard
our science, and not only general practitioners, but even many
who are assumed to occupy a higher rank in the profession owing
to their reputation for peculiar skill in a particular field of medical
knowledge. It is true that one does not now so often hear the
opinion openly announced that too much physiology is taught
to medical students, although it is sometimes still expressed by
those who ought to know better. Such a doctrine is coming to
be regarded as dangerous. Even the laity is awakening to the
fact that, without Physiology, Medicine can make no progress
— cannot, indeed, continue to exist, for a science which fails to
progress becomes dead. Only a few weeks ago, one of the leading
London papers published an article in which not only was the
importance of Physiology insisted on, but the dependence upon it
of the whole superstructure of Medicine and Surgery was clearly
recognised. Nevertheless, it is rare to hear medical men express-
ing this opinion, the reason perhaps being that most of them are
ignorant of the true relations of Physiology to Medicine. What
little Physiology they managed to imbibe they usually promptly
forgot, having found amongst their clinical instructors no
encouragement offered to continue its pursuit. They were not
taught by those instructors, who probably did not admit it them-
selves, that every disease, if its conditions are to be understood,
must be the subject of physiological study; nor was it pointed

* Presidential address delivered to the Edinburgh. University Physio-
logical Society, 16th January 1919.

The Position of Physiology in Medicine 145

out to them that the methods of such study are in the main
identical, whether the subject be Rana temporaria, Canis familiaris,
or Homo sapiens. Nor is this to be wondered at. Many — prob-
ably most — clinicians never had an opportunity of studying
physiology in the only way it can be effectively studied, viz. by
the experimental method, which necessarily implies long hours of
laboratory work. How should the clinician know, and why should
he care, whether his methods are scientific or not, if they prove
sufficiently successful to enable him to gain a reputation as a
practitioner and a more or less lucrative income ? He may well
believe that if he himself has been able to acquire skill and
experience in the diagnosis and treatment of disease by methods
traditionally handed down from preceding generations, this is
going to be the procedure until the end of time, and that
these methods would succeed in turning others into just as good
practitioners as himself. And very probably they would !

Far be it from me to include the whole profession in this
indictment. There are, we all know such, many exceptions who
have endeavoured with a considerable measure of success to keep
pace with the progress of Physiology, and to apply its methods
to diagnosis and treatment. But the accusation will apply to a
majority of practitioners, whether general or special, and it is
this which renders reform in the desired direction so difficult.

Unfortunately the tendency to underestimate the value of
Physiology is not confined to individuals, but also affects the
corporate bodies which have been established to uphold the
interests of Medicine and Surgery. The General Medical Council,
for instance, which lays down the minimum of time required for
the teaching of the subjects of the medical curriculum, makes
the scantiest possible allowance for practical instruction in
Physiology, and were it not that most of the universities and
Medical Schools recognise the impossibility of attempting to get
so large a subject into so small a space of time, it might just
as well be omitted. The Eoyal College of Surgeons of England,
the Fellowship of which is so highly prized as to be a sine qua
non for the consulting surgeon in England, has never instituted
a practical examination in Physiology for this important diploma,
although I notice that the Council has lately appointed a Com-
mittee to consider the possibility of altering the examination,
" with the view of making it of more practical value as a test for
surgeons likely to become chiefly engaged in operative practice."
Whether this means a raising or a lowering of the standard of

146 Sir Edward Sharpey Schafer

knowledge required I cannot say, but I feel sure that if some of
our leading surgeons were consulted, they would report that they
had been taught too little physiology rather than too much.

Up to the present I have not, except by implication, intro-
duced the text of my discourse, which in a sermon like this should
have come at the very beginning. I will now proceed to do so
in the form of a proposition, viz. that Physiology is the pivotal
subject around which all the medical sciences are centred, and
furnishes the basis upon which the whole of Medicine and Surgery
is founded. Our predecessors in this university exhibited
their wisdom when they gave to Physiology the name of "The
Institutes of Medicine"!

The proposition is one which admits of such easy proof that
no sane person will attempt to controvert it. For Physiology is
the science of the living organism, and seeing that it is with the
living organism that the physician or surgeon has to deal, a sound
knowledge of Physiology is as essential to him as a knowledge
of arithmetic to the mathematician.

In former days men thought that Anatomy occupied this
pivotal position. But the object of Anatomy is the investigation
of the dead body. Anatomy can only be of value in so far as
it throws light upon the functions of that body during life — in
other words, on its physiology.

Perhaps you will excuse me if I digress for a moment in order
to criticise the methods by which Anatomy is taught in our
Schools. It is surely unfortunate that the study of Anatomy
is so exclusively confined to the dead subject. For, as I have
just pointed out, it is a knowledge of the living body which
you will require when you come to make investigations upon
your patients, and this knowledge can never be obtained by the
mere investigation of the cadaver — least of all by the antiquated
and time-devouring methods which are employed in the dissecting-
room. It is not altogether the teachers of Anatomy who are
responsible for the retention of these methods. Even if they
had the will to alter them — most of them, I fear, have not — they
would come up against the fiat of the General Medical Council,
which prescribes that every student shall dissect the whole of
the body in the course of his anatomical training. The prescrip-
tion at least implies that he shall have a body to dissect, but
takes no thought as to where the supply is to come from, and a
student is lucky to get at a sixteenth part of a subject in order
to work out his allotted task. But he can never acquire in this

The Position of Physiology in Medicine 147

manner the knowledge which will enable him to understand the
condition of the body during life, and most of the time which he
gives to dissection is — to make no bones about it — wasted. The
supposed necessity for the dissection of the whole body, from
skin to skeleton, is a myth which appears to have come down
from the Middle Ages. It is extraordinary how it has clung to
the curriculum, when one considers that every medical man must
be well aware of the amount of profitless time he spent in the
dissecting-room. A much more useful knowledge could have been
got by the study of specimens in which the parts retain their
natural relation to one another, and this in less than half the
time taken up by laborious dissections. Every student is aware
of the value of such specimens, and for the physician and
surgeon the knowledge to be gained by their study is priceless,
far exceeding anything than can be learned by dissection. No
one supposes that the relations of the viscera to one another
during life — the knowledge of which is absolutely essential to
the medical practitioner — can be learnt by dissection of the dead
body. And the same is true for every other part and organ with
which the doctor may have to deal. And yet this antiquated system
of study is responsible for the fact that in our medical school —
and I have no doubt things are as bad in others — out of the
2100 working hours of the first two years of the curriculum each
student is expected to give 1300 to Anatomy, and only 260 to
Physiology. And this in spite of the fact that Physiology is not
only a more extensive and more difficult subject, but is the science
of the living body, upon a knowledge of which the whole of
Medicine and Surgery are based, and to which the physician and
surgeon must every day look for guidance ; whereas Anatomy is
the science of the dead body, and owes its main value to the con-
sideration that it is necessary for understanding Physiology. As
soon as it is applied to the living body it becomes Physiology, and
its problems are identical with those of Physiology.

That it is impossible to practise either Medicine or Surgery
without a sound knowledge of Anatomy is indeed true ; it is the
soundness of the knowledge which has been so painfully acquired
which I am impugning. Indeed so little that is really useful in
Surgery and Medicine is learned by the ordinary methods of
teaching Anatomy that it is necessary to have special courses of
instruction in so-called medical and surgical Anatomy in order to
supplement the deficiency of this teaching, in spite of the great
amount of time which ha3 been devoted to it!

148 Sir Edward Sharpey Schafer

As an excuse for the study of Anatomy by means of dissection,
it is sometimes urged that this affords training in manual dexterity
of great importance to the future medical man, which cannot
otherwise be acquired. An argument such as this serves to
demonstrate the weakness of the case of those who employ it.
It resembles that used by the advocates of the continued waste
of time upon classical studies in schools, viz. that these studies
afford the only mental and educational training which is of any
value, whatever the profession for which the schoolboy is destined
— an argument which, although frequently refuted, crops up
perennially.

Before we leave the discussion of the true relation of Anatomy
to Physiology we may briefly consider the position of that branch
of Anatomy which is termed Histology.

As to this, whatever has been stated regarding the position
of Macroscopic Anatomy applies equally, perhaps more so, to
Microscopic Anatomy. Its chief interest lies in its utility for
the elucidation of physiological problems. It has therefore been
a sound tradition in Great Britain to place the teaching of Micro-
scopic Anatomy with the physiologist, rather than, as is done in
Germany, with the anatomist. There has been lately a tendency
on the part of certain English physiologists to neglect or belittle
this important asset in their methods of inquiry; but the best
physiologists have usually been good histologists, and it is an
indisputable fact that many of the most important advances in
Histology have been made by physiologists in the pursuit of purely
physiological problems.

To return now to our main subject : besides Anatomy, there
are two other branches of science which lead up to Physiology
and are essential to its understanding — these are Physics and
Chemistry. To Biology I need not specially refer in this connec-
tion, since it is a recognised part of Physiology and is usefully
employed to inculcate the fundamental principles of that science
as they are exhibited in the lower animals and in plants. Nor
need those portions of Zoology and Botany which lie outside the
immediate range of Physiology detain us, valuable as they are
in themselves, for they are not essential to its understanding, nor
have they any important clinical interests. But since Physiology
consists in the application to the living body of Physics and
Chemistry, a sound knowledge of the general principles of these
sciences is an essential part of the education of the medical
student. There may be a difference of opinion as to where these

The Position of Physiology in Medicine 149

subjects are best learned. Some authorities hold that they can
only be properly taught in a medical school. Others believe that
they would come more naturally into the ordinary school curri-
culum, instead of a part of the inordinately inflated classical
instruction which has hitherto dominated everything else in our
large public schools. Personally, I share the latter opinion, since
the principles of a science are the same whatever their subsequent
applications are to be; and the application of the principles of
Physics and Chemistry to the elucidation of Physiology is the
function of the teacher of Physiology, not of the teachers of
Physics and Chemistry. At any rate, if these sciences are to
be taught in a medical school, they should at least be taught
efficiently, and a year would be too little to devote to that purpose,
even if Zoology and Botany were not included in that year. But
unfortunately they are included, and to add to the overcrowding, the
cuckoo has laid her egg in that nest also, so that these unfortunate
hedge sparrow chicks are almost starved out of existence, owing
to the appropriation of a large part of their pabulum by that time-
devouring bird !

It seems scarcely credible that there are some amongst us who
wish to introduce yet other subjects into the work of the first
two years, overburdened as these already are. And it is still
more incredible to hear that the subjects it is desired to introduce
are those which are now confined to the final years — subjects
which cannot be so much as comprehended until the sciences on
which they are based are already mastered.

The idea is current amongst the laity that the study of
Medicine and Surgery consists in " seeing cases " and in learning
from a practitioner the methods by which he treats them. Persons
who have no acquaintance with science are unable to understand
the relations of the medical sciences to one another, nor how the
study of the more complex must be preceded by that of the
simpler. Now the science of the living body is one of the most
complex, and when the body is modified by disease the complexity
becomes even greater. It is, therefore, about as logical to begin
the study of medicine before a knowledge of the sciences upon
which it is founded has been acquired as to attempt to learn
arithmetic before the multiplication table has been mastered.

The present generation of medical students has, fortunately
for itself, no experience of the consequences of such a reversal of
procedure ; but those of us who belong to an older generation had
that experience in abundance. At the time that I myself became

150 Sir Edward Sharpey Schafer

a medical student in London, in the late sixties, it was still
customary, although no longer compulsory, for a boy after leaving
school to be apprenticed to a medical practitioner, with whom
he visited his cases, and for whom he helped to compound his
medicaments; and the practitioner was supposed to impart to
the apprentice a knowledge of the diagnosis and treatment of
illness and disease. And when a young man entered at a medical
school — whether he had previously served an apprenticeship or
not — he was expected from the first to attend the hospital to
which the school was attached, and to listen to the clinical
teaching there given, whether in the wards or operating theatres
or out-patient department. This we, all of us, had to go through,
and we were said to be "walking the hospitals." Our fond
parents supposed that we were thereby acquiring a practical
knowledge of our profession, and we, no doubt, looked upon our-
selves as budding practitioners, especially when a patient insisted
upon addressing us as "Doctor"! But we subsequently found
that all this early attendance at hospital was so much wasted
time; for although we listened open-mouthed to the words of
wisdom which flowed from the lips of our teachers, we were
unable even to understand the language they were speaking,
knowing nothing about the organs the diseases of which were
being explained to us ; their very names in many cases were
strange to our ears. As a result of this waste of time no student
could, at that time, hope to pass his examinations in Anatomy and
Physiology — although there was then much less to be learned —
until three years after entry ; and everything which he had been
supposed to be acquiring in the way of medicine and surgery had
to be learned over again in the light of the new knowledge which
he had gained from the study of these sciences. I cannot imagine
it possible that anyone who has himself been a victim of this
superseded system would wish to inflict it upon others, and I can
only assume that those who are working for this end have had
no personal experience of its consequences.

It is possible that when diagnosis and treatment were of the
rule-of -thumb character there may have been something to be
said for early visitation of the hospital, and even for apprentice-
ship. In the old days Medicine and Surgery were regarded as
"Arts" rather than "Sciences," and even when their scientific
character came to be conceded, text-books were still written on
the " Science and Art of Surgery " and the " Science and Art of
Medicine." But it is no longer possible to look upon them as

The Position of Physiology in Medicine 151

anything but sciences — unless the cultivation of a "good bedside
manner" may be regarded as a relic of a lost art, in the same
way that the buttons at the back of the professional frock-coat
are relics of the swallowtail which was de rigueur in the reign
of the fourth George. Fortunately, this point of view has for
the most part disappeared with the recognition of the entirely
scientific character of Medicine and Surgery — a recognition which
we primarily owe for Medicine to the great Frenchman, Louis
Pasteur; for Surgery to the great Englishman, Joseph Lister.
As a result of this recognition it became unusual, at least in
London, in the course of the seventies, for the student to attend
the hospital clinics in his earlier years, and ultimately it was
laid down in most of the medical schools that Anatomy and
Physiology must be studied, and the examinations passed, before
the student could be permitted to spend any part of his time on
the more distinctively medical subjects. But in Scotland changes
have come more slowly, and it was only in quite recent years
that a similar rule was adopted in the University of Edinburgh.
When I came here from London in 1899, I found to my surprise
that my Physiology students were required to attend Surgery
lectures and practice in their second year, and Medicine lectures
and practice in their third year — in both cases concurrently with
Anatomy and Physiology — and had therefore to spend every
morning from eleven to one in the wards of the Infirmary. I
need hardly say they were not in a position to learn much from
this premature attempt to impose clinical work upon them ; and
I leave you to imagine how their physiology suffered ! Needless
to say, there was friction between the Professor of Physiology
and the Clinical Professors, which at one time threatened to
culminate in a deadlock. [In my own defence I ought, perhaps,
to explain that if this friction was not felt so much in the time
of my predecessor, it was not necessarily because his successor
was of a more combative disposition, but because experimental
work in Practical Physiology had not been introduced into the
curriculum.] The deadlock was averted by the removal of
Surgery to the third year and Medicine to the fourth,*' and the
concentration of the teaching of Physiology into the second year,
attendance on that subject during the third winter session being
dispensed with. On the other hand, the condition was laid down
that since the whole instruction in Physiology had now to bo got

* The relative positions of Surgery and Medicine in the curriculum have
since then been reversed.

152 Sir Edward Sharpey Schafer

within the compass of a single year, the student must not be
required to attend any other course within that year, with the
exception of Practical Anatomy. This change was made in 1908,
and a great improvement at once manifested itself from the
point of view both of Physiology and of Medicine and Surgery.

Physiology is a vast subject with many ramifications, and a
year is all too little to acquire a practical acquaintance with
it. Nevertheless, if every student could really devote a whole
academic year to this subject, he might have a chance of obtain-
ing such a knowledge of it and its methods as would be of great
value in their application to the study of disease. But so far
from a whole year being devoted by each student to the subject,
it has not hitherto been possible to arrange that he should have
more than one-third of that time. This result is due to a lack
of laboratory accommodation as compared with the number of
students to be provided for. The effect of the deficiency is that
the work has to be carried on in at least three relays, and the
time parcelled out into thirds. Moreover, the work has to be
done hurriedly, without the leisured effort which is the first
requisite for all scientific experimentation. And as the places
used are required for the next relay, the tables have to be cleared,
the work interrupted, and a large amount of time taken up in
dismantling apparatus used by the one set of students and in
re-establishing it for the next set. As a consequence of this lack
of laboratory space, each nominal three months' course — which
academically means ten weeks — is really represented for every
student by little more than three weeks !

The remedy for so serious a condition of things is the provision
of enough laboratory accommodation to permit every student to
have his own — properly equipped — place, to which he can come
and do his work without undue haste, and without the necessity
of disarranging his apparatus at the end of an hour or two. This
provision of adequate space is obviously necessary, and must be
found if we are honourably to recognise our obligations to the
students we admit to our courses of instruction. It will neces-
sitate a completely new Institute of Physiology, for no amount of
tinkering with the present laboratory will avail to meet the want
of accommodation from which we are suffering. For the ordinary
practical classes alone four times the present amount of floor-
space is required, to say nothing of provision for advanced
teaching and research, without which no university is worthy
the name. And the university is under obligation not only to

The Position of Physiology in Medicine 153

the students whom it admits to its courses, but also to the
professors appointed to conduct the instruction. Previously to
the last Eoyal Commission on the Scottish Universities, the
professors themselves took the fees of their students and were
expected to provide the means of instruction. Under that system
the gross income of the Professor of Physiology exceeded £3000,
and that of the Professor of Anatomy £4000. The Commission
cut down the salaries to considerably less than half these amounts,
but on the expressed condition that all the requirements for
teaching, including the provision of adequate laboratory accom-
modation and assistance, should be met by the university. No
doubt with the growth of the system of laboratory work the
expense of providing for these requirements has greatly increased,
but this does not absolve the university from its obligations.
The professors in charge of the practical departments have been
called upon for much more work than before : in the case of
Physiology, the time now occupied in teaching is more than three
times as much as it was under my predecessor. But strange as
it may seem, I have not yet heard that the University Court are
proposing to increase either my salary or that of my colleagues
in proportion to the additional work and responsibility thrown
upon us !

Obviously the provision of increased accommodation requires
a large capital expenditure — far too large to be met by voluntary
gifts, even if the beneficent millionaire were as common in
Scotland as in America. Not that I personally have any desire
that the want should be met in this manner; for beneficent
millionaires have a way of laying down conditions which hamper
the free development of a university. Moreover, we do not ask
for charity, but we do ask that the Government of this great
country shall admit its responsibilities in the matter of university
education. It has been compelled to admit them in the spheres
of elementary and secondary education. Why should not the
universities be similarly supported ? I for one have no hesitation
in believing that the future welfare of the Empire largely depends
upon its universities. Nevertheless the United Kingdom is far
behind even its own Colonies in this matter, and seons behind
the United States of America. What has struck me more than
anything else in my visits to the States has been — not the
enormous advances in agriculture, in manufactures, and in
commerce, wonderful as these undoubtedly are — but the extra-
ordinary development of the universities. Of the large number

154 Sir Edward Sharpey Schafer

of States in the Union — I forget how many there may be now —
there is hardly one that has not a first-class university, with all
the financial resources of the State Government to back it up,
and with the highest intellectual interests of the State centring
upon it. Privately endowed universities exist in addition, their
endowments ranging from five to thirty millions of dollars. But
it is the State-supported universities which must in future form
the backbone of higher education, and it is upon them that
the development of the country, both moral and material, will
ultimately depend. The empire of education has already bent
its way westward. Only by a great effort on the part of our
universities, backed freely by funds furnished by the State —
measured not in thousands but in millions — can we hope to
maintain, indeed to recover, that pride of place in higher educa-
tion which has hitherto been the confident boast of this nation.

I find myself again almost losing sight of my text, owing to
the vast perspective which the discussion of the necessity for the
future development of the universities in this country has opened
out. That text, I must remind you, is the pivotal position of
Physiology in medical study. Everything that you learn before
you come to Physiology leads up to it, and owes its main value
to that circumstance. On the other hand, Physiology through
its sister sciences, Pathology and Pharmacology — between which
and Physiology there is no dividing line — leads to Clinical
Medicine and Surgery. And besides this connection through
Pathology and Pharmacology, Physiology has a still more intimate
relationship with medical and surgical practice, for without a
present and accurate knowledge of the normal functions of the
body the investigation of abnormalities is impossible. And this
is just as true for Surgery as for Medicine; partly because most
surgical cases are, in the first place, medical cases ; partly because
the surgeon, as well as the physician, is constantly coming across
problems which are purely physiological in character. This has
been lately brought home to me, because I have been frequently
consulted since the war on disturbances of function consequent
on wound injuries and the best methods of dealing with them.
Most physiologists have, I fancy, had a similar experience; not
that the physiologist possesses a magic wand warranted to clear
all difficulties out of the way, but he may often be able to indicate
in what direction the solution of a difficulty is to be found, and
this will be, at any rate, a step towards its disappearance.

The ancient notion that Surgery is based on Anatomy and

The Position of Physiology in Medicine 155

Medicine on Physiology is an erroneous one. Both these subjects
are dependent — and equally so — upon Physiology. Both are also
dependent upon a knowledge of Anatomy, but only in so far as it
is applicable to the living body. In this case, as I have already
said, the distinction between Anatomy and Physiology vanishes —
the one is merged into the other.

I have so far only dealt with Medicine and Surgery as general
subjects, but everything I have said about their relations with
Physiology applies very evidently to the branches in which men
are inclined to specialise. In this connexion I need only mention
midwifery, diseases of the nervous system, affections of the eye,
diseases of the secreting glands, and, last in date but not least
in importance, derangements of the endocrine organs. There is
no dark spot in clinical medicine and surgery which cannot be
illuminated by the lamp of Physiology, although we may have to
wait a little for its rays to penetrate to every corner. The first
necessity is that the medical student shall have a thorough
practical acquaintance with this science, which can only be met
by setting aside a reasonable amount of time for experimental
work. Three months might suffice if the larger part of the day
were given to it ; three weeks is absurdly inadequate ! Naturally,
also, the student must be thoroughly grounded in the subjects
which lead up to Physiology, and that again largely by practical
work. And lastly, the applications of Physiology to Medicine
ought to be in the hands of clinical teachers who are themselves
trained physiologists, and who owe their selection as clinical
teachers partly to the possession of this qualification. It is not
necessarily the brilliant operator or the fashionable physician who
makes the best clinical teacher. He will generally prove to be
the best who has had the best scientific training, provided always
that he possesses the gift of imparting knowledge to his pupils.

156 Alexander Goodall

MALAKIA IN MACEDONIA.

A Clinical Lecture Delivered in the Eoyal Infirmary.

By ALEXANDER GOODALL, M.D., F.R.C.P., Lecturer on Clinical
Medicine, University of Edinburgh, Temporary Major, R.A.M.C.

Ladies and Gentlemen, — Since I last lectured in this room I have
seen and been responsible for the care of some 20,000 cases of
malaria. This disease is caused by a parasite which infects the
red blood corpuscles, and it is conveyed to man by the agency of
certain mosquitoes. Nearly thirty varieties of mosquito are
known to carry infection, but only three are met with in
Macedonia. These are anopheles maculipennis, anopheles bifur-
catus, and myzomyia superpicta. The males are vegetarians, but
when the females come out in the evenings they are out for blood.
A glance at a contour map of Macedonia shows, that Salonika
is surrounded by an enormous plain for about 40 miles. An
important ridge to the north-east separates this plain from the
Struma Valley, but the rest of the environs of Salonika is low-
lying and marshy and offers ideal conditions for the propagation
of mosquitoes. Thousands of pounds have been spent in drain-
age and other antimalarial operations round camps and hospitals,
but it would take millions to complete the work.

Life-History of the Parasite. — The malaria parasite lives part
of its history in the mosquito and part in man. When an infected
mosquito bites a human subject, the sporozoites enter the red
blood corpuscles as trophozoites, enlarge, and eventually form
rosettes. These rosettes break up into twelve or more merozoites,
each of which may infect a new blood corpuscle. On the other
hand, some of the parasites differentiate into sexual forms.

The females in some cases may sporulate and reinfect
corpuscles, but the male forms probably die out unless taken into
a mosquito.

When a mosquito sucks blood containing sexual forms these
conjugate and form cysts in the mucous membrane of the stomach
of the mosquito. These cysts eventually rupture and liberate
sporozoites.' Some of the sporozoites reach the salivary glands,
and thus the parasite may infect man again when next the
mosquito feeds.

Three varieties of malaria parasites are recognised. These are
Plasmodium vivax, which causes tertian fever; P. malaria, the

I

Malaria in Macedonia

157

cause of quartan fever ; and P. falciparum, the cause of malignant
or subtertian malaria.

Each time a group of rosettes breaks up to form merozoites,
toxins are liberated, and thus the incidence of symptoms corre-
sponds to the life-cycle of the parasite.

P. vivax runs through its cycle in man in forty-eight hours.
The host thus receives a dose of toxin and undergoes a febrile
reaction once in two days.

The quartan parasite has its cycle in man in seventy-two

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a Tlie asexual cycle in man. /. The female cycle in man. m. The male cycle in man.
/i, m1. Female and male gametes which conjugate in the mosquito to form a zygote — the ookinete.
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hours. The paroxysms therefore occur every third day, e.g.
Tuesday, Friday, Monday, Thursday.

P. falciparum runs its course in forty-eight hours or less. The
incidence of symptoms is thus on alternate days, but the intervals
are often shorter. The fever is therefore sometimes called sub-
tertian. Tertian and subtertian fevers are common in Macedonia.
Quartan malaria is hardly ever seen.

Symptoms. — After a person is bitten by an infected mosquito
it takes ten to twelve days till the parasites are sufficiently
numerous for their toxins to cause a reaction when the rosettes
break up. This is the incubation period.

A typical paroxysm consists of a cold stage, a warm stage,

12

158

Alexander Goodall

and a sweating stage. The cold stage begins with a feeling of
chilliness and a succession of rigors which may be very violent,
and, in spite of the patient's sensations, the rectal temperature is
steadily rising. In from ten to twenty minutes this stage has
passed. The patient begins to feel flushes of heat. These become
more frequent and last longer, and soon the patient is uncomfort-
ably hot. The pulse is full and dicrotic, the arteries throb visibly,
and there is severe headache and often vomiting. This stage may
last several hours. Belief comes with the sweating stage. At
first perspiration is slight, but it soon becomes profuse. The patient
generally falls asleep and awakes much more comfortable, though
sometimes there is danger from collapse. In a typical case no
further symptoms arise for forty-eight (or seventy-two) hours
from the beginning of the attack.

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Chart I.

Typical chart of simple tertian malaria from case of a Serb private,
aged 37.

Multiple and Local Infections. — A simple typical attack is
rarely seen in Macedonia. Mosquitoes are so numerous and so
heavily infected that the human infection is usually multiple.
Thus patients are exposed to a fresh dose of toxin every day, or
even twice a day, and it is nearly as common to see cases with
remittent or continuous pyrexia as with typical intermittent
fever.

Another factor giving rise to special symptoms is a localisation
of toxins. The infected corpuscles, especially in malignant tertian

Malaria in Macedonia

159

cases, have a tendency to adhere to each other and form little

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plugs in the capillaries. These act as thrombi and as local centres
for the production of toxins. The symptoms which may arise

160 Alexander Goodall

from multiple or localised infection may be conveniently grouped
under the different systems of the body.

Alimentary System. — Vomiting is a common feature. It is
sometimes very persistent, and is not infrequently associated with
jaundice. This type of case is well known, and is referred to as
bilious remittent fever.

Parotitis is not uncommon. The chief difficulty it presented
was in distinguishing it from mumps. It usually subsides but
rarely suppurates, and more rarely there is a sloughing of the
whole gland.

Malarial appendicitis is a common and a difficult condition to
deal with. The questions that have to be answered are : —

Is the condition purely malarial ?

Is the condition a septic one in a malarial subject ?

Is the condition purely septic ?

Fortunately a reliable guide to treatment is to be found in
the blood examination. The finding of parasites is helpful but
insufficient. The leucocyte count, however, generally keeps one
right. In the absence of a leucocytosis and increased polymorph
percentage the case can be left to the influence of quinine.
When leucocytosis is present the case may be commended to a
surgeon. I saw many such cases and the leucocyte count only
once led me astray. The patient appeared to have a definite
appendicitis ; he had a high leucocyte count and high percentage
of polymorphs. On the strength of this we advocated operation,
with the result that an appendix, showing only slight congestion,
was duly removed. The cure was completed by the administration
of quinine.

The opposite and more serious error is even less likely to
occur, since an appendicitis demanding operation does not occur
without a disturbance of the leucocyte count.

Malarial diarrhoea, when associated with blood and mucus
in the stools, at once raises the question of superinfection with
dysentery. Some authorities regard all such cases as dysenteric,
but I cannot accept this view. The finding of parasites in blood
or organisms in the stools and the results of quinine treatment
generally clear up the diagnosis. As in all cases of disturbance
of the alimentary canal, the quinine should be given by intra-
muscular injection.

Hemopoietic System. — Enlargement of the spleen is almost
invariable, and is an important diagnostic sign. In one case I
saw an enlarged spleen cause obstruction of the colon, which

Malaria in Macedonia 161

was overcome with purgatives and quinine. Lymphatic adenitis
sometimes occurred but was not common.

In one case I saw a thyroiditis which went on to abscess
formation. Its relationship to the malaria was not clear.
Anaemia was always present but was seldom so severe as the
patient's appearance had led one to expect. In almost all cases
it was of secondary type. I saw one definite example of per-
nicious anaemia with numerous megaloblasts and high colour index.
The patient rapidly recovered under quinine and arsenic, and I
regarded the condition as due to a localisation of parasites and
their toxins in the bone-marrow.

Circulatory System. — In every case there is a certain amount
of cardiac dilatation, and the number and variety of murmurs
one hears is astonishing. In all the more severe cases serious
damage is done to the heart, and heart failure is the most
common cause of death. Most of the other dangerous symptoms
can be met by adequate quinine treatment, but quinine does not
restore a failing heart. The pathological changes are described
by Dudgeon and Clark {Lancet, 1917).

Respiratory System. — A moderate degree of bronchitis is
common, and patches of broncho-pneumonia are frequently found.
In most cases these clear up rapidly under quinine. On the
other hand, pneumococcal pneumonia complicating malaria is a
formidable condition.

Integumentary System. — Herpes labialis is extremely common.
Erythema and urticaria are not infrequent. Other rashes are
less common and may be difficult to distinguish. A malarial
rash may imitate that of measles or scarlet fever, and I once
saw a case with an eruption and mottling which closely resembled
typhus. A localisation of parasites in the extremities may lead
to gangrene of the fingers or toes, but this is very rare.

Urinary System. — Malarial symptoms are rare, but I have
seen cases of cystitis, nephritis, and haematuria. The exact
etiology of blackwater fever is a matter of controversy, but it
is always associated with malaria. After the Serbs crossed
Dobropolje on 15th September 1918 they advanced so rapidly
over mountainous country that their ambulance service could
not keep pace with them, and a week or more might elapse
before a sick or wounded man reached hospital. At one general
hospital at that time I saw over a dozen cases of blackwater
fever. The causal factors were malaria, exposure, and fatigue.

Special Senses. — Among symptoms affecting the special senses

162 Alexander Goodall

the one which was most frequently noted was a superficial
stellate ulceration of the cornea.

Nervous System. — Symptoms referable to the nervous system
were frequent and of great interest. A local neuritis was
common. I saw two examples of multiple peripheral neuritis.
One case of great interest presented all the common phenomena
of locomotor ataxia except the Argyll - Robertson pupiL A
complement - deviation test for syphilis was negative. The
cases of outstanding interest, however, were the cerebral cases.
Symptoms might arise with startling suddenness, and when
treated timeously the almost immediate transition from grave
danger to obvious recovery was one of the most dramatic and
gratifying experiences of medical practice. Most of these cases
were due to the malignant tertian parasite, but a few were
caused by P. vivax. A common occurrence was for a malarial
patient, often regarded as convalescent, to complain of giddiness
and go to bed. In a few minutes he became drowsy, then
comatose, and unless treatment was prompt and drastic a fatal
outcome was the result in a few hours. More rarely the patient-
would be struck down as if by apoplexy or sunstroke. Many
different conditions might be imitated, and among the cases of
which I have notes were the following : — A type which suggested
that the patient was malingering was not uncommon, and I once
saw a case where the man had almost run amuck, and I found
him in a detention tent under a charge of assaulting a non-
commissioned officer. These cases when examined would not
answer questions but resented interference. When the pupils
were examined the eyes were tightly closed and the head turned
away. If the reflexes were examined, the legs would be drawn
up and the patient appeared to try to make difficulties. In
other cases epileptic fits supervened. Stertorous breathing and
twitching of the limbs might suggest apoplexy. I saw two cases
of actual cerebral haemorrhage. Other conditions which were
imitated were cerebro-spinal fever, acute mania, and tetanus.
The diagnosis was often difficult. Perhaps the most helpful
factor was that cerebral malaria was the most common and
therefore the most likely condition. The spleen was practically
always enlarged, and parasites could usually be found. The
temperature gave no guidance. Many of the cases were afebrile.
The knee-jerks were usually absent but were often normal and
occasionally increased. Some cases showed Kernig's sign. Our
rule was to treat the doubtful cases as malaria. We argued that

Malaria in Macedonia 163

we could do little for the condition imitated, but that with half
a chance we could cure cerebral malaria. We had our failures.
These were practically always due to seeing the patient too late,
and the cause of death was almost always heart failure. Nearly
all my fatalities occurred among the Serbs and Jugo-Slavs after
the push on 15th September. Many of these cases were comatose
and some of them more dead than alive on admission. A com-
plication of cerebral malaria which almost always precluded
recovery was pneumonia. Here one faced the dilemma that,
untreated, the patient would die, and that, on the other hand,
an intravenous injection of quinine would almost certainly be
fatal.

Treatment. — The treatment of malaria is a big question, and
time permits me to give only the baldest outline of my own
practice. When a case was first seen, unless symptoms were
urgent, one gave 10 grs. of sodium salicylate and a dose of
calomel. The following morning one began the administration
of quinine by the mouth. One gave either 45 or 60 grs. a day,
according to the severity of the case. As the temperature gener-
ally rose in the afternoon, one usually gave 30 or 40 grs. in the
morning, and 15 or 20 grs. at noon. If pyrexia continued after
forty- eight hours one gave 20 or 30 grs. by intramuscular injection
into the buttock or deltoid, care being taken to keep away from
the great sciatic or musculo-spiral nerve. The injections were
repeated daily till the temperature came down.

Administration by the mouth was then resumed for ten days
and thereafter half the dose was given for another ten days.
Many authorities continue quinine for a much longer period.
I need only remark that I am not convinced of the efficacy of
quinine in preventing relapses, and that I am convinced that
harm may result from a prolonged course of quinine.

I do not intend now to discuss the prophylactic use of quinine.
In cases which resist quinine it is well, if it can safely be done,
to stop its use for a week and then start again with intramuscular
or intravenous injections. I have had no success with methylene
blue, salvarsan, or galyl. Arsenic may do good, but is a very
poor substitute for quinine.

Cerebral cases must be treated promptly with intravenous
injections of quinine. These may be given either concentrated
)r in a large quantity of saline solution. I am not convinced
that one method is better than the other, unless the patient is
collapsed and a saline infusion is indicated on its merits.

164 Alexander Goodall

Technique. — When concentrated quinine is used, one draws a
boiled solution of 30 grs. of bihydrochloride of quinine into a
sterilised 10- or 20-c.c. syringe with a rubber connection to the
needle. The syringe is then nearly filled with warm, sterile,
physiological salt solution. The arm is cleaned with spirit, and
then the upper arm is constricted by twisting a folded triangular
bandage round it so as to engorge the veins. This bandage is
held by an assistant. The needle is inserted into a vein with
the bevelled surface of the point downwards, and held at such
an angle that the bevel is parallel to the deep wall of the vein.
A little blood is withdrawn into the syringe, and then the
assistant is asked to let go the bandage. The injection is made
very slowly, and the pulse must be carefully observed.

When the injection is given in a large quantity of saline, say
a pint, the needle is connected with a glass funnel containing
saline only, and the quinine is added when the saline is seen to
be entering the vein.

The patient is often obviously out of danger before the injec-
tion is complete, but in some cases half an hour may elapse before
symptoms have subsided, and in other cases a repetition of the
dose may be required.

The procedure is not without danger, and disconcerting
symptoms, such as opisthotonos or convulsions, may occur. The
danger is in direct proportion to the state of the heart, and when
the circulation is poor one may have to rest content with repeated
small doses.

Some Illustrative Cases.

Case I. — Private I., aged 24, had been twice on the danger-
ously ill list with malaria in summer 1917. He had several
minor attacks the following winter. On 22nd May 1918 he felt
fevered but did not report sick. At 10 p.m. on 24th May he
became delirious and I was asked by the orderly medical officer
to see him. He was then comatose and delirious. He did not
recognise acquaintances and his attention could not be attracted.
He muttered continuously, and threw about his limbs and twisted
his body. Occasionally he shouted incoherently. The skin was
hot and dry. Temperature was 105° F. The spleen was just
palpable. The heart and lungs seemed healthy. Pupils were
dilated. Knee-jerks could not be elicited. At 10.50 p.m. I
administered 30 grs. of bihydrochloride of quinine in 10 c.c. of
saline solution intravenously. There was immediate improve-
ment. The patient became quieter and he could be roused. He

Malaria in Macedonia 165

■could answer " Yes " or "No" to questions, but said nothing further.
The violent movements of his limbs were replaced by muscular
twitching of cerebral type. Great restlessness and occasional
muttering continued. The forehead became moist but there
was no general perspiration. At 11.30 p.m. this condition
persisted; temperature was then 104*5° F. I therefore repeated
the intravenous injection of 30 grs. of quinine. The effect was
immediate. There was profuse perspiration. The restlessness
-and twitchings stopped, and questions were answered readily.
Patient fell asleep and awoke in the morning with a temperature
of 97*8° F., and had no complaint beyond a slight headache. He
had no recollection of the previous night's proceedings. His
subsequent progress was uneventful.

This was a case seen early where the pulse was good and one
could push quinine without anxiety. Sixty grs. intravenously
within an hour is heroic dosage, but I do not think a less dosage
would have succeeded. In any case, the end justified the means.

Case II. — Private L., aged 32, admitted to hospital on 10th
October. He had reported sick on 3rd October with headache,
vomiting, and pains in the legs. He had no previous malaria.
On admission temperature was lOTo" F., pulse 100. The tongue
was furred; there was slight icterus and some sickness. The
spleen was enlarged, but not palpable. Parasites were not found.
He was ordered quinine, 40 grs. daily, by the mouth, but as he
became dull and drowsy later in the day, he received 18 grs.
by intramuscular injection. Next day he was better, but as he
had occasional vomiting the intramuscular injection was repeated.
On the 12th the temperature was 103° and patient became
delirious. He received an intravenous injection of 24 grs. of
quinine at 2 p.m. and an intramuscular injection of 18 grs. at
9 p.m. On the 13th he seemed better and the temperature was
normal. He received 40 grs. of quinine by the mouth. At
9 p.m. he became restless and delirious — said there were people
below his bed. On the 14th he was more quiet and seemed
better, but had delusions of suspicion. On the 15th he became
maniacal, and argued fiercely that he should not be shot without
a court-martial. He had hallucinations of sight and hearing.
The tongue was furred, the knee-jerks were sluggish, the speech
was thick and slurring. A consultation of experts was now held.
An asylum superintendent thought the patient had general
paralysis of the insane; a gynecologist thought he suffered from

igg Alexander Goodall

quinine poisoning; while our eye specialist maintained that the
true diagnosis was delirium tremens. Fortunately for the patient,
my surgical colleague strongly supported my view that the case
was one of persistent cerebral malaria. Acting on this opinion,
we administered 18 grs. of quinine intravenously at 11 a.m. and
again at 6 P.M. On the 16th patient was drowsy and heavy, but
quite rational. Quinine was continued by the mouth. He steadily
improved, and was practically well by the 20th. By this time
the spleen had become palpable, but parasites, in spite of repeated
search, were never found.

Case III. — A Serb private was admitted unconscious to hospital
on 21st September. He had been diagnosed as a case of tetanus
in a French field ambulance, and had received an injection of
20 grms. of antitetanic serum. No further history was available.
The temperature was 105-4° F. No wound could be found. The
patient was taking fits of opisthotonos every few minutes and
minor convulsions which chiefly affected the left arm and leg.
Between the fits there was complete muscular relaxation. The
muscles of the jaw were not specially involved, and external
stimuli had no effect in determining convulsions. For these reasons
the fits were thought to be malarial rather than due to tetanus.
Moreover, the spleen was palpable, and the blood contained
numerous malignant tertian parasites. The pulse was miserably
poor, so that it was thought unsafe to give an intravenous injec-
tion. We gave an intramuscular injection of 20 grs. of quinine.
At 9 p.m. the pulse seemed stronger, and we decided to give an
intravenous injection of 20 grs. in a pint of saline solution. By
11 p.m. the spasms had stopped, but the pulse was still very poor.
At 3 next morning the temperature had risen to 107° F., and at
3.30 there was another severe convulsion. Patient was sponged
with tepid water. By 5 a.m. the temperature had fallen to
104"5° F., but the pulse was almost imperceptible. The usual
stimulants were employed, but death took place an hour later.

Case IV. — Serb private, age 34, admitted 4th December 1918
as a case of influenza. He had suffered from malaria in 1917 and
again two months before admission. He had been ill four days,
complaining of fever and pains in the limbs. Temperature was
102° F. He was slightly cyanosed. The tongue was furred;,
the spleen was palpable. Ehonchi could be heard all over the
lungs and crepitations at both bases. The blood contained
malignant tertian parasites. In a few hours the patient became

Malaria in Macedonia 167

semi-conscious. He lay in a most uncomfortable attitude, with
the head just off his pillow. The neck muscles were very stiff
and almost rigid. The lips twitched and there were clonic move-
ments of the jaw. Every now and again the muscles of the
forearms passed into a condition of spasm resembling tetany.
The knee-jerks were brisk; the pupils were dilated. Patient
would neither swallow nor answer questions, and there was
incontinence of urine. In spite of his feeble pulse and the
condition of the lungs we gave an intravenous injection of
quinine, 18 grs., and in addition he received 20 grs. daily by
intramuscular injection. There was a gradual improvement of
the cerebral symptoms. By 8th December he had completely
recovered consciousness. The stiffness of his neck and the
twitching of his lips and arms had disappeared. He could
swallow and answer questions. Unfortunately, there was now
percussion dulness at both bases, with bronchial breathing and
much cyanosis. He died on 11th December. A post-mortem
examination revealed an enlarged fibrous spleen and double lobar
pneumonia.

This case illustrates one of the diagnostic difficulties we had
to meet : Had a patient malaria or influenza, or both ? This man
certainly had malaria and probably influenza as well. The case
also illustrates the serious import of a pneumonic complication.
One gives an intravenous injection to a pneumonic patient with
fear and trembling. It was the more disappointing that this
case, having survived the operation and benefited therefrom as
regards his malaria, should succumb seven days later to his
pneumonia.

Case V. — Private N., aged 26, admitted 15th August 1917,
complaining of headache, pains in legs, arms, and abdomen, and
profuse sweating. He first had malaria in India in 1913, and
had nine attacks afterwards. No other illness. Temperature on
admission was 103°, pulse 90. The spleen was enlarged and very
tender. Malignant tertian parasites were present in the blood.
Patient was weak and restless. Knee-jerks were absent. There
was an extraordinary sensibility to touch and pain all over the
body. A slight touch was painful, and it was impossible to
percuss the chest. He was ordered 45 grs. of quinine daily. On
18th August temperature was 101°, pulse 100, respirations 28.
Patient looked vacant and was listless and disinclined to speak.

168 Alexander Goodall

During the night he became delirious. On the 19th he was
almost comatose. He would neither speak nor feed. Later there
was subsultus tendinum and incontinence of urine. He received
an intravenous injection of 25 grs. of quinine in a pint of saline
solution. His pulse improved, but he had a very restless night,
with some vomiting. On 20th August he was quiet and drowsy,
but answered questions. On the 21st all the movements of his
face and limbs were weak and tremulous. Knee-jerks could be
elicited with difficulty. The plantar response was flexor. There
was some cervical rigidity and Kernig's sign was present on both
sides. The pupils and cranial nerves were normal. There was
no squint or photophobia. Gradual improvement now began.
For a long time he was tremulous, weak, and stupid, but by
1st October he had made a complete recovery.

Three Cases of Quinine Amblyopia 169

THREE CASES OF QUININE AMBLYOPIA.

By H. M. TRAQUAIR, M.D., F.R.C.S.E.

The recent prevalence of influenza and pneumonia makes it
opportune to call attention to the possible harmful effects of
quinine upon the eyes. Burney Yeo, in his Manual of Medical
Treatment, praises it highly in the treatment of influenza, and
goes on to say : " . . . even if it should give rise to some headache
or slight deafness, it is far better to bear with these trivial incon-
veniences than incur the risk of serious toxic after-effects." The
risk of toxic after-effects of quinine is apparently not contemplated.
I have selected Burney Yeo's work as an example of a much-read
and deservedly relied-upon authoritative text-book. At the same
time, considering the amount of quinine which must be consumed
every year by our population, permanent visual damage due to
quinine poisoning is rare in this country.

The following three cases have recently been observed : —

Case I. — Miss M. N, age 23, seen in July 1916. I am indebted
to Dr. Byrom Bramwell, who sent the patient to me for examination,
for notes on this case. The patient had been feeling " run down " and
had been taking quinine as a tonic. About as much as would go on a
threepenny bit was taken two or three times a day for three weeks.
Then on one occasion rather more than a teaspoonful was taken in one
dose.* Stupefaction, tinnitus aurium, and loss of sight ensued. Thirty
hours later the stupefaction and tinnitus were better but vision remained
"quite gone" for a week. An ophthalmic examination two days after
the quinine had been taken showed absence of perception of light in
each eye ; pupils dilated and inactive to light. The fundi were found
normal. Vision gradually returned, and four months later was -fa in
each eye, fields of vision much contracted, pupils unequal but reacting
to light. In July 1916, after nearly eight months, I examined her eyes.
Vision was now f partly with the right and £ with the left eye after
correction for astigmatism. The pupils were of normal size in ordinary
daylight but tended to dilate slightly after primary contraction to light.
The fields of vision were greatly contracted even for comparatively
large objects. Central colour vision was good. The fundi showed
optic atrophy, with much-contracted retinal vessels. She complained
of bad vision in the dusk and of inability to "see if things fall."

• These amounts correspond to about 1 gr. and about 20 grs. respectively
of ordinary crystalline sulphate of quinine.

170 H. M. Traquair

Case II.— 0. P., age 28, female. In May 1918 her doctor
informed me she had "a bad, almost hopeless pneumonia." Hypo-
dermic injections (she was not able to swallow) containing 15 grs. of
quinine-urea hydrochloride were given every four hours, commencing
late on the first day and ceasing early on the third day. In all, eight
injections were given, equal to 120 grs. of the combined salt. Tinnitus
began after the third injection and next day she was very deaf. Early
the following morning after the last injection vision became very dim,
and a few hours later total blindness supervened. The quinine was
stopped and hydrobromic acid given. Eight days later perception of
light began to return, and a week afterwards colour could be detected.
Improvement continued for the next three weeks but was not notice-
able after that time. When seen by me three months later the vision
of the right eye was £ partly and of the left eye J's. The fields of
vision, especially for colour, were much contracted. The optic discs
were pale and the retinal vessels constricted. She complained of
" dimness " over the eyes, and when last heard of described her vision
as " very unsatisfactory " and not improving.

Case III. — Q. R., male, age 53. In July 1918 had influenza.
•Quinine was taken for one night only every four hours in cachets con-
taining 2 to 5 grs. each. Tinnitus soon came on, and when he got up
after two or three days he found he had to be led about, as he was
unable to see. As far as I have been able to ascertain, the total
amount of quinine consumed in about twelve hours was under 20 grs.
The patient's memory of the circumstances is very hazy ; evidently
a certain amount of intoxication was soon produced. Two months
later he was seen at the Royal Infirmary by Dr. Sym, who kindly
allowed me to use his notes. His vision was £ in the right eye and
JL in the left. The fields were contracted. A trace of pallor was
noted in the optic discs, especially the left. No reduction in size of
the retinal vessels was seen. A month afterwards he came under my
observation at Craiglockhart Poorhouse. Vision was now T5^ in each
eye. In bright light the pupils were equal and normal in size, in
subdued light the right pupil was rather larger than the left. Both
pupils contracted well to light but the right dilated slightly after
primary contraction. The fields of vision were greatly contracted,
especially the right field. The fundi showed pallor of the optic discs
and constriction of the retinal vessels, both changes being more marked
on the left side. His chief complaint was of difficulty in reading.

It will be noted that two of the cases were associated with
the recent epidemic of influenza and pneumonia. In one case the
amblyopia was caused by a relatively small dose, in the other
two comparatively large, but by no means massive, doses had been
received.

Three Cases of Quinine A mblyopia 171

The first symptom was tinnitus. Blindness was quickly
reached and slowly recovered from. The patients were left with
good central vision but restricted fields, partial optic atrophy, and
contracted retinal vessels. It is noteworthy that in spite of the
good central vision all the patients complained of inability to see
satisfactorily, showing the importance of para-central and inter-
mediate zone vision. An interesting point, bearing on the path-
ology of the condition, is exemplified by Cases I. and III., which
had already been examined before they were seen by me. In
these cases the fundus changes had evidently developed after the
blindness and had continued to develop while vision was improving.
In Case III. also the fundus changes did not correspond to the
visual symptoms in the two eyes. Two views have been advanced
■as to the mode of production of quinine amblyopia — one that the
action is primarily vasomotor on the retinal vessels, the retinal
cells and nerve fibres suffering secondarily, and the other that the
toxic action is primarily on the retinal cells, the visible fundus
changes being secondary. The late development of the optic
pallor and vascular constriction has been noted by several
observers and is in favour of the second view, which is also
supported by the authority of de Schweinitz.

Several points of practical importance deserve consideration.
We have seen that the dose need not be excessive or even large.
Big doses are naturally more likely to cause ill-effects, but cases
are on record in which amblyopia followed doses as small as
22 grs. in three days, 15 grs. in twenty-four hours, 12 grs. in one
dose, and so on. It is hardly necessary to mention that enormously
larger doses are quite commonly taken without harm. Idio-
syncrasy evidently plays an important role, and it is not possible
to state definitely what constitutes a dangerous dose of quinine.
There is good evidence that an absolute or relative overdose may
produce a state of increased susceptibility, and persons who have
once suffered from quinine poisoning should use only minimal
doses or avoid the drug altogether.

The development of the symptoms of cinchonism — tinnitus, a
feeling of fulness in the head, and partial deafness — indicates
that the patient is absorbing more of the drug than is safe and
that it would be well to stop its administration. Patients and
their attendants should be warned to discontinue the medicine
on the development of ringing in the ears. The writer remembers
having very nearly caused quinine amblyopia, over twenty years
ago, in a case of typhoid fever. Fortunately a timely change

/

172 H. M. Traqttair

of medicine enabled the patient to recover without loss of
sight.

These symptoms of cinchonism precede actual quinine poison-
ing when it occurs. Cases are recorded, however, in which the
latter developed very suddenly. The diagnosis of quinine poison-
ing should not be difficult. Vision is lost, the pupils are dilated
and inactive, hearing is affected, headache, drowsiness, and even
stupor may be present. Such symptoms may be confounded with
the results of the disease under treatment, and it is necessary to
avoid any such mistake. The ophthalmoscopic signs are pallor
of the optic discs and constriction of the retinal vessels — features
which, as already stated, may not appear for a little time. Later,
when some vision has returned, the contraction of the visual
fields can be made out. The prognosis is usually good as regards
central vision but bad as regards peripheral vision. Only in mild
cases is completely satisfactory vision recovered, while permanent
blindness is the result of only the most severe cases. Improve-
ment is fairly rapid at first and then goes on more slowly for some
months or possibly even longer.

Treatment, apart from stopping the quinine, is of little avail.
A number of drugs have been advocated from time to time and,
as is often the case, their diversity indicates their inefficiency.
Strychnine, caffeine, hydrobromic acid, digitalis, iodides, and other
drugs have all been recommended. Measures directed towards
increasing the retinal blood-supply, such as the recumbent position
or the exhibition of nitrites, appear somewhat more rational, but
their value is doubtful. Obviously, to be of use, treatment must
be adopted early.

The main point which should be borne in mind is that quinine
amblyopia is a condition which can be recognised and checked
in its early stages by the general practitioner, who is on the spot.
Specialists practically always see the cases too late to be of any
service.

The Teaching of Dermatology 173

THE TRAINING OF THE STUDENT OF MEDICINE:

An Inquiry Conducted under the Auspices of the
Edinburgh Pathological Club.

LXIX.— THE TEACHING OF DERMATOLOGY.

By NORMAN WALKER.

I take it we should keep in mind, first, that the aim of our discussion
is practical politics and not ideals ; and second, that we are dealing
principally with the Edinburgh Medical School. At our last meeting,
in the paper by Mr. Treacher Collins, there was a sentence to the
effect that students should be shown rare cases, so that they might
recognise them in future. Among the many discussions which have
taken place in my time on medical education I remember one about
thirty years ago in which this point was taken up by the late Sir
William Gairdner. He emphasised the importance of thorough
grounding in principles on a few diseases as against a superficial
acquaintance with many, and Osier followed this excellent plan in
Johns Hopkins.

The question I am to try to answer is, What ought a teacher
of dermatology in Edinburgh to teach his students'? I am sure we
ought to recognise two types of students, viz. one who is going to be
the successor of the old apothecary, the other the successor of the old
physician. This distinction does not follow the class of practice ; there
are lots of successors of the old physicians on the panel engaged in
very busy industrial practices, and not a few successors of the old
apothecaries in very fashionable ones.

In our ordinary classes they are grouped together, and as one is
under obligation to see that all one's students learn enough not to dis-
credit their school when they go out into practice, one has to keep the
inferior type constantly in mind.

It is quite impossible, even if it were wise, to cover the whole
subject of dermatology in any ordinary course, and I think one ought
to devote oneself mainly to general principles and to the common
diseases.

The apothecary type of student ought to be able to recognise all
these, and especially the more serious ones (lupus, syphilis, rodent) among
them, and with these we ought to try to make him so familiar that
he will at least recognise that a rare case is not one of the common
diseases. It is no disgrace to a practitioner not to recognise pityriasis
rubra pilaris, but he should recognise that he does not recognise it.
Then we ought, I think all will agree, to make provision for the

13

174 Norman Walker

man who is going to be of the physician type. I do not use this word
in the restricted sense. As he is a very old friend I make free to use
his name, and I will say that what I mean is the practitioner of the
type of Dr. Crerar, who addressed us recently.

Before the war I tried to make such provision. For many years
I conducted a senior class. It met once a week, and was limited in
its membership to twelve, all of whom must have been members of my
ordinarjr class.

I have not the affection which was proclaimed last week for the
"quiz" class, and I made it more of the nature of a conference.
Often the students questioned me. Sometimes one of the members
read a paper; sometimes two of them collaborated to prepare one.
On other occasions I asked the class to decide at the end of one
meeting what subject they would like to discuss the following week,
and each of them read it up. I regret that the war has put an end to
this class. Not that I could not have found the time — I should have
managed it somehow — but the students could not.

It was a very pleasant class to teach, and I remember with some
satisfaction that nearly every Ettles man was a member of it.

Just one practical point in connection with it. I began it as a
"gratis" class, but I found the attendance was not so regular as it
required to be for such a class, and so I imposed a fee of half a guinea,
which was handed over to Sister Watt for the provision of flowers,
etc., for the ward. Student nature is very human, and the attendance
was much more regular thereafter. I am still hoping that the war will
end before my period of office, so that I may have one or two more of
such classes. They bring one into very intimate acquaintance with the
students, and I have many friends among their members.

There has been a good deal of criticism during this discussion of
existing things. Some of it is, I think, misplaced, but on the whole
it is healthy ; indeed, I think one of the healthiest features of this
discussion has been the evidence of conviction of something amiss —
the first step to repentance and reform.

I do not think that the present system of educating students in
"skins" is satisfactory — the time spent on the subject is too short.
The official class consists of twenty meetings spread over ten weeks.
Along with most other lecturers on special subjects, I interpret the
twenty liberally, and each member is expected to attend on thirty
occasions. But the mistake is that it is all pressed into ten weeks.
We shall never get the best out of our material until this is altered.
It was not so formerly.

I began my hospital work in my first winter as a dresser with
Joe Bell, and during my four years of medical study a very large
part of my time was spent in hospital. I agree with many previous
speakers as to the great value of those evenings spent in the wards

The Teaching of Dermatology 175

and side-rooms, educating each other by discussion — a feature not
prominent enough in our school. All through my four years I saw
something of skins. They came to Bell's " out-patients " ; they turned
up in the medical waiting-room ; and the probable reason I am
speaking on this subject to-night is that my chief (Dr. Claud Muirhead)
was himself interested in skins, and owned a considerable collection of
Baretta's casts, which he brought from Paris, and which must have
cost him at least £100. Teachers should never be afraid to spend
money.

I did not actually begin my teaching of dermatology to women
students, but very early in my career I was appointed lecturer to one
of the then two women's schools, and I gave a course the lines of
which I think might well be imitated now. During the summer
session I lectured four days a week at 8 A.M. in Minto House, and
during a whole year I had the ladies for an hour's clinic once a
week. The opportunity for this last I owed to the continual kind-
ness and wisdom of my predecessor, who had no notion of curbing
the zeal of his assistant. I will undertake to say that — with the
exception of one or two men who have taken a special interest in
dermatology and have attended my special classes for three or four
terms — not a very uncommon thing — no graduates have left this school
better equipped in dermatology than the seven generations of women
I taught in Minto House.

What I think might be done to imitate this — in my judgment the
best practicable system — is that arrangements should be made for
systematic lectures — and I am one of those who think there ought to
be lectures — to be given once a year to all students. I am entirely
with those who maintain the necessity of small cliniques — and I have
long enforced a limit ; but in lectures it does not really matter how
lany listeners one has — indeed, the more the better, and I should be
spared the necessity of going over three times every year the elementary
principles of the subject. This would leave six days a week for
clinical teaching, and it should be possible to arrange that every
student during his fourth or fifth year attended once a week.

Now I know that there are difficulties about this, but I am con-
vinced that these difficulties largely depend upon our obstinate
idherence to two things, viz. the 2 o'clock consulting hour and the
limitation of hospital work to the hours of 11 a.m. to 1.30 p.m. The
irst, I am glad to say, I had the courage to abandon some years ago
when I adopted the plan of making appointments with all my patients,
md I for one am perfectly ready, for the general convenience, to
lecture at 2 o'clock.

With reference to the limitation of hours, I see no serious reason
igainst some change. I know there would be a little difficulty at first
-some nurses' dinner hours might require to be changed — but if it

176 Norman JValker

helped the school to turn out better qualified doctors, it would be
worth while spreading the hospital hours over 10 o'clock to 3 or even
4 o'clock. In Glasgow the hospital cliniques are at 9 o'clock, and I
have sat with my friend, the late Dr. Colcott Fox, in Westminster
Hospital up to 7 o'clock seeing patients, so that changes are not
impossible.

In many ways the student of to-day has advantages which were not
present in my time, but in others I am sure he is not so well off. We
are discussing how his condition can be improved. There is only one
thing I want from the Managers, and that is room for my museum.
I am the fortunate possessor of a collection of casts which, as only one
of them is my own handiwork, I can say is unsurpassed out of Paris
and Breslau ; but for want of room they are not available to the
student as they might be. If I had a proper room for the display of
these, in which the student could spend an occasional hour with a
descriptive catalogue, I will undertake to say that the students of this
school would know a lot more of the subject when they graduate.

With reference to the discussion last week on the certificate which
we lecturers on special subjects are expected to give our students, I
may say that I lay far more stress on regular attendance than on
written answers to questions. If the plan I have suggested were
adopted, I should ascertain attendance by making the students present
sign their names at each clinique, and if each student had attended
over a period of one year (say sixteen cliniques) I should assume that
he had absorbed enough to practise on. I think if I did not feel able
to assume that, it would be time for me to consider the termination
of my career as a teacher.

One more suggestion and I am done. Both students and teachers
in Edinburgh require more supervision. The Dean does his best,
and far more than any Dean in my memory. And he does not
always get thanks. My third and youngest son has just completed
his first term at Balliol. To a parent the knowledge that his boy
is helped and guided in his work by a tutor to whom he has regular
and easy access is a great satisfaction, and I should like very much
to see a modified tutorial system in our university.

And we teachers require supervision too. There is nothing to
prevent me limiting my class to twenty lectures and making these
lectures mere dictation lessons. A tactful visitor might be a useful
addition to the university staff. The good teachers would welcome
the visits, and the others need them.

The Teaching of Dermatology 177

LXX.— THE TEACHING OF DERMATOLOGY TO
UNDERGRADUATES.

By F. GARDINER, M.D., F.R.C.P.

In the consideration of the teaching of skin diseases as part of the
medical curriculum there are four problems which emerge, and these
are of necessity closely interwoven : (1) the position of the curriculum
as regards time ; (2) the standard of knowledge to be attained ; (3)
the hours available ; (4) the methods of teaching.

In discussing these points I shall endeavour to be practical and not
to be a visionary with a selfish point of view.

1. Placed at present in the fourth year, dermatology has to yield
a place in the fifth year to eye diseases, which, in my opinion, is not
correct, although it must yield to the claims of diseases of children.

At present students come to the lecturer with some knowledge of
medicine and surgery at least, and this is essential for a proper com-
prehension of diseases of the skin. Having said this I am satisfied
that this matter has been well considered in the past.

2. The standard of knowledge to be attained should be that for
the general practitioner, dealing therefore only with the commoner
skin diseases. A thorough instruction in these few diseases is much
to be preferred to a skimming over a large list imperfectly. After all,
with these few diseases perfectly grasped, the student, when he subse-
quently commences practice, can, with the aid of books and the first-
class atlases now available, acquire knowledge of the rarer types.
Among post-graduates I find that the desire, even with them, is to
see the common conditions.

It is to be understood that the school medical officer and the
tuberculosis medical officer will both require post-graduate courses.

3 and 4. The hours available and the methods of teaching are
best considered together. Twenty hours is not enough for the ordinary
student, but his hours are already overburdened and I fear to ask for
extension. Some years ago I got excellent results with the women
students by giving twenty-five to thirty consecutive lectures every
morning at 8 A.M., while during these and the remaining weeks of the
session they had also one weekly clinical meeting at 11 A.M. It is
generally accepted nowadays that the demonstration of actual cases is
)f paramount importance and that lectures should be subsidiary.

The problem, then, is how to make the best use of the material

ivailable. The out-patient department is crowded and there are, of

course, many cases not suitable for demonstration. The crux of the

latter is the sifting out and assorting of this material to enable it to

)e of the greatest use to the student. Examining patients from 1 1 A.M.

12 noon and lecturing from 12 noon to 1 p.m. on selected cases

178 R> Cranston Low

would suit admirably, but it sounds like a revolution to disturb clinical
medicine.

The only other solution is to have more assistants to attend to the
more chronic cases and pick out suitable material for demonstration.
The varieties of the commoner diseases can be thus readily shown and
this amplified by exhibition of casts, plates, and photographs.

There are six waiting days now available, and these should be used
to the full by both lecturers with mutual co-operation for the good of
the students.

Provision has to be made for individual instruction in microscopic
work, chiefly with reference to ringworm, favus, scabies, pediculosis,
and molluscum contagiosum. This should be given in the form of a
tutorial demonstration and amplified at cliniques. Hours have also to
be given to the commoner applications for skin treatment of lotions,
pastes, and ointments, and the rationale of their use. It is advisable
also to give at least two ward demonstrations on the treatment of
cases in bed.

With a class of about forty divided into three sections each will
have at least one clinique a week, and, if possible, more, and with, say,
four to six hours spent on the above demonstrations there is left only
time for about a dozen regular lectures, a few introductory lectures,
then the demonstrations, and lastly the lectures on diseases not dis-
cussed in the cliniques. It is my firm conviction that some serial
lectures are necessary to enable the student to grasp the subject of
dermatology as a whole, and I think the above is a fair division of
the time available. In conclusion, I am sure I voice a general thought
when I say that the extension of the curriculum and the advances in
treatment are hastening the time when post-graduate classes will
become, if not compulsory like continuation classes, at least a necessity
for a graduate who wants to attain a high standard in his profession.

LXXL— THE TEACHING OF DERMATOLOGY TO
UNDERGRADUATES.

By R. CRANSTON LOW, F.R.C.P.

If it were possible for every student after graduation to have a year
or more hospital work before starting practice I think it would be
better to leave the teaching of dermatology over till after graduation
and include it as part of the clinical examination for the M.D. The
same result could also be obtained by increasing the curriculum by
another year to be devoted entirely to the special subjects, such as
skin diseases, eye diseases, ear, nose and throat diseases, mental diseases,
and gynecology. But as things are at present a student should have
at least an elementary knowledge of dermatology before going out to

The Teaching of Dermatology 17&

practise. Everyone will agree that dermatology should come as late
as possible in the curriculum after the student has studied pathology,
medicine, and surgery. The present arrangement, where a student
takes dermatology in his final year, seems to be the best possible, but
it has the disadvantage that he begins the study of a new subject
whilst he is in the midst of working at his other larger final-year
subjects. The result is, that as skin diseases do not bulk largely in
the Final Examination the student is apt to devote just as little time
and energy to them as will satisfy the Regulations.

Taking into consideration the importance of other subjects I do
not see that any longer time than three months could be devoted to
dermatology. In such a three-months' course naturally only the
common diseases can be taught. The common complaints, such as
scabies, ringworm of the scalp, impetigo, psoriasis, etc., should be
thoroughly taught and the rarer diseases left out entirely. In order
to teach the general principles of diagnosis and treatment a certain
number of systematic lectures are necessary. These could be given
to all the students once a year and the clinical teaching be spread out
over the three terms of the session. In this way a great deal of
repetition of lectures could be avoided. On the other hand, for the
clinical teaching the class must be divided into small cliniques of not
more than ten students in each. In this way the student can be
sufficiently near the patient to see all the details of the eruption when
they are pointed out.

At present dermatology is taught from 11 till 12 o'clock. As the
teaching at cliniques has to be done almost entirely from untreated
out-patients it is often difficult to get material at 11 o'clock and
frequently the best teaching cases only arrive after 12 o'clock. It
would be an advantage if dermatology could be taught from 12 to
1 o'clock and clinical medicine, which is almost entirely taught in the
wards from in-patients, could be taught from 11 to 12 o clock.

In teaching skin diseases the dermatologist should have access to
cases of syphilis. The student can never learn syphilis without being
able to compare the rashes with those of non-venereal conditions, and
vice versA.

One of the chief difficulties in skin diseases is that, as the diagnosis
is almost entirely a visual one, the impression is not easily retained
for any length of time. Even although a student may be able to
recognise a given skin disease with fair accuracy when he has finished
his three-months' class, six months or so later, if he has seen no
cases in the interval, he has forgotten the appearances of the disease.
Therefore after he has had the class, the student must have an
opportunity of keeping in touch with skin cases. This he did formerly
at the Wednesday and Saturday forenoon cliniques, which were open
to all students with hospital tickets. This difficulty could be overcome

180 Discussion

to a great extent if there were a museum of casts of the common Bkin
diseases, where the student could go at any time and read up from
the notes of his lectures or a text-book with the models before him.
A cast of a skin eruption also has the advantage over the actual patient
in that, if the student repeatedly sees the same cast, he gets a more or
less permanent visual impression of that eruption.

The present method of examining students in skin diseases is
unsatisfactory and would be better omitted altogether. The lecturers
on dermatology should be examiners in the Final.

By arrangement with other lecturers some overlapping might be
avoided. Diseases such as chronic leg ulcer, rodent ulcer, etc., should
be left to the dermatologist and not taught by the surgeon as at
present.

DISCUSSION.

Dr. Traquair. — As far as undergraduate education is concerned, the
special subjects should not be taught as such, but as part of general surgery
and medicine. Special teaching is rather for post-graduates. It is not rare
cases that should be shown to students, but common ones. An obscure case
is much more likely to be an atypical appearance of a common disease than it
is to be a rare disease. I sympathise with what Dr. Walker says about a
museum.

Mr. Miles. — Dr. Walker has raised again the question of spreading out
the special courses over a longer period. Our difficulty arises from the fact
that some of our courses — the course of clinical medicine,' say — last only for
nine months. Why should the student not attend for three years ? If we
had a scheme by which he began clinical medicine in the summer following
the second winter, his clinical medicine and clinical surgery might extend
from this time on to the end of his course. Dr. Walker's part would then be
to come into that clinical medicine course at some period found suitable, and
continue his teaching throughout that course. In clinical surgery we woidd
have a three-years' course, and into that course the eye, ear, nose, and throat
specialists would come. Dr. Knox's subject would be worked in in the same
way. Radiology, as applied to surgery, would be spread over the whole course,
with such didactic teaching as might be necessary to give the student an
understanding of the subject at the beginning. That involves the arrange-
ment of a syllabus in co-ordination between the teachers of the different
subjects.

Dr. Norman Walker said in reply. — In the Edinburgh school there
always has been, and certainly is now, ample opportunity for the keen
student. He will get his work always, just as with the more limited
opportunities we had years ago he was able to get it. I am not quite sure
that the student is altogether to blame. We have got into a more con-
centrated form of teaching, and these specialties have perhaps encouraged it.
My experience is that when students get opportunities and are encouraged to
make use of them they do so.

I would be very willing to fall in with the course of clinical medicine,
but I should also require to fall in with the course of systematic medicine

Utilisation of the Poor Law Hospital isi

to teach something of the general principles to the students. I would not be
satisfied merely with a course of demonstrations.

I do not agree about confining our teaching to the idea of the general
practitioner— the apothecary type. We expect to teach a large proportion
of the better-class practitioner — the man who is really an interested and
enthusiastic physician.

If we had an extension of the hospital hours we would solve a great
many of our difficulties, and it would help if we had some of the out-
patient departments in the afternoon.

With regard to the question of the vacation, it is surely strange that in
the fourth and fifth years of his apprenticeship to one of the most important

! professions a student should be allowed to idle for three and a half months.
No other profession would allow it.

LXXIL— SUGGESTIONS FOR THE UTILISATION OF THE
POOR LAW HOSPITAL FOR TEACHING MEDICAL
STUDENTS.

By T. Y. FINLAY, M.D., Medical Superintendent, Edinburgh
Poor Law Hospital.

In some of the earlier papers read before this Club — and I refer
especially to those of Sir James Mackenzie and Dr. Robertson — great
stress was laid upon the study of disease from the preventive point of
view. Sir James Mackenzie drew attention to the out-patient depart-
ment of the Infirmary as a centre for the study of the early stages of
disease, whilst Dr. Robertson advised the teaching of medicine not
only as a curative but also as a preventive science and art, its pre-
ventive application to individuals and to all diseases — in other words,
a clinical form of preventive medicine. An adequate study of disease
in its development is what is required in clinical teaching, for it is
important to the patient that the first beginnings of disease should
be detected and its subsequent development arrested if possible. This
is the knowledge which is most required in general practice from the
very first.

Up to the present, medicine has been taught mainly from the
standpoint of curative measures, and the student's attention has been
directed to the study of the signs, symptoms, and treatment of disease
in its fully developed form. The reason for this is obvious — the
student has to rely chiefly on the Infirmary for his clinical teaching,
and before the patient finds his way to the Infirmary wards his disease
is more or less serious ; hence it is that the pronounced, fully developed
type is presented to the student, and his interest is apt to be con-
centrated on this to the neglect of the less serious and less developed
stages of the disease, though these are equally if not more important
from every point of view. Again, the Infirmary patients do not stay
and only very seldom do they return, therefore the opportunities of

182 T. Y. Finlay

following the development of disease are correspondingly very limited.
Sir James Mackenzie points out the knowledge which comes to the
men in general practice who can follow the health history of their
patients from year to year, and he advocates the appointment to a
chair in clinical medicine of a general practitioner who could give the
students the results of his continuous observation of cases.

With the view of suggesting another method of solving this
question, I have thought it might be useful to consider the facilities
for clinical study and teaching which are offered by the poor law
hospital. The poor law hospital receives patients who, when they are
ill, have no other resource than that of coming to the hospital. There
are two types of these patients — first, the chronic invalid, and second,
the person suffering, for example, from some painful symptom, not
severe, but which is sufficiently bad to prevent him doing his work
and earning his living for the time being. Both these types of cases
are excluded from the Infirmary wards — the first because the accom-
modation is not sufficient to retain them for prolonged periods to the
exclusion of acute cases ; and the second is the type which presents
itself at the out-patient department and, not being considered sufficiently
ill to warrant indoor treatment, consequently next seeks admission to
the poor law hospital. Now, these two types bulk largely in the
clientele of the general practitioner, who has little opportunity of
studying them in his student days. The chronic cases remain in the
poor law hospital for a prolonged period, if not permanently, whilst
the second class of case comes back repeatedly, and gradually there
are accumulated observations on the development of their illnesses
which are invaluable for the study of disease. It is in the number of
such cases (on an average 1000 a year excluding re-admissions) that
the poor law hospital can offer the opportunity which is not sufficiently
provided in the Infirmary. The essential feature of the poor law
hospital is that within its wards are to be seen cases of almost every
description from infancy to old age. It may, therefore, be likened
to a general practice with this advantage, that all the patients are
collected together under one roof and under the close observation of
trained nurses. *

The only poor law hospital of which I have any experience is
that of Craiglockhart under the Edinburgh Parish Council, so that
the following remarks are based entirely upon my experience
there.

Let me first give you a brief description of the hospital to show
that it is run along modern lines, and is up to date in hospital equip-
ment, thus offering facilities for teaching purposes.

The hospital itself is built mainly on the pavilion system. There
are about eighteen wards, with, in addition, a maternity department
and side-rooms for the isolation and treatment of special cases, two

Utilisation of the Poor Law Hospital 183

open-air sheds, a modern and fully equipped operating theatre and
sterilising room, a dispensary for drugs, a clinical laboratory for
side-room work, an out-patient department in connection with the
poorhouse proper, a suitable post-mortem room, and the usual adminis-
trative offices. At the present time, as a war emergency, several
more wards in the adjoining poorhouse have had to be devoted to
hospital cases. This has been rendered necessary for the accommoda-
tion of the sick poor from Craigleith and Seafield, both of which
buildings are at present otherwise utilised. In all there are about
500 beds available for patients at the present time.

In normal times the staff consists of a principal medical officer, a
consulting surgeon — Mr. Beesly ; a consulting eye specialist — Dr.
Traquair; two assistant medical officers and two unqualified clinical
assistants — though during the war even this small staff has had to be
reduced — a matron, assistant matron, night superintendent, charge
nurses, and probationer nurses.

The name of every patient on admission is noted on a card index
and a number given to each, which is also noted on the medical
history sheet. Each time the patient returns he retains the same
number, so that the medical history sheet bears not only a record of
the condition at one admission, but forms a complete account of the
whole of the patient's medical history, no matter how long or how often
he has been in hospital. Thus is constructed a valuable record of
disease over many years, and in many cases up till the time of death,
with, in addition, the post-mortem findings at least in the case of
nearly all but unclaimed bodies. It is a well-recognised fact that in
general practice the treatment of many cases resolves itself into the
treatment of symptoms, for a large majority of them do not conform
to text-book descriptions ; so also at Craiglockhart a large number of
such cases present themselves — they come not once or twice but many
times, and each time records are kept, so that in many cases, when
each of these records is read as a whole, the various stages of disease
can be followed out and studied until the fully developed disease, as
seen in the Infirmary, shows itself. Further, I can foresee much
useful information being collected from these records for the preventive
treatment of disease, which to be complete should not only include
a description of the symptoms, but also any facts — and I speak of
facts in the broadest sense — which may in any way be connected with
the onset of the symptoms — weather conditions, diet, exposure, mode
of living, over-exertion — in short, any condition, moral or physical,
leading up to each of these stages of disease.

It may be of interest to briefly describe the general type of cases
dealt with at Craiglockhart Hospital. In the children's ward there are
about 500 admissions in the year. Some of these children are admitted
suffering from skin diseases such as scabies, impetigo, and ringworm,

184 T. Y. Finlay

whilst others are tuberculous, congenitally syphilitic, and in a large
proportion infants suffering from nutritional disabilities. There are
about thirty confinements in the year, and the patients are admitted
in both early and late pregnancy. The births as a rule are normal,
but every now and again interesting abnormal cases are dealt with.
Surgical operations are performed by Mr. Beesly on one afternoon a
week, and of these there are an average of 100 to 150 per annum.
Most of the surgical cases are tuberculous or malignant, though many
of a general character also are admitted. Dr. Traquair holds an eye
clinic, when many instructive cases present themselves. Of the medical
cases there are always a good number of chronic and senile heart
disease, aneurysm, arteriosclerosis, chronic bronchitis and emphysema,
asthma, senile pneumonias, fibroid lungs, chronic rheumatism, rheu-
matoid arthritis, senile chorea, cerebral haemorrhage, locomotor ataxia,
paralysis agitans, hemiplegia, cerebral softening, not to mention the
normal changes resulting from old age. Other cases are those of
general pediculosis, scabies, venereal disease, and leg ulcers. In this
rapid sketch I have only mentioned a few of the many diseases which
have to be dealt with, but sufficient, I trust, to give a general survey
of the work involved in a poor law hospital.

It seems to me that there are possibilities at Craiglockhart for
teaching both the junior and senior student of medicine, and I offer
the following suggestions for the consideration of the Club : —

I. A junior course for the beginning of medical study. I have
long thought that Craiglockhart Hospital offered excellent scope for
such a course, but as I find that Dr. Fowler has already dealt with this
subject in a former paper before this Club, I shall not trouble you
with any details. There is ample material at Craiglockhart for
teaching everything which he includes in his suggested course of
clinical physiology. Take only one example from his list : "Where
better than in the poor law hospital could be taught the effect on the
functions of the body and on symptoms generally, of exhaustion anc
debility, of pregnancy, the menopause, and of old age 1

II. Another opportunity offers in the large number of excellent
cases suitable for teaching physical signs. When I was a clinical tutor
in medicine at the Infirmary the difficulty often was to get enougt
suitable cases to teach from. One was dependent upon the cases ii
the ward for the time being, and these did not always show unmis
takable typical physical signs necessary for teaching the junior student.
At Craiglockhart, on the other hand, there is no lack of such patients-
for example, chronic heart and lung cases who are permanent inmate
and therefore available at all times. After having mastered gros
lesions the student is in a better position to make out and appreciat
the physical signs in less advanced cases.

III. Thirdly, courses on chronic diseases and clinical preventive

Discussion 185

medicine for senior students would be valuable in preparing them for
general practice. Such a course would naturally come in the final
year after the student had completed his course in clinical medicine at
the Infirmary. Such a course has already been arranged to begin next
winter — Professor Gulland is to hold a class on Saturday forenoons
in the October term — subject to the final approval of the Edinburgh
Parish Council at its next meeting.

IV. Lastly, the subject of infant welfare is one which has become
very important, and one with which the medical student should be
made familiar. I know of no other institution in or around Edinburgh
except Craiglockhart which has more unique opportunities for practical
training in infant welfare. The material includes pre-maternity cases,
maternity cases, nursing mothers and their infants, a nursery for
healthy infants, and wards where the nutritional diseases of infancy
can be studied. At present the student's experience is limited to
what he learns at the Maternity Hospital and the Sick Children's
Hospital. There is thus a very important gap in his training, namely,
the practical study of the normal healthy baby, and the knowledge of
how to prevent disease in infancy. Dr. Fowler remarks in his paper
that " at present we have no material for showing the student how to
manage a healthy infant from birth onwards." Now it is exactly this
material that is available at Craiglockhart and which could be used
for teaching purposes. From what I have said it will be evident that
there is all the material at Craiglockhart for a very complete course
on every aspect of infant welfare. I may say that such a course of
practical training is at present being held — the Committee of the
Edinburgh School of Social Study and Training having obtained per-
mission from the Edinburgh Parish Council for the teaching of their
students at Craiglockhart, and it only awaits the approval of the
Parish Council to have a similar course available for the medical
student.

In conclusion, I think that we are fortunate in Edinburgh in
having a Parish Council which is in sympathy with the medical school
and anxious to co-operate with the university in extending its teaching
facilities.

Note. — At a meeting subsequent to the reading of this paper the
Edinburgh Parish Council unanimously consented to clinical teaching
being carried out at Craiglockhart Hospital.

DISCUSSION.

Dr. Chalmers Watson. — Twenty-five years ago I was house physician
at a poor law hospital, and I formed there a first-hand impression of its
extreme value as a teaching institution. It is not so much the lack of
material in the Infirmary wards as some defect in our organisation which

186 Reports of Students Societies

has increased the tendency of the student to do less clinical work. There is
no question of the value of the material at the poorhouse and of the willing-
ness of the Infirmary staff to take advantage of it, as they find it would be
useful, provided it is not going to detract from the already extremely limited
time that the students spend in the wards. Sir James Mackenzie laid stress
upon the importance of watching disease in the making. We do not lay
sufficient stress on the early signs of deterioration in health, a knowledge
of which can be acquired by careful study of the antecedents of our cases.
There is no question with regard to the advantages of the poor law hospital
in connection with child welfare, infant feeding, and the diseases of children.

Dr. Rainy. — I have on several occasions been able to borrow from the
poor law hospitals quite a number of cases illustrative of a special condition
for lecture purposes. They have advanced cases and types of cases that we
cannot possibly get at the Infirmary. I cordially endorse the opinion that
these poor law hospitals should be made much more use of than they are at
present.

Professor Lorrain Smith. — I gather that Dr. Finlay contemplates the
student spending half a day or a day at the poor law hospital ?

Dr. Finlay. — I suggest that Saturday forenoon only should be devoted to
the poor law hospital, where the student would take up more than one
branch of a subject at once.

LXXIIL— EEPORTS OF STUDENTS' SOCIETIES.

At the request of the Pathological Club, the Royal Medical Society
took into consideration the subject of medical education from the point
of view of the undergraduate.

A series of discussions were held in which, in addition to the
members of the Society, other students, representative of all years,
took part. A special committee of the Society subsequently drafted
a report which was forwarded to the Pathological Club. The members
of the Women's Medical Society, who had taken part in the Royal
Medical Society's discussion, submitted a separate report.

These reports, which covered the whole of the ground, agreed in
the main in their criticisms of the existing curriculum and in the
suggestions made for improving it. They have proved most helpful
to the Club in framing its report, in which a number of the proposals
made by the undergraduates, particularly in the direction of increasing
the facilities for practical work, have been incorporated.

Report of the Edinburgh Pathological Club 187

REPORT OF THE EDINBURGH PATHOLOGICAL CLUB ON
THE TRAINING OF THE STUDENT OF MEDICINE.

I.— General Considerations.

The inquiry into the medical curriculum has included within its
scope all the subjects of study in the general course of medicine.
The great majority of the students are preparing for general practice,
and in this course they lay the foundations of their future work.
Each contributor to the inquiry has dealt with his subject by showing
the place which it should occupy in a complete course, and a review
of the contributions brings out the fact that criticism of the present
curriculum is advanced from two points of view, determined by the
distinction which is drawn between curative and preventive medicine.

The Teaching of Curative Medicine. — It is agreed that the main
purpose of medical teaching in general is to train the student in
clinical observation, so that he may become skilled in the diagnosis
and treatment of cases of illness and disease. His chief aim is to
acquire knowledge of the science and art of curative medicine. The
courses included in the present curriculum have been instituted with
this end in view, but the inquiry has brought out abundant evidence
of the necessity of reorganising the present methods of teaching.
Before considering this aspect of the question in detail, it is necessary
to take account of the criticism of the curriculum which has been
offered from the point of view of preventive medicine.

The Teaching of Preventive Medicine. — It is pointed out by a number
of contributors that the basis of the present curriculum is too narrow.
A complete curriculum should include a study of the prevention of
disease, but the training which is obtained at present is restricted
almost entirely to curative medicine. This far-reaching criticism
extends the conception of prevention to the whole field of medical
teaching. In the past, preventive medicine has developed chiefly in
the form of public-health measures for the protection of the community
from the spread of disease. Examples are found in the regulation
of general sanitary conditions and in the safeguarding of industrial
workers from the harmful effects of their occupation. General
measures of this type were, as a rule, simply preventive. In certain
cases — as, for example, in dealing with infectious disease — the public
authority made provision also for the treatment of individual patients.
In recent legislation, such as that dealing with tuberculosis and
venereal disease, public responsibility for the treatment of patients
has been greatly extended.

188 Report of the Edinburgh Pathological Club

The development of State medicine has produced various important
changes in the medical profession. In former times the medical care
of the community was left entirely to the medical profession. The
members of the profession worked each in his own practice, or joined
together to establish hospitals and dispensaries to bring the resources
of medicine within the reach of the whole community. However
ample such provision might be, it nevertheless failed when the
necessity for preventive measures arose. Although these measures
are the direct outcome of medical investigation of the causes of
disease, the profession had neither the means nor the authority to
apply them to the community. The responsibility for preventive
administration must remain in the hands of the State. It is found,
however, that the State, in taking up this responsibility, may profoundly
modify the conditions of medical practice. The Act of Parliament
which deals with a health problem includes provision of the mechanism
required for the administration of the measure. In certain cases
medical officers are appointed, who give their whole time to the
particular branch of medical work to which the Act relates. In other
cases the work is done by general practitioners. In medical practice
for the State, whatever form it may take, prevention is a primary
object. At the same time it must be remembered that there is no
fundamental distinction between curative and preventive medicine.
Medicine has always been essentially both curative and preventive,
and the inseparable connection of the two types has been shown by
the recent developments of State medicine. Further, the preventive
measures introduced by the State do not include more than a limited
part of preventive medicine. On the contrary, the field for preventive
work is unrestricted, and the practitioner, in all his work as physician,
surgeon, or obstetrician, finds that preventive care of his patients is
becoming more and more a definite part of his responsibility.

In view of this widening of responsibility, it becomes necessary for
the medical faculty to extend the training of the student, so that he
may obtain the knowledge required for medical care of this type.
Instruction in preventive medicine must be given to all medical
students. It is altogether undesirable to separate curative and pre-
ventive medicine.

The piecemeal introduction of State measures has a tendency to
create medical officials whose interest is too much limited to a defined
and circumscribed field of work, and one of the unfortunate effects of
setting up medical departments by the State has been to displace the
general practitioner. The benefits which the community can derive
from the most comprehensive efforts of a State department will be
unduly limited unless the whole profession of medical practitioners
become the exponents of preventive as well as of curative medicine.

To render unnecessary any separation of curative and preventive

Report of the Edinburgh Pathological Club i8£

medicine, it lies with the medical schools to include in the general
course the training in preventive medicine which is required.

The Arrangement of Subjects in the Curriculum. — The commencement
of the study of clinical medicine at the beginning of the third year
forms the most important point of division in the present medical
course. The subjects of the first two years are botany, zoology,
physics, chemistry, anatomy, and physiology. During these two years
the student has little or no instruction in clinical work. On the other
hand, during the following three years he has few opportunities of
continuing the study of the earlier subjects. A reorganisation of the
course is required, so that the earlier and later subjects may be brought
into more vital connection with each other. Continuity of study is
required to enable the student to make full use of the knowledge he
gains. From lack of connection and co-ordination of the courses he
often fails to grasp clearly the meaning and value of what he has been
taught. His knowledge does not become a permanent possession.
One example may be taken from the discussion to illustrate this
criticism.

The student is, by the end of his second year, well grounded in
anatomy, and passes the examination in that subject ; but in his fifth
year, when he is asked to apply his anatomical knowledge to the inter-
pretation of a case of disease, he often reveals the fact that his former
knowledge has melted away in the interval. The modicum of working
anatomical knowledge which should have been permanently fixed in
his mind is no longer his. This form of failure is found more or less
in all branches of the course.

The root cause of it is that the subjects are taught without sufficient
correlation with each other and with the main purpose of the course.
The earlier scientific studies are not brought into sufficient connection
with the later work in the hospital, and the clinical studies are not
kept in continuity with the preparatory courses. The present system
of periodic examinations is no remedy. Teaching and training in
water-tight compartments are followed by corresponding examinations,
and in some ways they tend to increase the dislocation of the course.
The remedy which has been suggested by many contributors is that
the student should study clinical work from the beginning to the end
of the five years' curriculum, and that the study of the fundamental
sciences should be brought into direct connection with the later subjects,
and should not be confined to the first two years.

The course in chemistry gives an example of the co-ordination
which is required. The student has chemical teaching throughout the
whole curriculum, but the teaching varies from the early introduction
to the science till the final stages are reached, where clinical methods
are applied to the interpretation of the processes of disease. The
chemical department of the medical school should be responsible for

14

190 Report of the Edinburgh Pathological Club

the subject in all its aspects, and supply at each stage the teaching
in the form required. The complete course would become unified in
the student's mind, and there would be no dislocation.

The Method of Teaching. — The general method of teaching which is
now adopted is that for each subject there is a course of systematic
lectures and a course of practical instruction. The courses of practical
instruction have come to occupy a relatively large part of the time
devoted to the subject, but reorganisation is required to bring the two
methods of teaching into more direct connection with each other. The
systematic lecture class is separate from the practical course, and the
lectures furnish an exposition of the subject more or less resembling
that of a text-book. It is generally agreed that this is an unfruitful
method of giving instruction to the student. On the other hand, the
facilities for practical instruction are now developed to such an extent
that it becomes possible to devise courses in which the two methods of
teaching are united and immediately complementary to each other. The
lectures to which a student is asked to listen should be directly related
to his practical work — an illustration will make the point clear. The
student is expected to make himself acquainted with the commoner
varieties of disease of the blood. On the present system he may
receive a full exposition of this complicated subject before he has had
the opportunity of estimating the haemoglobin or observing for himself
the numbers and varieties of blood corpuscles in the living subject.
On the method of combined practical and theoretical teaching now
proposed this would be impossible. The systematic lecture could
not be given until the foundation of practical knowledge had been
laid. The occasion for giving the systematic lecture would arise when
the data obtained from practical observations demanded further
interpretation.

To organise teaching in the form of a combined course would
without doubt present much greater difficulty than the present method.
On the other hand, the effects of the separation of practical and
theoretical teaching are felt nowhere more than in the professional
courses. Here the systematic courses are given in the University and
the practical instruction in the Infirmary, and there is no direct con-
nection between the two.

The Examinations. — Much adverse criticism has been advanced with
regard to the present method of testing by examinations. It is
pointed out that the examination which is separated from the teaching
course is liable to become an artificial test. It encourages book know-
ledge and belated cramming on the part of the student. The passing
of examinations tends to become the chief occupation of his mind, and
he refuses to attend to those aspects of the subject which do not
lend themselves to this purpose. The examinations come at intervals
through the course, and for each the student makes a strenuous effort,

Report of the Edinburgh Pathological Club 19 1

which becomes in many ways an interruption of his course of study.
Further, the examination is a great burden on the teaching staff, and
consumes time and energy which, if spent on teaching, would add
much to the course. The professors conduct the examinations with the
co-operation of external examiners appointed by the University. In
addition to this, the General Medical Council appoints inspectors whose
duty it is to attend the Final Qualifying Examinations and report on
their sufficiency as a test of the student's knowledge.

It is suggested that the test of the student's proficiency should
apply not to what he does at an occasional examination, but to the
whole of his term work. It would be the duty of each department
to keep a record of the student's work which would afford clear and
sufficient evidence of his success or failure in reaching the requisite
standard of knowledge. This method of testing would form a powerful
stimulus to the student throughout the whole course. The external
examiner would co-operate as before, but in this case the whole work
of the term would come within his purview.

II. — Proposals.

After discussion, the Club adopted the following propositions : —

1. Age to Commence Medical Studies. — The Club is unanimously of
opinion that students should not begin the study of medicine in the
Medical School before the age of eighteen. It is further of opinion
that the standard of the preliminary examination should be raised.

2. Curriculum to Begin in Winter Session. — To obviate the confusion
which results from students beginning their studies at different periods
of the year, and to facilitate the arrangement of a co-ordinated course
of study, the Club considers it essential that all students should
commence their studies in the Medical School in the winter session.

3. Proposal to Lengthen Terms. — The Club suggests that the time
available for teaching throughout the year should be increased by
shortening the vacation periods. It appears to the Club that this would
best be effected by adding two weeks to each of the three terms.

4. Facilities for Evening Study in Hospital. — The Club desires to
impress upon the authorities concerned the importance of providing
facilities for students attending at the Infirmary wards and out-
patient departments in the evening for purposes of clinical work and
study — subject always to the interests and comfort of the patients
being safeguarded.

5. Facilities for Physical Culture. — With a view to encouraging the
students to engage in sports and other forms of physical culture, the
Club recommends that the afternoon of each Wednesday, as well as of
each Saturday, be left free of classes.

192 Report of the Edinburgh Pathological Club

6. Holidays in Term. — It strongly urges that there be no other
statutory academic holidays during term.

7. Preliminary Study of Chemistry and Physics. — The Club recom-
mends that the subjects of Elementary Cliemistry and Elementary Physics
be taken either at school or as preliminary courses, and that the
courses of physics and of chemistry within the curriculum be corre-
spondingly modified. It is also suggested that the position of Botany
in the course be reconsidered.

8. Systematic Lectures. — With regard to the place of systematic
lectures in the curriculum, the Club is strongly of opinion that in all
courses of instruction these should be closely associated with practical
laboratory or clinical work, and that the role of the lectures should be
to elucidate the work done in the practical and clinical classes and to
correlate the subject under consideration with allied subjects. The
time devoted to didactic teaching could thus be reduced, and more
time made available for observational classes.

9. Junior and Senior Courses. — The Club recommends that, as far as
is practicable, all courses of instruction should be divided into " Junior "
and "Senior" courses, the junior course to be conducted as early in
the curriculum as possible, and the senior course in a later year, after
the student has acquired sufficient practical knowledge of the subject
dealt with, e.g. (a) the junior course in medicine in the third year, just
after the "physical signs course," and the senior course in the fifth
year, after the student has spent several terms in clinical study ;
(b) the junior course in surgery in the third year, after the student
has worked in the out-patient department during two or three terms,
and the senior course in the fifth year, after he has worked in the
wards for several terms ; (c) the junior course in midwifery in the
fourth year, and the senior course in the fifth year, after maternity
cliniques have been attended and midwifery cases taken out.

10. Co-ordination of Subjects. — To cultivate in the student a scientific
interest in his professional work, the Club strongly urges that the
teaching of the fundamental subjects — physics, chemistry, anatomy,
physiology, pathology, etc. — be closely co-ordinated with that of the
clinical subjects with which they are related.

11. Necessity for Syllabus. — To provide for such co-ordination it
would be necessary for the teachers of each associated group of subjects
to draw up a syllabus defining the scope of the work to be overtaken
by them, jointly and severally.

After being approved by the Faculty of Medicine, this syllabus
should be made available to the student as a guide to him in con-
ducting his studies. The syllabus should be subject to revision
annually.

On such a plan, co-ordination of teaching could be effected between
the subjects included in the curriculum in such a way as to impress

Report of the Edinburgh Pathological Club 193

upon the student their bearing upon one another, and to maintain
continuity of study of associated subjects throughout the curriculum.

12. Attendance at Hospital Recommended during Whole Curriculum. —
Still further to ensure that the student shall acquire and maintain a
scientific attitude of mind towards the purely professional aspects of
his studies, the Club is of opinion that he should be brought into direct
contact with the work of the hospitals throughout the whole of his
curriculum. It is felt that an early introduction to the clinical features
of elementary surgery and medicine would add interest and give point
to his studies of the biological and physical sciences, and still more
to such subjects as anatomy and physiology. It would also be an
advantage if anatomical and physiological demonstrations were illus-
trated as far as possible from living human subjects.

The draft curriculum which has been drawn up provides for the
student attending the hospital during every term of the course.

13. Co-operation with Dispensaries, etc. — To widen the scope of
clinical teaching, and to give the student a broader outlook on
problems of health in relation to the State as well as to the individual,
the Club strongly urges that close co-operation be established between
the Medical School and the dispensaries, poor law hospitals, child-
welfare organisations, and other medical and social institutions
throughout the city and district.

In any new arrangements that may be made under the proposed
Ministry of Health, the educational importance of public hospitals and
other institutions must be borne in mind and provision made for
teaching being carried on therein.

14. Instruction re Practice under National Insurance Act. — In the
interests of the large section of the community who obtain medical
care under the provisions of the National Insurance Act, the Club
recommends that some arrangement be made by which senior students
may receive instruction in the practical working of the Act, with
special reference to the management of illness in small houses and with
limited resources.

15. Examinations. — Lastly, the Club is unanimously of opinion that
the existing method of testing the student's knowledge by periodic
" Professional Examinations " is not satisfactory. It recommends that
it be made part of the duty of every teacher, in co-operation with
extra examiners, to test and record each student's progress throughout
the course, as part of the class work, and that such records be the
main criterion of the student's fitness to proceed further with his
studies. Such a plan does not preclude the holding of examinations
apart from the class work, either to test doubtful students or to award
"distinction" to the most proficient.

194 Report of the Edinburgh Pathological Club

III.— Outline of Proposed Curriculum.

Guided by the general considerations above set forth, and assuming
the acceptance of the foregoing proposals, a provisional curriculum has
been drafted, in which the suggestions that seemed to find most favour
in the inquiry have been incorporated.

The accompanying tables show how the suggestions can be embodied
in a complete curriculum.

In the draft curriculum prepared by the Club, each subject or
section of a subject is allocated to its appropriate term in each year,
but to avoid confusing detail the tables here given merely indicate the
year in which a particular subject is studied.

Report of the Edinburgh Pathological Club 195

COURSE OF INSTRUCTION IN CHEMISTRY.

Year.
School. Elementary Chemistry.

I. Introductory Course — Lectures and Practical Class.
II. Physiological Chemistry, with Physiology.
III. Pathological Chemistry, with Pathology.
II.-III. Chemistry in relation to Clinical Medicine, with Clinical
Medicine.
V. Chemistry in relation to Public Health, with Public Health.

COURSE OF INSTRUCTION IN PHYSICS.

School. Elementary Physics.

I. Introductory Course — Lectures and Practical Class.
II. Electricity and X-rays, with Physiology and Hospital Work.

III. Sound and Acoustics, with Aural and Laryngeal Surgery.

IV. Light and Optics, with Ophthalmology.

COURSE OF INSTRUCTION IN ZOOLOGY.

I. General Course — Lectures and Practical Class.
( B iological Problems relating to Pathology.

' (Parasitology, with Pathology

COURSE OF INSTRUCTION IN BOTANY.

I. General Course — Lectures.

„ Practical Class.

„ Field Botany.

196 Report of the Edinburgh Pathological Club

l-ii.

COURSE OF INSTRUCTION IN ANATOMY.

Year.

(Introductory Course.
Histology Course.

Practical Course — Dissecting (5 terms).
Medical Anatomy, with Physical Signs Course in Clinical
v Medicine.

III. Regional Surgical Anatomy, with Clinical Surgery.
Anatomy in relation to Aural, Nasal, and Laryngeal Surgery,

with Aural, etc., Surgery.

IV. Obstetric Anatomy, with Midwifery and Gynecology.
Anatomy in relation to Ophthalmology, with Ophthalmology.

V. Anatomy of Central Nervous System, with Neurology.

COURSE OF INSTRUCTION ON PHYSIOLOGY.

I. General Course — Junior.

Practical Class.
II. General Course — Senior.

Experimental Physiology, with Physical Signs Course in

Clinical Medicine.
Physiological Chemistry, with Physical Signs Course in
Clinical Medicine.

III. Physiology of Digestion, Excretion, etc., with Mediciue.

„ in relation to Aural, Nasal, and Laryngeal

Surgery, with Aural, etc., Surgery.

IV. „ in relation to Obstetrics, with Obstetrics.

„ in relation to Ophthalmology, with Ophthalmology.

V. „ of Central Nervous System, with Neurology.

Report of the Edinburgh Pathological Club 197

COURSE OF INSTRUCTION IN MATERIA MEDICA.

Year.

III. General Course — Materia Medica.
„ „ Pharmacology.

Prescription Writing, with Medicine.
Practical Class.
IV.-V. Therapeutics, with Clinical Medicine.

COURSE OF INSTRUCTION IN PATHOLOGY.

II. Morbid Anatomy in relation to Physical Signs, with Clinical
Medicine.
Bacteriology in relation to Venereal Diseases, with Venereal
Diseases.

III. General Course — Lectures.

„ „ Practical Class.

„ „ Class of Morbid Anatomy.

Bacteriology — General Course — Lectures.

„ „ „ Practical Class.

Parasitology (Zoologist).
Surgical Pathology and Morbid Anatomy, with Surgery.

IV. Pathology in relation to Obstetrics and Gynecology, with

Midwifery and Gynecology.
V. Pathology of Central Nervous System, with Neurology.
Pathology of Tuberculosis, with Tuberculosis.
II.-V. Post-mortem Examinations — Medical.

,, ,, Surgical, etc.

198 Report of the Edinburgh Pathological Club
COURSE OF INSTRUCTION IN CLINICAL MEDICINE.

Year.
II. Physical Signs Course — Clinical Demonstrations.

„ Regional Anatomy of Chest, etc.

„ Experimental (Clinical) Physiology.

„ Medical (Side-room) Chemistry.

„ Use of Ophthalmoscope.

,, Use of Laryngoscope.

„ Use of X-Rays Clinically.

„ Morbid Anatomy bearing on Physi-

cal Signs.

III. General Medicine Course — Junior — Lectures.
„ „ „ „ Tutorial Classes.
„ „ „ Prescription Writing, with

Materia Medica.
„ „ „ Elementary Psychology.

Clinical Medicine — Lectures.
„ „ Cliniques.

,, „ Out-patients.

IV. Medical Diseases of Children— Lectures.
„ „ ,, Clinical.
„ „ „ Tutorial.
„ „ „ Baby Clinics.

Child-Welfare Work.
Clinical Medicine — Lectures.
„ „ Cliniques.

„ „ Out-patients.

Ophthalmology.

Dermatology in Association with Venereal Diseases.
Mental Diseases — Asylums.

„ „ Cliniques in Royal Infirmary.

„ „ Incipient Mental Diseases.

Dispensary.
V. General Medicine Course — Senior.
Clinical Medicine — Lectures.
„ „ Cliniques.

„ ,, Out-patients.

Infectious Diseases at Fever Hospital.
Tropical Diseases.
Tuberculosis.
Neurology.
Therapeutics — Physical Methods of Treatment.

„ Practical Nursing.

Dispensary.
Poor Law Hospitals.
Incurable Hospitals, etc.

Report of the Edinburgh Pathological Club 199

COURSE OF INSTRUCTION IN CLINICAL SURGERY.

Year.

I. Surgical Out-patient Department — Elementary Demonstra-
tions (two hours weekly).
II. Surgical Out patient Department — Dressing.
Venereal Diseases.
III. General Surgery Course — Junior — Lectures.

„ „ ,, „ Demonstrations.

„ ,, ,, „ Tutorials.

Surgical Pathology and Morbid Anatomy, with Pathology.
Clinical Surgery — Cliniques.
„ „ Operations.

„ „ Tutorials.

Anaesthetics.

Regional Surgical Anatomy, with Anatomy.
Aural, Nasal, and Laryngeal Surgery.
Sound and Acoustics, with Physics.
Anatomy of Ear, Nose, and Larynx, with Anatomy.
Physiology of Ear, Nose, and Larynx, with Physiology.
V. General Surgery Course — Senior -Lectures.
,, „ „ „ Tutorials.

„ „ „ „ Demonstrations.

Surgery of Children — Lectures.

„ „ Cliniques in Wards and Out-patient

Departments.
„ „ Operations.

Clinical Surgery — Cliniques.
„ „ Operations.

„ ,, Tutorials.

„ „ Practical Nursing.

Practical (Operative) Surgery.
Surgical Dispensaries — Minor Operations.

200 Report of the Edinburgh Pathological Club

COURSE OF INSTRUCTION IN OBSTETRICS AND
GYNECOLOGY.

Year.

IV. General Midwifery Course — Junior.
„ „ „ Lectures.

„ „ „ Tutorials.

Maternity Cliniques.
Maternity Cases.
Ante-natal Cliniques.
Anatomy in relation to Obstetrics and Gynecology, with

Anatomy.
Physiology in relation to Obstetrics, with Physiology.
Operative Midwifery.
Clinical Gynecology — Cliniques.
„ „ Tutorials.

Pathology and Morbid Anatomy in relation to
Gynecology, with Pathology.
V. General Midwifery Course — Senior.
„ „ „ Lectures.

,, „ „ Tutorials.

Maternity Cliniques.
Maternity Cases.
Gynecology — Lectures.
Clinical Gynecology — Cliniques.
,, ,, Tutorials.

Gynecological Dispensaries — Minor Operations.

COURSE OF INSTRUCTION IN PUBLIC HEALTH.

V. General Course — Lectures.

„ „ Practical Classes.

Vaccination.
Chemistry in relation to Public Health, with Chemistry.

COURSE OF INSTRUCTION IN MEDICAL JURISPRUDENCE.

V. General Course — Lectures.

„ „ Demonstrations.

„ „ Post-mortems.

Medical Ethics.

Edinburgh Medical Journal, Vol. XXII. No. 3.

The Late Dr. Mackixxox.

Obituary 201

OBITUARY.

FRANK I. MACKINNON, M.B., C.M.(Edin.), M.R.C.S.

On Saturday, 4th January 1919, a cablegram, delivered in Edinburgh,
stating that Frank Mackinnon of Damascus had died in that city on
30th December of pneumonia, brought deep sorrow not only to his
relatives but also to a very large circle of friends who esteemed and
loved him, some of whom had towards him feelings akin to reverence.
The sense of loss is keenly felt by the Edinburgh Medical Missionary
Society. Dr. Mackinnon had represented that Society for upwards of
thirty years before the war, and had returned to Damascus on 7th
November to resume work in that very important centre. They
valued his able and devoted labours, and it was to him they were
looking with implicit confidence for the reconstitution of the great
work which he had built up so skilfully. His intimate knowledge of
Eastern character, and the powerful influence which he had acquired
among the inhabitants of Damascus and of the whole of Syria, including
the Arab Sheiks, would have enabled him to re-organise the work as
no other person could do it. Lord Guthrie writes : " At any time his
death would have been greatly felt ; at this stage in Syria's history it is
nothing but a calamity."

Frank Irvine Mackinnon was born at Avoch, in the Black Isle,
in December 1855. His father was a Congregational minister. He
graduated at Edinburgh University in 1 883, and the same year he also
passed the examination for M.E.C.S.(Eng.). In January 1884 he went
to Damascus to succeed Dr. Mackenzie, whose health had broken down.
In 1886 he married Lydia, daughter of the Rev. John S. Macphail of
Benbecula. The next twenty-eight years constitute a wonderful
romance of medical missionary work, until, in 1914, at the outbreak
of war, a German officer appeared in Dr. Mackinnon's hospital, and
took an inventory of its instruments and equipment, then ordered
their removal. One may realise with what anguish Dr. Mackinnon
witnessed the looting of the hospital which had cost him so much
thought and labour to build and to organise, which had witnessed so
much blessing to thousands of sick and suffering, under his loving care.
In December of that year he along with other sixteen men of position
in Damascus were seized by the Turkish soldiery, under the command
of Von der Golz, and were imprisoned, under threat of being shot, in one
small room, which was suitable for only two persons, and "they were
not the only occupants of that filthy hole." After being released he

202 Obituary

came to this country, and later served first in Malta, as CO. of a
hospital, then in Egypt. While at 17 General Hospital, Alexandria,
he was offered the post of Surgeon-Specialist with extra pay, for which
appointment he was admirably qualified by his skill and experience,
but "as there were many young and able surgeons who were burning
to do surgery," he declined, and continued the work of the ordinary
wards. When our troops reached Damascus he was sent to the scene
of his former labours. He arrived there on 7th November 1918. It
is very touching to realise that he died in his own home after he had
begun to re-organise the work which was so dear to him. He is sur-
vived by his widow and their three sons, who are all three serving in
the Army. The eldest had been for two years house surgeon to his
father in Victoria Hospital, Damascus.

Dr. Mackinnon was a man of strong personality, with strength in
every feature ; he had a very quiet manner, but brimming over with
humour. He lived his religion, and was a very warm-hearted, steadfast
friend. He had great driving power, and when convinced that a thing
was right, he spared no pains to carry it through. At a time when
he required a new assistant in the hospital, he defined the essential
qualifications for a medical missionary assistant as follows : — " Intelli-
gence, tact (i.e. sanctified common sense), and no small amount of
patience." All three of these qualifications he himself possessed in no
small measure.

At an early age he gave evidence of the missionary spirit. Before
he came to Edinburgh to study medicine he was a zealous worker in
the M'Call Mission in Paris. When Dr. Lowe, Superintendent of the
E.M.M.S., presented him to the directors as qualified for appointment
to Damascus in 1883, he described him as " a man of true missionary
devotion, who had taken a very active part in all departments of the
missionary work of the Society." After his appointment by the
directors, he, with characteristic thoroughness, asked permission to
delay entering on his new work for some months, in order that he
might take special courses on eye and other diseases, which he thought
important for work in the East. During these months he studied
Arabic under two Syrian medical students in Edinburgh.

On arrival in Damascus in January 1884 he met with considerable
opposition, but before long his mental qualities and his skill, especially
as a surgeon, caused very large numbers of all classes to seek his
advice. Dr. Kelman, who had on more than one occasion travelled
with him in Syria, writes : " I knew him well, and loved and honoured
him very greatly. I never knew anyone whose whole spirit and
attitude of mind were so essentially and constantly heroic. His fame
as a doctor had spread among the Arabs until be came to be regarded
with almost superstitious reverence. Legends sprang up about him.
He was supposed even to have raised the dead. But it needed no

Obituary 203

legend to account for his power over the mind of the Arab. ... He
whs not one who could accommodate his principles to circumstances.
He utterly abhorred the circuitous dishonesties which in Oriental
dealings are sanctioned by immemorial custom. He was one of the
great men who have confronted them with the honour of a British
man."

It soon became evident that a hospital was an absolute necessity
for the due performance of his work in that great city of 210,000
inhabitants. The first step towards this was to procure a site. In
this he encountered great opposition in the Law Courts. While his
suit was pending a circumstance happened which had a wonderful
influence in his favour. One evening one of the judges in the Court
rushed into Dr. Mackinnon's house and begged his immediate presence
at the house of the Chief Cadi (judge). Although tired after a trying
day's work, and just about to sit down to dinner, he went at once,
found the house in great distress and disorder because of the illness
of the Chief Cadi's only son, a child of three years, who was lying
comatose and cyanosed from an overdose of opium. He at once took
off his coat, and, after many hours of constant work, he was able to
leave the child in safety. The Cadi, with tears of gratitude, embraced
Dr. Mackinnon, and declared himself through life his debtor. Although
the Chief Cadi had not previously taken any interest in Dr. Mackinnon's
just claims for the site, now the position was altered, and before long
a site of about 4 acres was secured to him.

Mackinnon was a many-sided man. He was his own architect and
clerk of works, and in May 1898 the hospital built under his super-
vision was opened. Queen Victoria graciously acceded to the request
that it be named " The Victoria Hospital." Dr. Maxwell of London
•describes it as " One of the finest buildings, for such a purpose, to be
found on the mission-field." In relation to the working of the hospital,
Colonel Henry Knollys, after various favourable remarks regarding
the hospital, Dr. Mackinnon, and his staff, wrote : " I do not presume
to go beyond the expression of my profound admiration for their skill,
kindness, and exercise of Christian virtues. I have never seen — no,
never — higher types of their noble avocation."

The Wali (Governor) of Damascus had a very high opinion of
Mackinnon's ability. In 1903 Damascus suffered from a very severe
and fatal epidemic of cholera. The first case was sent to the Victoria
Hospital, labelled chronic dysentery. A glance convinced Dr. Mac-
kinnon that it was Asiatic cholera. He refused the case, reported it
to be cholera, and advised immediate isolation. This was not done.
The native municipal doctor declared that it was not cholera. The
"Wali, however, sent for Dr. Mackinnon, who then made cultures, and
demonstrated by the microscope that his diagnosis was correct. In
the meantime the disease had spread rapidly, the native doctors fled,

204 Obituary

but Mackinnon and other two Europeans and some army doctors
remained and fought the plague.

On 7th May 1909 four hundred Damascenes met on the tennis
ground of the Victoria Hospital to celebrate the semi-jubilee of Dr.
Mackinnon's work in the city. They presented to him and Mrs.
Mackinnon many valuable and beautiful gifts, and many flattering
speeches were made in Arabic and French, to which he briefly replied
in these languages.

Mackinnon shone not only as a medical missionary but in every
position which he occupied — the platform, the drawing-room, in
sportsmanship. He was pleased when he took home partridges or
snipe, and at times brought down larger game — gazelle, or Syrian bear.

He carefully cultivated friendly relations with all, and, in order to
foster these, he remained at home the whole of New Year's Day to
receive guests. Their names were entered in a book, and he returned
their visits on their respective feast-days. " These visits " (wrote
Mackinnon) " afford opportunities of saying a word in season, and
giving a reason of the hope that is in you." Every Saturday evening
he dined in the hospital with his staff, and on Sabbath evening those
of the staff who could be spared from duty crossed to his house, where
they had hymns and, later, family worship. His house was a home to
many visitors — " a piece of Scotland " to some. Small birds realised
that the garden was a sanctuary, and Mackinnon rejoiced in the large
number of his feathered friends who found it a refuge. Mrs. Mac-
kinnon's rose-garden was well known to the Damascenes, and admired
by all who saw it.

Mackinnon had a fine sense of the beautiful, especially of the
beauties of Nature — the snows of Hermon, the sunsets of Egypt and
of Malta, his own Highland moors and mountains, and he loved to
transfer to a Whatman block in water-colours some memorial of what
he admired. After one of his climbs he wrote as follows : " I had
been up amid the solitude of the grand old hills, where one's spirit
so often gets into sympathy with Nature, so full of voice, eloquence,
and praise — to David as to the sky-pilot the mountains lived, breathed,
and spoke. Like a mirror they catch the reflection of the Creator, and
respond to the rains, sunshine, and shadows, and break into joyful
praise. Would that our spirits responded more frequently to the
many Divine influences and blessings so abundantly bestowed on us."

His remains were laid to rest in the small Protestant cemetery near
the East Gate of the city. The funeral, which was a military one, was
attended by men of many nationalities and of widely different religions.
Two Grhurka pipers played the laments — "The Flowers of the Forest"
and "Loehaber no More." The silence which followed the "Last
Post," when the officers filed past the grave and saluted the remains
and the flag, was broken by the cry, " All beloved of Damascus " from

Obituary 205

one of Mackinnon's Syrian friends who had known and loved him for
many years.

It is in the influence of such men as Mackinnon that we discover
the secret of the British Raj. We have received from many visitors to
Damascus written testimony as to the influence of the man and the
value of his work. But he was in a still higher sense an Empire
builder ; his chief aim was the building of the Empire of Righteous-
ness. Mr. Basil Matthews, in his Riddle of Nearer Asia, writes : " I
discovered, little by little, that in all the city of Damascus, the most
ancient city now standing in the world, there was one man who had
universal authority, not by position, nor by wealth, but by the
power of service and of personality. That one man was Dr. Frank
Mackinnon." J. R.

15

206 New Books

NEW BOOKS.

Chemistry of Synthetic Drugs. By Percy May, D.Sc. Second Edition.

Pp. x. + 250. London: Longmans, Green & Co. 1918.

Price 10s. 6d. net.
This is an account of the structural formulae of a large number of
substances — some of them used as drugs, others as poisons, others of
purely chemical interest. Many chemists still lean to the view that
the action of drugs in the living tissues is analogous to their behaviour
in the beaker and test-tube, and is largely determined directly by
their chemical structure. The author is obviously prepossessed in
favour of this theory, though it is true that he devotes some attention
to the physical characters of his substances. He appeals to these,
however, mainly to explain the exceptions to the rule, rather than as
primary factors in the distribution of drugs in the tissues, and there-
fore in their pharmacological effects. Many examples of the direct
connection between structure and action are given, and these may
prove convincing to readers who do not appreciate the insecurity of
some of the pharmacological work which is cited. The author, as a
chemist, is unable to differentiate between statements which are
universally accepted by pharmacologists and others which rest upon
quite inadequate observations, and a critical survey would materially
reduce the number of examples in which structure seems to determine
action. The point of view of the author is well brought out and the
book is interestingly written. In future editions one would wish to
see a more critical attitude towards the biological observations, and
greater attention paid to the physical characters of the drugs as
compared with their chemical structure. A few well-considered and
well-authenticated examples would carry more conviction than a
wealth of citations given without references, and many of them of
questionable value.

Surgical Therapeutics and Operative Technique. By E. Doyen. English

Edition, Prepared by the Author in Collaboration with H.

Spences-Browne, M.B., Chef de clinique de lTnstitut Doyen.

Vol. II. Pp. viii. + 680. With 982 Illustrations. London:

Bailliere, Tindall & Cox. Price 25s. net.
We reviewed the first volume of this comprehensive work at some
length when it appeared about eighteen months ago,* and we welcome
this further instalment, which is quite up to our expectations. It is
devoted to regional surgery and embraces a number of operations on
the head and neck which were not included in the first volume,
• Edinburgh Medical Journal, October 1917, p. 266.

New Books , 207

operations on the thorax, and on the upper and lower limbs. Through-
out the work the authors maintain a nice balance between simple and
complicated operations, the former being described without unnecessary
elaboration, while no detail is omitted from the description of the
latter. The illustrations have been selected with the same discrimina-
tion, some of them depicting so many stages of the procedure as to
be almost cinematographic in their effect. If there is any criticism,
it is that the actual field of operation might have been enlarged at
the expense of the dramatis personce, e.g. the figures illustrating supra-
condylar amputation of the femur.

We look forward with pleasure to the appearance of the third
volume, which will conclude one of the most valuable works of
reference in operative surgery available to the practical surgeon.

Intravenous Injection in Wound Shock. By W. M. Bayliss, F.R.S.,
Pp. xi. + 172. With 59 Illustrations. London: Longmans,
Green & Co. 1918. Price 9s. net.

In this volume Professor Bayliss has amplified his Olner-Sharpey
Lectures delivered before the Royal College of Physicians in May
1918, and has incorporated a considerable amount of evidence which
has been produced by surgeons on active service since the lectures
were delivered. The result is a most exhaustive consideration of the
whole subject, particularly from the physiological side, but supported
by much clinical evidence. Although the scope of the inquiry does
not extend to an investigation of the actual nature of the conditions
underlying "wound shock/' the writer arrives at certain definite
conclusions which are set forth on page 156. The most obvious signs
of the condition are a low blood-pressure and the consequences of the
deficient supply of blood to vital organs which result therefrom. The
ground is cleared, however, by excluding certain conditions which are
not the cause, viz. : — Acapnia, suprarenal exhaustion, exhaustion of
nerve centres, inefficient cardiac contraction, and arterial or venous
paralysis. The author then proceeds to consider the injurious effects
of a low blood-pressure, and the means that may be taken to
counteract these by raising the pressure. Of these the most efficient
is the introduction of fluid directly into the circulation, the various
solutions that have from time to time been recommended for this
purpose are considered seriatim, and the physiological and chemical
evidence bearing on each is analysed. In the end the author con-
cludes that the most satisfactory is a 6 per cent, solution of gum
acacia in 0*9 per cent, sodium chloride.

The need for an authoritative finding on the difficult problems
relating to wound shock and its treatment is great, and we feel that
Professor Bayliss has met it in this exposition.

208 Books Received

Medical Bacteriology. By John A. Roddy, M.D. Pp. xi. + 285.
With 46 Illustrations. Philadelphia : P. Blakiston's Sons &
Co. 1917.
According to the author's preface this book is intended as a " text-
book for beginners and laboratory guide for medical practitioners and
pharmacists." Dr. Roddy's aim has been to give as briefly and clearly
as possible a description of the more common micro-organisms which
are capable of producing disease in man, and of the technique used in
a bacteriological laboratory.

Various sections are already out of date. The chapter on the
meningococcus requires rewriting in view of recent work in this
country. The sections on the typhoid-paratyphoid and dysentery
groups also require revision. The author lays little stress on the all-
importance of specific sera for the identification of these organisms,
and emphasises rather the use of certain cultural tests which are now
regarded as of much less value. In the agglutination test, with the
patient's serum in dysentery and Malta fever, he regards as diagnostic
a dilution of serum much lower than that accepted by most workers
in these subjects. Various other criticisms on minor points might
be made.

The brevity which Dr. Roddy has aimed at prevents the book
being of value as a work of reference for laboratory workers ; but for
the student of medicine and others reading for examinations in
bacteriology it may be recommended as a concise and clearly expressed
manual.

BOOKS RECEIVED.

Alport, A. Cecil. Malaria and its Treatment . . {John Bale, Sons & Danielsson) 21s.

Daw, S. W. The Orthopaedic Effects of Gunshot Wounds and their Treatment

(Henry Frowde, Hodder & Stoughton) 7s. 6d.

Gay, Frederick P. Typhoid Fever (TJie Macmillan Co.) —

Greene, W. H. Clayton. Pye's Surgical Handicraft. Eighth Edition

(John Wright & Sons, Ltd.) 21s.

Johnson, A. E. Webb. Surgical Aspects of Typhoid and Para-Typhoid Fevers

(Henry Frowde, Hodder S Stoughton) 10s. 6d
Martin, T. Moirhead. Pocket Notes on Nerves .... (William. Bryee) 2s.

Page, C. Max. A Medical Field Service Handbook (Henry Frowde, Hodder <t Stoughton) 6s.

Sadtler, Samuel P., Virgil Coblentz, and Jeannot Hostmann. A Text-Book of

Chemistry. Fifth Edition (J. B. Lippincott Co.) 21s.

Snowman, J. Lenzman's Manual of Emergencies . (John Bale, Sons & Danielsson) 15s.

Transactions of the College of Physicians of Philadelphia. Third Series. Vol. XXXIX. —

APRIL 1919-

EDINBURGH
MEDICAL JOURNAL.

EDITORIAL NOTES.

In their inception our hospitals and infirmaries
TraSmonersPital were merely bouses into which sick people
were received in order that they might have
skilled medical treatment under more convenient conditions than
obtained in their own homes. They were often ill-adapted for their
purpose, and in many cases the surroundings were even less favourable
to recovery than those from which the sufferer had been removed.
It is perhaps not an exaggeration to say that the transfer was
frequently effected as much for the comfort of the patient's friends
as for his own safety. In any case, their purpose was essentially
curative, and little or no attention was paid to the social or economic
interests of the patients. It is true that in some of the older
foundations, for instance "St. Thomas' Spital," provision was made
for lodging and boarding " poor pilgrims to and from Canterbury "
who might have fallen sick by the way, and on their recovery to
furnish them " with alms and provisions to continue their journey."
In time this germ of a social service department in hospital adminis-
tration developed, and, with the awakening of a social conscience and
the growth of humanitarian views, u Samaritan Societies," " Humane
Societies/' "Truss Societies," and other similar institutions were'
founded and became affiliated with the hospitals, with the object
of assisting the patients in directions other than those which were
purely medical. In a sense the convalescent hospital is an extension
of the same idea — to rehabilitate the patient who has been "cured"
in the hospital before he resumes his work in the world. And so
with those hospitals or " hostels " where provision is made for those
who are incurable but may still be relieved by care and nursing.

Within recent years a further extension of social service work
in connection with hospitals has evolved in the form of the trained
hospital almoner. This movement has not hitherto made much
progress north of the Tweed. So far as our information goes, it has

E. M. J. VOL. XXII. NO. IV. 16

210 Editorial Notes

chiefly centred in the London area and in a few of the larger
provincial towns of England.

We are not here concerned with the employment of almoners to
inquire into the social and financial circumstances of those who seek
advice and treatment at our voluntary hospitals. This is purely a
matter of hospital management, and lies within the province of those
who are responsible to the subscribers for the proper administration
of the funds entrusted to them. If " hospital abuse " exists (and
we confess we have seen little of it in Scotland), it can be checked
without instituting a general inquisitorial system.

There are various directions, however, in which a trained lady
almoner can co-operate with the medical staff to the advantage alike
of the patient and the hospital.

The need for such co-operation is perhaps greatest among those
who are treated as out-patients. The medical officers are often
seriously handicapped by the fact that the patients are not in a
position to obtain the medicines, appliances, or other requirements
necessary for efficient home treatment. Charitable or civic agencies
may exist in the district which would provide what is wanted, but the
patient is ignorant of these, and the doctor has neither the time nor the
means to put him in touch with them. The lady almoner acts as a
connecting link between the doctor and these organisations. It is her
business to be familiar with all such agencies in her district, to know
the nature and scope of their activities, and the steps to be taken
to secure their aid. The needs of a particular patient are explained
to her, and she is left to make such arrangements as are possible, and
to report what she has been able to do.

Any out-patient medical officer could recall from his last week's
experience numbers of cases in which such assistance would have been
invaluable. How often does he feel that the purely medical treatment
he may order is of secondary importance, and may even be of no value
at all, unless the patient can be placed under more favourable con-
ditions for recovery, or can receive some extraneous aid which it is not
in his power to give. Some special article of diet, a surgical appliance,
a few weeks' rest at a holiday home, may be the most essential factor
in treatment, but the patient cannot obtain such accessories unaided,
and there is no agency connected with the hospital to help him to
secure them. This want the hospital almoner supplies.

There are many other directions in which the services of an
almoner have been found useful. It often happens, for example,
that a nursing mother requires immediate admission to hospital,
but has difficulty in arranging for the care of her infant and of her
other children, and to keep the home going. In such a case the
almoner can arrange for the admission of the younger children to a
children's shelter, or otherwise provide for them. In some districts

Editorial Notes 211

the almoner keeps a list of reliable women — very much as a doctor-
has his roster of nurses or mid wives — who can be employed as
temporary housekeepers under such conditions. In this way the
admission of the woman is expedited, and her mind is kept at ease
regarding her family during her stay in hospital. Or again, if a
patient requiring indoor treatment is found unsuitable for admission
to the hospital at which he has applied and has to be referred to some
other institution, the almoner can take the necessary steps to facilitate
the transfer.

There is another class of case in which a lady almoner is peculiarly
adapted to be of service — the case of the unmarried girl who has got
into trouble and requires the advice and sympathy of one who by
training understands her need and can do something to help her
in her present difficulty and to guide her in the future.

The functions of the almoner are not confined to the out-patient
department. There are many ways in which she can be helpful with
regard to in-patients, particularly when the time comes for them to be
discharged. Every hospital physician or surgeon knows the difficulty
there often is in disposing of a patient who no longer requires to be
detained in the ward but is still unfit to look after himself outside.
It may be that he cannot be attended to at home, or he may not even
have a home to go to. When the requirements of the patient have
been explained to the almoner she takes steps to find out the home
conditions, the resources of the patient or his friends, and makes
the best arrangements possible for his care and comfort. It would
be easy to suggest circumstances in which such aid is valuable in
expediting the discharge of patients, and so freeing beds for more
necessitous cases. To cite only a few of the more common : the
old woman, living alone, who has had a fracture of the femur, and
who cannot be sent back to her garret ; the child with hip-joint
disease who must lie up for months if a cure is to be expected ;
the hemiplegic who cannot be attended to at home ; the child with
interstitial keratitis which has improved to the usual degree in
hospital but who will inevitably relapse if he returns to his old
surroundings, and so on. It is true that an almoner cannot always
provide for such cases, or for others like them, because agencies do
not exist to meet every emergency, but she can at least enable us to
make full use of such as do exist, and her repeated inquiries may point
the way for others being established.

In other ways the almoner can usefully co-operate with the medical
or the nursing staff — for instance, by acting as an intermediary between
them and the Samaritan Society, the Truss Society, the various
societies for helping the indigent, the Charity Organisation Society,
or the poor law authorities. She can also keep in touch with chronic
cases, reporting their progress from time to time, and^ensuring their

212 Editorial Notes

frequent attendance at hospital for purposes of further investigation
or demonstration.

It is evident that to perform such varied and, in some cases,
delicate duties, the lady almoner must be endowed to an exceptional
degree with tact, sympathy, and common sense, and must, in addition,
be specially trained. This training is part of the work of our Social
Study Schools and Schools of Economics. It includes, in addition
to an elementary knowledge of physiology, general hygiene and
sanitation, and social questions, a knowledge of the powers and
duties of the public health and poor law authorities. She is also
instructed in the functions and resources of charitable organisations
in general, and in the means of obtaining their aid. Practical
knowledge is acquired by visiting the homes of the poor along with
her instructor, and in interviewing the applicants for help. Although
she is neither a doctor nor a nurse she must be familiar with the
general methods of hospital administration and with hospital
etiquette. This experience she obtains by working for a time
under an experienced almoner in a hospital. It is also required
that she spend a certain time in the almoner's office learning business
methods, the keeping of statistics, records and accounts, and official
correspondence.

It is scarcely necessary to add that such a widely trained official
must be sufficiently remunerated, but experience has shown that the
expenditure in this direction is fully justified.

Evidence from various quarters shows that the
principles which govern the award of disable-
ment pensions are not universally understood. This applies not only
to pensioners themselves but to a good many medical men, and as
there falls on the latter the duty of giving certificates as to the health
of pensioners, it is worth while drawing attention to certain current
fallacies.

It cannot be too clearly stated that a pension for injury or ill-
health is intended as a compensation for damages both as regards
earning capacity and enjoyment of the amenities of life. In the case
of a number of specific injuries — e.g. loss of an eye or of a limb — the
degree of disablement entailed is definitely laid down ; in certain cases,
such as epilepsy and cardiac disorders, an approximate standard of
disablement is somewhat generally adopted; in a larger group of
diseases and injuries there is no definite standard, but each disability
has to be judged on its merits. The test applied throughout is : To
what extent does the disability impair the pensioner's value in the
ordinary labour market? The answer of a Board to this question,
given as a percentage, determines the award of the Pensions Ministry.

Editorial Notes 213

With the actual sums granted the Boards have no concern. These vary
according to circumstances — the military rank of the pensioner, the
number of his dependants, his service, the pensions scale for the time
being, and so forth.

The point which is not quite obvious at first sight is this : the
pension, though its amount is based on diminution of earning capacity,
is not intended to make up to the pensioner the wage which he has
lost through disablement 5 on the other hand, the effect of the disable-
ment on his social as well as his economic life is taken into considera-
tion, though it will usually happen that the economic disability, being
the greater, includes the social disability. (Examples of the contrary
will readily occur to mind — extensive facial deformity, for instance,
is in some cases a greater social than economic disability.)

The reason for the apparent contradiction between basing a pension
on diminished earning capacity and yet disregarding occupation in
fixing its amount is not far to seek. To make up to a man his loss
of wage would involve a determination of the pensioner's actual and
potential earnings which, even if practicable, would seldom be accurate,
would often be unjust, and would invariably create comparisons
between one pensioner and another. The least consideration shows
that a disability which tells slightly on one man may throw another
out of work altogether. A labourer who has lost a finger of his left
hand is a very different case from a violinist with the same injury :
a gardener suffering from shell-shock is not disabled as an accountant
is by the inability to concentrate his attention. Examples might be
multiplied indefinitely, but these are enough to show that the principle
of compensation for injuries on a uniform scale is the only practical
one : to compensate for individual loss from these injuries would be
a hopeless impossibility. The problem, in fact, is analogous to that
set to recruiting Boards : to determine a man's fitness relative to his
age and not relative to the work required of him after enlistment,
that being a matter on which Boards had no opportunity of forming
an opinion.

Misconception of the principles on which pensions are awarded
sometimes leads to medical certificates being given to pensioners to
the effect that, since the disability from which B. suffers is such as
totally to prevent his following his occupation, the award of the Board
is, in the writer's opinion, inadequate. Such certificates, based on
erroneous premises, lose what value they otherwise would have, and
this is the more unfortunate because a certificate from a private medical
attendant giving information a Board cannot otherwise obtain is often
of the greatest assistance in assessment. In the same way, pensioners
sometimes object that the pension they are getting does not raise their
income to what they could otherwise have earned. If, however, it is
pointed out that to do this would involve giving a pound a week to A.,

214 Editorial Notes

two pounds a week to B., and five pounds a week to C, they recognise,
if they are intelligent, that the apparent injustice arises from social
conditions, and not from the parsimony of the Ministry of Pensions.

CASUALTIES.

On 4th February, of pneumonia, Captain Robert C. Davie, R.A.M.C.

Captain Davie graduated ALA., 13.Sc. at Glasgow University, and
received the degree of D.Sc. in 1915. In April 1913 he was appointed
Lecturer in Botany at Edinburgh University, and in 1914 made an expedi-
tion to Brazil to carry out botanical research.

On 18th February, of influenza and pneumonia, Captain John
Cameron, R.A.M.C.

Captain Cameron graduated M.B., Ch.B. at Glasgow University in
1914.

On 21st February, of broncho-pneumonia, Captain Arthur Meurig
Pryce, R.A.M.C.

Captain Pryce graduated M.B., Ch.B. at Edinburgh University in
1903. Before taking a commission in the R.A.M.C. he was Demonstrator
of Bacteriology in Leeds University.

It was intimated at a meeting of the Edinburgh
orSSfsurSry. University Court, held on 17th March, that a

donor, who desired to remain anonymous, had
offered to the University, through Professor Alexis Thomson, a gift
of £10,000 to further progress in the study and teaching of some
subject related to surgery, and that it was proposed to devote the
money to endowing a Lectureship in Orthopaedic Surgery.

At the recent Dental Examinations just concluded
BuxSS^O^EtobSgh. ^e following candidates passed the First Dental Ex-

amination : — Willeni Frederik Pauw, George Izzett
Alexander, and Thomas Bird Gregor ; and the following passed in the
subject of Chemistry and Physics : — John Macnaughton Mein, Margaret Helen
White, Rosamond Caseley, James Duncan Cumming Archibald, and Johan
David Beyers.

At the same diet the following candidates passed the Final Examination
and were granted the Diploma L.D.S., R.C.S.(Edin.) : — John Bruce Watson
Telford, Leith ; Nico Hofmeyr Albertyn, Paarl, South Africa ; Andrew John
Molyneaux, Kimberley, South Africa ; George Laing, Keith ; John Storey,
Alston, Cumberland ; Egbert John Charle Steyn, Riversdale, South Africa ;
Robert Mitchell du Preez, Riversdale, South Africa ; and William Harvie Kerr,
Edinburgh.

Disease in Macedonia 215

DISEASE IN MACEDONIA.
By ROBERT A. FLEMING, M.D., Major, R.A.M.C.(T.).

I have been asked to write a short account of the medical diseases
whicli we met with in Macedonia.

After an experience of eighteen months in Salonika one learns
an enormous amount about the tropical diseases peculiar to that
region, and, what is more important, the best methods of keeping
oneself and others in a state of health.

I purpose, referring to the more important diseases met with
and to offer the conclusions which experience taught us.

Dysentery.

We saw comparatively few cases of amoebic, and many cases
of bacillary, dysentery. While there were undoubtedly endemic
cases of amoebic dysentery, the bulk of our amoebic patients appear
to have contracted the infection in Gallipoli or Egypt.

The Army term " dysentery " is a very wide one. It means the
presence of blood and mucus in the patient's stools, and obviously
only a small proportion of such cases are due to any of the
recognised organisms of bacillary dysentery.

The following statistics, covering 1000 cases, may be of interest.
Almost all of these were examined in the hospital laboratory
during the months of November and December 1917. In
November 8*2 per cent, were due to the Shiga organism, 10*4
per cent, were due to the Flexner organism, while 42 per cent,
were marked as " Clinical Dysentery." In December 1917 6*9
per cent, were due to the Shiga organism, 11 "3 per cent, to the
Flexner, and 0*8 per cent, were due to one or other Morgan
organism, while 44-7 per cent, were described as " Clinical." The
balance of these percentages during November, amounting to
38*8 per cent., and in December 33*2 per cent., were simply cases
of " diarrhoea " in which no blood and mucus were found. It is
certainly true that the Shiga cases vary somewhat with the time
of year, but the whole of our experience during 1916 and 1917
shows that there were invariably a larger number of cases of
Flexner than Shiga. It was also the rule that Shiga cases were
more severe than Flexner, and this was borne out by the deaths
we had from the 11th November 1917 to the last day of December
of the same year. Four were due to Shiga, two were due to Flexner,
and one to a combination of the two organisms, while two were

216 Robert A. Fleming

the result of " clinical dysentery," one was a death from miliary
tuberculosis and another from chronic interstitial nephritis ; one
death only was the result of amoebic dysentery.

In amoebic dysentery the chief site of pain is in the right iliac
region, undoubtedly because the caecum and ascending colon are
chiefly affected, while in bacillary dysentery the descending colon
and the splenic and hepatic flexures are the usual parts of the
large intestine which are involved. Sometimes a small part of
the ileum is affected in bacillary dysentery, but this is rare.

I do not propose to discuss amoebic dysentery, because we had
so few cases, although I may refer later to the treatment we
adopted in these cases.

In bacillary dysentery the worst cases were either those in
which long-standing and severe ulceration had occurred, or cases
complicated by malaria.

It is only necessary to see one post-mortem of a severe case
of chronic dysentery to realise how absolutely hopeless complete
recovery must be. The bowel is enormously thickened, especially
in the region of the descending colon and right down in the
rectum, while the flexures also suffer. One felt that if such a
case had been treated vigorously enough at an earlier period this
hopeless chronic stage, with its risks of perforation, generally
causing haemorrhage and not peritonitis, would never have
occurred. In any case where dysentery is fairly protracted the
experience of a few post-mortems help one to appreciate the long-
standing ill health which must inevitably follow as a result of
the disease.

It was a really serious complication in an}T form of dysentery
to have a superadded attack of malaria, and any attempt at treat-
ment of the dysentery was without avail until a sufficient amount
of quinine had been administered by muscle or vein to arrest the
malaria. Even a "clinical dysentery" was rendered much more
severe as regards dysenteric phenomena if malaria supervened.
The malarial attack appeared to increase the diarrhoea, to render
more pronounced the typical dehydration so constantly seen in
cases of severe chronic dysentery, and to add greatly to the risk
of haemorrhage. One does not, as a rule, see a high temperature
in dysentery, and it is therefore easy to recognise a malarial rigor,
and a blood examination should be made without delay. The
reader is directed to the remarks under the head of " Malaria "
on the importance of repeated blood examinations in cases of the
subtertian type and the significance of a differential leucocyte

Disease in Macedonia 217

count. It is absolutely futile to give quinine by the mouth where
even trivial diarrhoea is present, and we usually found that either
intramuscular or intravenous injections in doses of 10 to 20 grs.
proved most efficacious.

In the examination of patients' stools for dysentery, whether
amcebic or bacillary, it is most important to supply the bacteri-
ologist with a fresh stool. In cold weather a stool which has been
frozen or has not been kept at a reasonably warm temperature
after being passed is useless for examination, and an arrangement
with the bacteriologist to receive specimens at almost any time
during the working day greatly aided a rapid diagnosis. Where
a tented hospital is in use it is well to have some temporary
arrangement for keeping the stools passed by patients at a suit-
able temperature if they cannot be examined immediately.

Perhaps there is nothing more difficult than to distinguish
between amoeba coli and amoeba histolytica, but sooner or later
cysts will be passed by the patient and a diagnosis can then be
readily made. The part of the stool of greatest value in any kind
of dysentery is the mucus, generally stained with blood, which
the patient passes, and in examining dysentery carriers a pre-
liminary dose of castor oil often aids in clearing up the case by
producing a liquid stool with mucus.

Probably the best guide to the physician in deciding whether
a dysentery patient is doing well or not is the examination of the
pulse. When there is little diarrhoea, and possibly no temperature
at all, a jerky pulse always spells danger, and we found that the
actual number of stools could not be taken as a satisfactory
indication of improvement or otherwise, because many dysenteric
stools simply consist of a tablespoonful of blood-stained mucus.
It is, however, a good sign when the stools become tinged with
faecal matter, even if mucus still persists in considerable amount,
and it is extraordinary how, with sodium sulphate, a stool rapidly
becomes faecal.

There is no question of the great value of the sodium or
magnesium sulphate method of treatment, either giving 1 drm.
an hour for six or eight hours, or 1 drm. every two hours until
six or eight doses have been administered. The appalling tenesmus
is speedily relieved, although for the time being the stools increase
in number. Towards night the patient was given a hypodermic of
heroin, which procured sleep and arrested the diarrhoea.

In all severe cases we used antidysenteric serum, gener-
ally given subcutaneously in doses of 20 c.c. but sometimes

218 Robert A. Fleming

administered by the vein. When the patient proved responsive
to the sodium sulphate treatment, and where there was no
excessive pain, we did not in every case risk anaphylaxis ; but
there is no doubt that if serum is to be given at all, it should be
given at once, and in a very bad case it is well worth the risk.
After three or four days the serum treatment should be stopped.

We found the diet of the patient all-important, beef-tea with
absolutely no milk being the principal item ; but the kind of clear
soup may be varied, chicken or rabbit being equally good, and as
soon as possible meat or chicken jelly may be added. Several of
our medical officers gave many different jellies, etc., at intervals of
one to two hours. In some cases this meant an increased tax on
the nursing staff and certainly on the quartermaster's department
without, perhaps, any very great necessity, but in a really bad case
there was no question of the benefit.

All our patients were given large quantities of barley water or
rice water to drink, and, in fact, to counteract the dreaded dehydra-
tion no reasonable limit should be placed on the amount of fluid
which the patient may drink. Where malaria is present, sickness
and vomiting are very frequent, and in such cases champagne,
generally iced, proved of special value.

Lavage of the bowel was a method of treatment to which in
our experience we could not give unqualified praise. When one
remembers that, although in bacillary dysentery the descending
colon and rectum suffer chiefly, the hepatic flexure and the ascend-
ing colon may also be affected, it is easy to understand the limita-
tions of lavage — with a funnel and soft oesophageal tube it is
difficult to ensure that the solutions ever reach beyond a small
part of the descending colon. Some of us who had considerable
experience in the treatment of dysentery gave up lavage almost
entirely, and, to my mind, it should only be used where it at once
proves of benefit and causes no pain. Where it produces great
distress it should be stopped.

The initial abdominal pain, so distressing to the patient, is best
relieved by the application of heat.

It should never be forgotten that a case of dysentery which
seems to be cured may yet mean the presence of ulcers from which
haemorrhage may occur, and a haemorrhage rapidly proving fataL
One is wise, therefore, in travelling up the dietetic ladder, to do
so slowly, and, once out of hospital, to give the patient very light
work until he has completely recovered.

The treatment of amoebic dysentery is essentially the use of

Disease in Macedonia 219

emetine hydrochloride, which was given in courses lasting for ten
to twelve days, 1 gr. being administered intramuscularly, in one or
divided into two doses, per day. It is most essential during these
periods of administration to remember the effect of emetine on
the heart, and we gave, in the majority of cases, 5 to 10 minims of
tincture of digitalis thrice daily during each course. The courses
have to be repeated sometimes twice, occasionally oftener,
depending on the result of bacteriological examination.

The dietetic and other treatment is practically the same as for
bacillary dysentery.

We had several discussions with our surgical colleagues as to
the propriety in both types of dysentery, amoebic and bacillary, of
having appendicostomy performed and the bowel washed out with
a suitable antiseptic, such as permanganate of potash, but, as a
general rule, surgical opinion appeared to be against such procedure.

I have made no reference to flagellate or other forms of
dysentery than amcebic or bacillary. We had several cases in
which lamblia were found as the apparent cause of the diarrhoea.
In one of these cases lamblia cysts persisted for a long time,
the patient apparently doing well, as far as the control of the
diarrhoea was concerned, unless there was some indiscretion in
diet. On one occasion this patient ate about half a pound of
chocolate almonds, and on another, through some inadvertence, he
secured and ate a four-course dinner intended for another patient
and totally unsuitable for him. On both occasions a severe relapse
of diarrhoea occurred, but the remarkable fact was that, although
by means of suitable diet, lavage, and occasional doses of thymol
internally, his diarrhoea ceased and his motions became formed,
lamblia cysts were found right up to the end of his stay in hospital,
which was over six weeks.

The prophylaxis of dysentery is essentially the destruction of
flies, the disinfection of the water supply, and the elimination of
dysentery carriers from a military camp. It was found to be
equally essential to protect all food from flies during the warmer
weather, and to prevent flies from becoming infective by protecting
and destroying the stools of patients suffering from dysentery.

My destruction provided an interesting and useful occupation
for the convalescent soldier, while those confined to bed watched
with interest the various fly traps which we possessed, one of the
best types being a Japanese invention that went by clockwork.

Among our experiences in Salonika was the discovery that in
one of the kitchens of the hospital there was working a dysentery

220 Robert A . Fleming

carrier. There is an unfortunate rule in the Army that a soldier
who is unfit for any other work is at least fit to be a kitchen
assistant, and to this pernicious idea it is probable that not a few
cases of dysentery may be traced during war time. Our watchful
medical superiors gave strict orders that no man who had suffered
from dysentery of any kind should be allowed to work in connec-
tion with the patients' food, either in the kitchen or in the
quartermaster's department.

There was, further, a great risk of infection in dysentery wards,
because a patient suffering from one kind of dysentery was naturally
susceptible to another, and the greatest care was taken not merely
to attempt to segregate cases of the different types of dysentery,
but also to inculcate careful washing of the patients' hands after
stool, and the cleansing of bed-pans with a 5 per cent, cresol
solution.

Malaria.

In Salonika we saw the most malignant forms of malaria which
appear to exist anywhere, and these were invariably subtertian
in type.

An attack of benign tertian malaria has the advantage of being
readily cured, but relapses occur for a long time afterwards, and
it is difficult to know just when a patient is finally and completely
cured, because exposure to cold and wet, excessive fatigue, and
especially fatigue during great heat, may bring on such relapses
months, or even years, afterwards. In subtertian malaria the
trouble is that the attack persists for an indefinite time, often
causing great anaemia and debility, but, once really cured, the risk
of relapse is over. The difficulty in this type is to say when the
termination of such a subtertian case had actually been reached.
In the benign tertian type between the attacks the patient is
generally perfectly well.

We always dreaded cases of subtertian malaria in which the
spleen remained much enlarged and tender. In them mere absence
of temperature did not imply the termination of the disease, and
some of our worst cases of subtertian malaria with head symptoms
had extraordinarily little pyrexia.

Just as in our experience of typhoid and paratyphoid fever, we
looked in vain for the typical text-book temperature which, in our
cases of subtertian malaria, should have been " recurrent."

It is generally easy to find the parasite of benign tertian
malaria, because either rings, sporulating or sexually mature
forms, are found in the peripheral circulation, but it is a different

Disease in Macedonia 221

matter vvitli cases even of severe subtertian malaria, and often
many examinations had to be made in well-marked instances of the
disease before the parasites were recognised. Apparently, although
in very large numbers in the circulation, they may be limited to
the internal organs, and particularly to the spleen and bone-marrow.
In more than one fatal case the brain capillaries were packed
with parasites, although the usual blood examination conveyed
no conception of their enormous numbers.

We found the greatest assistance in all cases of malaria from
the examination of the blood. A leucopenia, with a relative
increase of mononuclear leucocytes, is typical of malaria, and the
tender, if not enlarged, spleen is also a helpful clinical feature.

It seems hardly necessary to describe the malarial attack, with
its typical rigor during the cold stage, the characteristics of the
hot stage and the sweating stage, or to refer to the constant
headache, the frequent sickness with vomiting, or a feature
commonly noted, namely, frequency of micturition. There was,
however, in not a few of our cases, a remarkable herpes, certainly
best marked on the lips, as in pneumonia, but peculiar, inasmuch
as isolated herpetic spots were frequently found dotted over the
face, and were responsible, in a small percentage of cases, for
corneal ulcers which proved extremely intractable to treatment.

I have not attempted to describe the many forms of subtertian
malaria which may be met with in Macedonia, but it may be
interesting to refer briefly to two special results or types of such
malaria.

Pathologically, there is no question that cerebral malaria of
comatose type is due to an enormous number of parasites blocking
the cerebral arteries, but there is evidently some connection between
cerebral malaria and the exposure of the infected patient to a long
railway journey or a drive in a stuffy ambulance car during
intense heat, and every effort was made to treat severe cases of
malaria as near the Front as possible, and with satisfactory result
in the way of limiting the number and severity of cerebral cases.
It is a curious fact that men over 35, and specially men who
had passed middle life, were more apt to die from cerebral malaria
than younger men, and possibly one might assert that a subtertian
malaria was more apt to become cerebral in type in the older man.
We found, on the other hand, that dysentery was apt to be much
more severe in younger patients, and the majority of our fatal
cases occurred in soldiers under 25.

It was, in the second place, remarkable how many cases of

222 Robert A. Fleming

insanity in the Salonika army were due to malaria, always of
subtertian type, and practically always eventually resulting in
complete cure. In these cases the effect of intramuscular quinine
was most striking, and the mental symptoms cleared up in a
marvellous way.

We had relatively very few cases of quartan malaria, but some
of these were of Very severe type, and several were associated
with marked jaundice.

Captain Logan, our bacteriologist at Salonika, made some
researches into the question of the cause of diarrhoea in malarial
patients. He proved that the majority of cases were really
dysenteric, and similar work was done by other bacteriologists in
the area of our Army. The point was of very great importance,
because it enabled us to segregate dysenteric malarial patients
and to prevent the spread of dysentery, and it also gave us an
indication for the suitable treatment of such patients.

The Army order for the treatment of malaria with quinine was
a week or ten days with 30 grs. daily in three doses, for the next
week 20 grs. daily in two doses, and for the third week 10 grs. a
day, and then, until a period of 3£ months had elapsed from the
date of the last attack, 30 grs. a week at least. This was, of
course, oral administration and was intended to be given in solution.
Iron and arsenic were ordered during the period of convalescence
after a severe attack of malaria. Our Italian colleagues gave red
wine freely as a tonic and considered it very beneficial.

We always preferred to give intramuscular quinine into the
gluteal muscles, about 2 ins. or thereby below the iliac crest, and
10 to 20 grs. of quinine bihydrochloride were thus administered
once or twice a day.

In some hospitals intravenous quinine was the stock treat-
ment, using the same salt diluted with normal saline solution, and
was preferred to the intramuscular method. Concentrated quinine
solution has a distinct effect on the heart and should not be used
without due care.

For the comatose cases, intensive intramuscular and intravenous
treatment was often the only method likely to save life, and up
to 80 or 100 grs. in twenty-four hours were given in doses of
20 grs. at a time.

The preventive treatment for malaria exercised us not a little,
and at a discussion on the subject held under the auspices of
the Salonika Medical Association, at which the writer had the
honour of making an introductory statement, there were several

Disease in Macedonia 223

absolutely diametrically opposed opinions expressed with regard
to the methods which should be adopted.

There were those who pled for a quinine parade for all troops
exposed to infection, the dosage being 5 or 6 grs. a day, or 10 grs.
twice a week, while others of much experience expressed them-
selves strongly with regard to the futility of such a measure.
The impression left on one's mind was that quinine did not act so
well if the soldier was even partially saturated with it, and that
it rendered treatment, when the disease did occur, much more
difficult.

An antimalarial mixture, the constituents of which were not
communicated to the soldiers, was administered to certain units
with the idea of finding out whether it helped as a preventive
measure, either for a first infection or recurrent attacks, but when
the writer left Salonika no statement had been made as to the
benefit obtained. It was an open secret that quinine formed the
staple ingredient of this secret remedy.

Needless to say, every one favoured all available methods for
destroying the mosquito breeding-grounds, and the use of mosquito
repellants, gloves, veils, mosquito nets, etc. Theoretically, a full
dose of quinine ought to kill the young parasites and so prevent
lodgment in spleen or bone-marrow, but it is hard to believe
that cases in which quinine failed to protect patients could be
explained by the soldier in question failing to swallow the quinine
ordered. Another argument against the quinine parade is, of
course, the enormous consumption and possible waste of the drug
which the parade necessitates, and if it is really wasted it renders
efficient treatment of the malarial patients difficult, should there
be any limitation to the amount of quinine available.

It is difficult to give statistics with regard to quinine amblyopia.
Considering the enormous quantities of quinine used in Macedonia,
and the large doses administered, it seems almost incredible that
at one of the largest eye centres for the Salonika army one saw
so few cases of blindness due to quinine. It is a fair assumption
that, just as in alcoholic neuritis there is some other agent than
alcohol responsible for the condition, so in quinine amblyopia
there must be another factor at work, although, of course, special
susceptibility to the drug may explain the extremely small
number of men who were afflicted.

One interesting prophylactic measure in cases of malaria was
the prevention of uninfected anopheline mosquitoes from getting
access to the malarial soldiers and so spreading the disease to

224 Robert A. Fleming

others. Our orders were to segregate all malarial patients in
certain wards and to have the patients in bed and under the
mosquito net at sundown. The joy of the cool evening, to which
everyone looked forward, rendered this order a most unpopular
one, and an evening visit to malarial wards usually caused an
unseemly scurry to coyer !

Sand-Fly Fever.

One of the very common, though less serious, fevers which we
had to treat was sand lly-fever. It came on in summer and
during the hottest weather.

The sand-fly or the phlebotomus papatasii is a minute mosquito-
like insect with a very hairy body, and about the size of a midge.
It had a curious spring resembling a Ilea, and which can be well
studied when one is writing or reading under a lamp in the open
air, as the fly often settles on the paper. The blood-sucker is the
female, and the parasite of the fever is an ultra-microscopic organism
not yet isolated. The sand-fly breeds in any old ruin or wooden
shed where there is a certain amount of moisture, and the difficulty
is to induce those who are exposed, to sleep under mosquito netting
fine enough to keep out the fly ; the ordinary mosquito repellant
will keep off the attack on face and hands, but the ankles require
protection by mosquito boots.

The fever has a sudden onset, sometimes with a rigor, and lasts
for only three days, the temperature falling the third day to
normal. Hence the term " three-day fever " often applied to it.
The chief characteristics of the attack are the " mad dog eyes,"
pain in the eyeballs and head, frequent sickness often leading to
vomiting, and a feeling of languor more correctly described as a
sequel. There is generally a leucopenia.

The great remedy is certainly opium, and 10 grs. of Dover's
powder with 10 grs. of aspirin form an admirable combination for
the relief of the condition.

Enteric Group.

We had a number of cases of typhoid and quite a number of
paratyphoid " A " and " B." As practically all our soldiers had
been inoculated with T.A.B. within the preceding one or two years,
the Widal reaction proved almost useless. By far the best method
was to obtain a blood culture, but this demands promptitude,
because a blood culture, to prove successful, must be taken with
a temperature of at least 102° F. and within ten days of the

Disease in Macedonia 225

onset of the fever. We noticed the rash in cases of paratyphoid
as a rule was much more diffuse and the spots much larger than
in true typhoid.

Many cases of the enteric group were remarkable for their
very atypical temperature charts. The " staircase " temperature,
with which one is familiar at home, was rarely seen in Macedonia,
but the most useful diagnostic points were, in the first place, the
slow pulse, in the second, the enlarged and tender spleen, and
lastly, the rash towards the end of the first week which was
almost always present.

Our chief difficulty was the dietetic one, because milk was
almost unobtainable except in the form of tinned milk, and the
patients had to be fed on beef-tea, chicken-tea, rabbit-tea, jellies,
and similar foods. One learned in the treatment of all our
patients to get on without a milk diet, except in cases of Bright's
disease, and certainly the results proved that the milk diet so
commonly used for a fever patient at home could be perfectly
satisfactorily superseded by beef-tea diet.

Among other diseases which we met with in small numbers
were dengue, relapsing fever, epidemic cerebro-spinal meningitis,
smallpox, and the ordinary infective fevers which one sees at
home. We had the usual periods of influenza, and plenty of
"myalgia" and disordered action of the heart. Of all troubles
to the M. 0. "myalgia" is one of the worst. It is a favourite
means of going sick. There is no outward evidence of a
muscular pain. Many patients, fed up with their particular
work, find their way into hospitals at home and abroad suffering
from this abominable "disease." That there are genuine cases
goes without saying. Perhaps one of the best methods of treat-
ing either a genuine case which has resisted other measures
or a case which is believed to be imaginary is to adopt a plan
stated to have been devised by the Chinese. It consists in
introducing acupuncture or any sterile needles into the specially
painful muscles. The pain produced by the treatment frequently
has a marvellous effect in abolishing "myalgia," and certainly
genuine cases not infrequently benefit when all other methods
have failed.

While I am alone responsible for this paper I have to acknow-
ledge much assistance in acquiring the data referred to in it.
Captain Fowler, Captain Carruthers, Major Mathewson, Major
Carmichael, and Captain Logan are a few of my colleagues to
whom I am indebted.

17

226 John A. Kynoch

PRIMARY CHORIONEPITHELIOMA OF THE OVARY.

By JOHN A. KYNOCH, M.B., F.R.C.S., Professor of Obstetrics
and Gynecology, St. Andrews University.

Primary ehorionepithelioma of the ovary is rare. Some authorities
consider the ovary to be by far the most unusual site for the extra-
uterine development of this form of malignant tumour. The first
published case is probably that reported by Kleinhans in 1902. In
this case the pelvic tumour was supposed to have had its origin in
a tubal or ovarian pregnancy, and although there was no positive
proof of either, the hsemorrhagic tumour histologically presented
all the signs of ehorionepithelioma. The patient died soon after
the operation, and at the post-mortem metastatic growths were
found in the vagina and lungs, the uterus and the appendages of
the opposite side being found normal. Our information on this
subject is derived chiefly from a paper published by Fairbairn
in the Journal of Obstetrics and Gynecology of the British Empire
for July 1909, where he describes a case coming under his own
observation, and also refers in detail to two very similar cases
described by Iwase which were observed in the Klinik of Professor
Doderlein in 1908.

In Fairbairn's case the patient was a married woman of
25 who had had three children and one miscarriage before
coming under observation. Her chief complaints were irregular
vaginal haemorrhages, abdominal pain, and sickness. On
examination a tender elastic swelling was found on the left side
of the lower abdomen, which, from its size, was regarded as a
probable ovarian cyst with twisted pedicle. At the operation
the tumour was found to be very adherent, as a result of which
it ruptured during removal. It was the size of a small cocoa-nut,
nodular on its surface, and covered with a thin white capsule
through which the dark blue-red colour of the tumour substance
could be seen. When cut into, there was found a deep red
coloured hsemorrhagic mass covered with a thin capsule (tunica
albuginea) of the ovary, suggesting from its appearance ectopic
gestation. Microscopically the tumour was found to be composed
chiefly of fibrin, blood-clot, and necrotic tissue. The typical
appearances of ehorionepithelioma were most marked under the
capsule and between the mass of blood-clot and fibrin. The
appendages on the opposite side were removed at the same time.

Kdinburgh Medical Journal, Vol. XXII. No. 4.

Fio. 1. — Chorionepithelioma from Primary in Ovary.

Fio. 2.- Ovum from the Wall of the Chorionepithelioma of the Ovary.

Edinburgh Medical Journal, Vol. XXII. No. 4.

Pig. 3. — Chorionepithelioma in Liver.

Primary Chorionepithelioma of the Ovary 227

The patient recovered, and showed no signs of recurrence when
the case was published two years after operation.

Iwase's cases were very similar to the above. They both
occurred in muciparous patients of the child-bearing period with
no history of having had a previous cystic mole. The tumours
removed had the same bluish-red colour, and microscopically the
usual characters of chorionepithelioma, most evident between a
well-marked capsule of ovarian tissue and a mass of blood-clot
and fibrin. In neither of the cases was there microscopic proof
of an immediately previous gestation or of teratomatous structures.
Kapid recurrence occurred in both cases, whereas in Fairbairn's
case the patient was alive when he published his report two. years
after operation. The following are the notes of my case : — M. S.,
age 24, nullipara, was admitted to the Gynecological Department
of the Dundee Koyal Infirmary on 26th April 1917. She com-
plained chiefly of severe pain in the left iliac region, with irregular
vaginal hsemorrhagic discharge of six weeks' duration. Men-
struation began at 13 — twenty-eight-day type, average duration
four days, and unassociated with any special discomfort. The
periods had been quite regular up till fourteen weeks before
admission, when there was eight weeks' amenorrhcea, followed by
the hsemorrhagic discharge, which was present for six weeks before
admission. On examination there was found hsemorrhagic dis-
charge, uterus slightly enlarged, appendages on the right side
normal, but through the left fornix there was felt a round tender
swelling about the size of a hen's egg, corresponding in position
to the left ovary. On 1st May coeliotomy was performed by
Pfannensteil's transverse suprapubic incision. The left ovary
was found enlarged, nodular on the surface, and of a dark purple
•appearance. It was of such soft consistence that it ruptured and
bled freely during the manipulation necessary for its removal.
The possibility of the condition being due to an ovarian pregnancy
was commented upon at the time of its removal, and the specimen
was promptly sent to the Pathological Department of University
College, Dundee. The Fallopian tubes on both sides appeared to
be unaffected. Convalescence was satisfactory, and the patient left
hospital three weeks after operation. On microscopic examination
Professor Sutherland reported that the ovarian tumour showed the
•characteristic appearances of chorionepithelioma.

The patient was readmitted to hospital one month after her
discharge, complaining of a swelling at the seat of the abdominal
incision. On examination the swelling was found to be about the

228 John A. Kynoch

size of a billiard ball, firm in consistence, slightly tender, and it
appeared to be situated in the abdominal wall. It was regarded
as being a hsematoma, a condition occasionally met with when the
abdomen is opened by a transverse incision. As it increased
rapidly in size and the patient's general condition did not improve,
an incision was made into the tumour, when it was found to be
firm in consistence and liver-like in appearance. Examination
per rectum now revealed a soft doughy tumour bulging into the
lumen of the bowel. The patient had several attacks of vomiting
and diarrhoea, she got progressively weaker, and died on 27th July,
three weeks after readmission. Professor Sutherland, who made
the post-mortem examination, reported as follows : — ■ A massive,
nodular, semi-fluctuant growth occupies the pelvic cavity as large
as a cocoa-nut, reddish-brown in colour, and markedly hemorrhagic.
It is adherent to the anterior abdominal wall, actually invading the
surrounding tissues in some parts. The uterus, elongated and
flattened over the tumour, is otherwise unaffected. The bladder
is free. The rectum is much narrowed by the bulging inwards
of the tumour. The mucous membrane is not directly involved,
and the tumour is mainly in front of and to the left side of the
uterus. The mesenteric glands are enlarged, two of them forming
prominent masses the size of chestnuts and invading the wall of
the intestine. The liver is enlarged, pale, and fatty, and on its
under surface there is found a tumour the size of a hazel-nut.
The kidneys, spleen, and stomach appear to be normal. The
lungs are non-adherent, but there is found on the anterior margin
of the left lung on its upper lobe one small tumour, and several
larger nodules are found on the posterior aspect of the right lung.
Heart normal. Microscopic examination of the secondary nodules
shows appearances resembling those of the primary growth of the
left ovary."

Professor Teacher kindly examined the primary and secondary
growths and reported that " The section of the primary growth is
clearly ovary with chorionepithelioma. One of the nodules from
the lung and one from the liver are typical secondary growths."

It is impossible to speak with certainty regarding the origin
of the chorionepitheliomatous elements found in the left ovary
in the case I have reported. With regard to the possibility of its
arising directly from a previous pregnancy, although there was a
clear, history of amenorrhcea, followed by irregular uterine hemor-
rhages and abdominal pains, too much reliance must not be placed
on clinical symptoms in the absence of microscopical evidence of

Primary Chorionepithelioma of the Ovary 229

pregnancy. As to its possible origin from a previous teratoma of
the ovary, none of the sections examined showed sarcomatous or
other unusual tissue elements. In reporting this case of chorion-
epithelioma of the ovary I desire to thank my colleague, Professor
Sutherland, for conducting the post-mortem examination, and
Professor Teacher for kindly examining the sections and providing
me with the accompanying photomicrographs.

230 David M. Greig

CONGENITAL (EDEMA.

By DAVID M. GREIG, CM., F.R.C.S.(Edin.).

About a year ago, through the courtesy of Professor Kynoch, I
was enabled to examine a male child 6 weeks of age, the subject
of congenital symmetrical oedema of the feet. He was born at
full time, a healthy, well-nourished, and (except in relation to his
feet) a well-formed infant. The youngest of three, neither of
the other children and neither parent presented any abnormality,
and there was no occurrence of a similar oedema known in any
relative.

The oedema, which was noticed at birth, was strikingly sym-
metrical. It formed on the dorsum of each foot a very prominent
swelling, more exaggerated and obvious to the lateral than to the
mesial aspect of the foot, and more pronounced towards the toes
than towards the ankle. This prominent mass appeared to over-
hang ^the fifth metatarsal and to bulge forward over the toes.
The toes themselves were involved in the oedema, giving them
the appearance of being fat and " podgy," while the transverse
grooves marking the metatarso-phalangeal and the interphalangeal
joints were deeper than usual. On the plantar aspect each foot
was full and slightly convex from side to side, and the transverse
lines were absent or less marked than normally. The skin over
the areas involved was smooth and had a distended appearance.
At its maximum the swelling on the dorsum would be fully an
inch in depth. The oedema did not pit easily on pressure, and
was peculiarly firm and resistant. It was not noticed that the
feet were less warm than natural, and there was no discoloration
nor dilatation of vessels. No enlarged lymphatic glands were
anywhere observable.

Congenital oedema is undoubtedly of rare occurrence. There
is not a large number of similar cases on record. All the more
need, then, to view the condition in its true perspective. Whether
it was first recognised in France or America is of little moment,
but there can be no doubt that to Milroy x is due the credit of
first bringing the existence of hereditary oedema clearly before
the profession. As a penalty it has been called by some writers
" Milroy 's Disease " — an unfortunate nomenclature which is objec-
tionable, in that it fails to convey to the mind any suggestion of
the nature of the affection, and in that it is probably more correctly
described as an abnormality than as a disease.

Congenital CEdema 231

Milroy's patient was an adult male presenting a bilateral
oedema of the feet and legs, and this had existed from birth.
Milroy was able to trace the existence of hereditary oedema
through six generations. The record involved ninety -seven
persons, of whom eighteen presented congenital oedema of one
limb, and four of both limbs. The other persons were either
normal or could not be traced. Milroy admits that the record is
incomplete, and that it is not possible to recognise the Mendelian
law in relation to the heredity, and he puts the characteristics of
the disorder succinctly thus : —

1. Congenital origin, with a steady growth corresponding to
the normal growth of the body until adult size is attained.

2. Limitation of the oedema to one or both lower extremities,
the areas involved varying.

3. Permanence of the oedema.

4. Entire absence of constitutional symptoms.

Milroy records the condition as one of angioneurotic oedema.
There is a difficulty in accepting this suggestion. I do not think
that hereditary congenital oedema fulfils the conditions generally
accepted as characteristic of angeioneurotic oedema. Angio-
neurotic oedema is an affection probably due to nerve influence
on blood-vessels. Hence its name. It is a more or less transient
temporary affection, though one can conceive how many attacks
may result in persistence of some of the swelling and its accom-
panying inconveniences. It indeed shows at times a tendency to
be hereditary, and that it may originate in the absorption of
intestinal toxins is probable in those cases in which gastro-
intestinal disturbance is pronounced. It appears to be an
entirely different condition from either congenital or hereditary
trophoedema.

To Milroy's paper a valuable addition was made by Hope and
French.2 In this paper the authors trace thirteen out of forty-
two persons who were affected with " persistent hereditary oedema
of the legs," the investigation involving five generations. The con-
dition was not, however, invariably congenital, and in one member
its appearance was delayed even till the age of twenty-one years.
A feature of the cases reported is that in a number of the patients
"acute attacks" occurred. These attacks were accompanied by
rigors, pyrexia, pain in the parts affected, and sometimes by
vomiting. The authors point out that these were not due to
sepsis, nor apparently primarily to micro-organisms, but are
ascribed to "vasomotor troubles." Hope and Trench write:

232 David M. Greig

" Upon the whole, therefore, although it cannot be called a satis-
factory explanation, we think with Milroy, Meige, and others
that the oedema in these cases is secondary, not to gross
structural changes in the blood-vessels or lymphatics, but to an
error in the function of these vessels, presumably, or at least
possibly, resulting from erroneous functions in the nerves supply-
ing them. In other words, we think the condition primarily
a 'vasomotor neurosis.'" They point out that there are three
well-known vasomotor neuroses, viz. Raynaud's disease, factitious
urticaria, and angeioneurotic oedema, and " it is to the last of these
that hereditary oedema may be considered to be allied." In Hope
and French '8 paper the " acute attacks " are acknowledged to be
very suggestive of " angeioneurotic attacks." Throughout the
families affected there was a distinctly neurotic strain. Hope
and French say : " Milroy lays stress on the oedema being present
at birth, Meige lays stress upon its appearing at puberty," while
with the cases dealt with in their paper the age at onset varied
considerably.

Bulloch7 gives a good rimmt, of "chronic hereditary troph-
cedema," though not adding any new case, and he gives a valuable
bibliography. The heredity is the point of view from which he
considers the condition.

Parkes Weber has recorded two cases which he classes as of
the same variety as those described by Milroy. In the first3
of these the patient was a female of 29 years, in whom the
enlargement had existed during two years, but there is neither
hereditary nor congenital factor present. In his second case,4
that of a woman of 20 years, though the swelling of the fingers
had existed "as long as she could remember," the blueness
justified Weber in considering it an "acrocyanosis."

It seems illogical to classify such cases as Weber's with those of
Hope and French, or of Milroy, or of Meige. To do so because the
etiology is obscure and the pathology not obvious is to mass under
one name a concatenation of dissimilarities which had better be
kept separate. Of the " three well-known vasomotor neuroses,"
Raynaud's disease is a progressive peripheral disturbance affecting
hands as well as feet, while in factitious urticaria there is evidence
of a general toxaemia, and again in angeioneurotic oedema there
is the periodicity of attacks. These all seem different from true
congenital oedema. It may be incorrect to link Hope and French's
cases with Milroy's or with Meige's. Though they are each
varieties of trophoadema the pathology may be distinct. In the

Congenital CEdema 233

former the striking features are the " progressive oedema " and the
" acute attacks," with subsequent aggravation of the oedema, while
in Milroy's cases the main features were the congenital nature
of the affection and the maintenance of its size proportionally to
the body-growth.

Isolated cases of congenital oedema, such as I have described,
may even form a third condition, or it may be the first instance
of what is to become later an hereditary defect. Its characters
and its progress suggest some local symmetrical congenital defect in
the lymphatics rather than a vascular affection, whether neurotic or
otherwise in origin. The condition is distinct from that inequality
of limbs not unfrequently found in new-born infants, in which
one limb or part of it appears unduly fat and the grooves at the
joints are deeper than usual, for in this condition there is no
oedema and the parts are normal to touch and not firm. The
condition is distinct from unilateral hypertrophy,5 in which the
determining factor of the overgrowth is very probably a central
nervous affection, secondarily involving alterations of blood-
vessels in growing foetal tissue. Finally, the condition is also
distinct from progressive subcutaneous oedema,6 in which there
is probably an ascending lymphangitis and perilymphangitis,
bringing about lymphatic obstruction, and characterised by its
late onset and its steady progression.

Not enough cases have yet been gathered and investigated
to place congenital trophcedema on a proper basis, and until a
sufficient number has been placed on record the pathology of the
condition is bound to remain obscure.

References. — J Milroy, W. F., " An Undescribed Variety of Hereditary
CEdema," New York Med. Journ., New York, 1892, vol. lv. p. 505. 2 Hope,
W. B., and French, H., "Persistent Hereditary (Edema of the Legs with
Acute Exacerbations," Quart. Journ. of Medicine, London, 1907-08, vol. i.
p. 312. 3 "Weber, F. Parkes, "A Case of Chronic CEdema of the Right
Lower Extremity," Trans. Med. Soc. Lond., London, 1912, vol. xxxv. p. 370.
4 Ibid., " Chronic Swelling of the Fingers," Proc. Boy. Soc. Med., London, 1909,
vol. ii., Clin. Sect., p. 126. 6 Greig, D. M., " Unilateral Hypertrophy," Edin.
Hosp. Reports, Edinburgh, 1898, vol. v. 6 Ibid., " A Case of Progressive Sub-
cutaneous CEdema," Edin. Med. Journ., September 1916. 7 Bulloch, W.,
■"Chronic Hereditary Trophedema," Treasury of Human Inheritance, London,
1909, part 2, p. 32.

234 Diets in Edinburgh Royal Infirmary in 1843

DIETS IN USE IN THE EDINBURGH ROYAL
INFIRMARY IN 1843.

Three-quarters of a century is a remote enough period of the
life of such an institution as a hospital to give historic interest to
the practices of that date. In 1843 the Managers of the Edin-
burgh Royal Infirmary approved a report on the diets of the
Infirmary, and a copy of this report has recently come into our
hands. The diets in use at the time were four — a low diet, a
common diet, a full diet, and an extra diet, each one with the
possible variation of bread being interchangeable with porridge,
making eight in all. Though the details of these are not given
in the report, their cost is; it varies from 1*81 pence for the
low diet with porridge to 6*04 pence for the extra diet with bread.
From the context of the report it would seem that the reason for
revising the diet schedules was the growing practice of ordering
" extras," for the committee were " satisfied that the dietetic treat-
ment of a very large proportion of the multifarious cases of
disease in the Infirmary may be appropriately regulated, without
the necessity of prescribing any extra articles of food, as is too
generally practised at present, for great pains have been taken to
supply, in the different rates, combinations of articles in such variety
as to suit every ordinarily supposable case." Nine new diets were
arranged : (1) low diet, (2) rice diet, (3) steak diet, (4) steak diet
with bread, (5) common diet, (6) common diet with bread, (7) full
diet, (8) full diet with bread, (9) extra diet. In Nos. (4), (6), and
(8), 6 ozs. of bread was substituted for each pound of potatoes, with
a slight increase (60 calories) in the nutritive value of the ration.
The two principal diets were composed thus : —

Table I.

(5) Common Diet.

(7) Pull Diet-

Breakfast

Bread, 6 ozs.

( Coffee, \ oz.
Coffee, \ pt. \ Milk, 2 ozs.

{ Sugar, \ oz.

Porridge, \\ pt. (4 J

ozs. oatmeal).
Buttermilk, 1 pt.

Dinner .

Potatoes, 1 lb.

f Barley, 1 oz.
Broth, 1 pt.j Vegetables, \ oz.

1 Meat, 2 ozs.

Boiled meat, 6 ozs.
Potatoes, 1 lb.
Bread, 3 ozs.
Broth, 1 pt.

Supper .

Bread, 6 ozs.

(Tea, Joz.
Tea, \ pt.K Milk, 1 oz.

1 Sugar, \ oz.

Potatoes, 1 lb.
Milk, 10 ozs.

Diets in Edinburgh Royal Infirmary in 1843 235

In the report the food values are expressed in terms of " solid
animal nutriment " and " solid vegetable nutriment." The details
given are sufficient to admit of their reduction to modern food
values, as in Table II.

Table II.

Breakfast.

Dinner.

Supper.

III

a'O e.

L. bo
* 1

Si

i

8

i

8
1020

Low Diet

Bread, 3 ozs.
Tea, \ pt.

Panado
(Bread, 3 ozs.
Milk, 2 ozs.
Sugar, \ oz.)

Bread, 3 ozs.
Tea, \ pt.

2-57

205

31

4

Rice Diet

Bread, 3 ozs.
Coffee, -§ pt.
One egg.

Beef tea, -| pt.
Rice pudding.

Do.

4-71

202

35

84

145

1092

Steak Diet

Bread, 6 ozs.
Coffee, \ pt.

Potatoes, 1 lb.
Steak, i lb.
Broth, 1 pt.

Bread, 6 ozs.
Tea, \ pt.

4-51

369

21

2146

Common

, Diet

Do.

Potatoes, 1 lb.
Broth, 1 pt.

Do.

3-51

369

60

9-6 1946

|

Full Diet

Porridge, \\ pt.
Buttermilk, 1 pt.

Meat, 6 ozs.
Potatoes, 1 lb.
Bread, 3 ozs.
Broth, 1 pt.

Potatoes, 1 lb.
Milk, -| pt.

3-31

403

110

42 2676

1

Extra Diet

Porridge, 2 pts.
Buttermilk, 1 pt.

Meat, \ lb.
Potatoes, l^lb.
Bread, 3 ozs.
Broth, 1 pt.

Potatoes, 141b. A.n~
Milk^pt. 4U'

488

142

56

3296

that
cont.
relat
more

tary
diffe
mate
prot

fos. (1), (2), an<
might be made
lin — 4 ozs., 5| c
ive prices of tea
s of the latter w
fo. (7) and No.
lives, and it w
rent foodstuffs is
s to the 300C
3in: fat of an £

1 (3) are in\
on these is

zs., and 3 ozs
and milk a

as not used.

^9) are quite

ill be noted

good, espeeiE

calories ai

tverage diet.

alid diets,
the small an
. respectively
t the time, il

adequate for

that the b*

illy in (9), wr

id 500:125

The<
aount

r. Cc

is rei

men
ilance
lich cl
:50—

jhief
of n
mside
iiarki

leadii

bet\

osely

carbc

comn
lilk t
jring
ible 1

lg sec
veen
appr
hydr

ient
hey
the
:hat

len-
the
Dxi-
ite:

236 Diets in Edinburgh Royal Infirmary in 184J

The common diet, (5), is, however, peculiar. It is one of the
two named as " principal diets " and is inadequate, especially in
fats. It is also a relatively expensive diet, being more costly than
(7), the reason being that it includes bread, tea and coffee for
breakfast and supper, instead of the cheaper and more nutritive
porridge, potatoes, and milk.

The following paragraph of the report, giving contract prices
for foods, may be quoted. The comparison with present-day
cost of living is striking: —

" Oatmeal, 28s. the sack of 280 lbs. ; bread, 6d. the loaf of 64
ozs. ; new milk, 8|d. the imperial gallon; buttermilk, 12s. 6d. for
100 Scotch pints of 64 ozs. each; barley, 13s. the cwt. ; meat, 4d. a
lb. 'overhead'; greens, 9d. the stone; leeks, 2d. the lb.; salt, 8d.
for 21 lbs. Tea is taken at 4s. 6d. a lb. ; coffee (burnt) at Is. 8d. ;
rice; at 3d.; eggs at 8d. (new laid) and at 5d. the dozen when
preserved from summer in lime water. It is probable that some
of these articles may be had at a cheaper rate."

The Doctors in some Modem French Novels 237

THE DOCTORS IN SOME MODERN FRENCH NOVELS.

By J. BARFIELD ADAMS, L.R.C.P., L.R.C.S., Member of the
Medico-Psychological Association.

Comparatively few novels have been published in France during
the war. With one exception all those referred to in this paper
appeared in 1913 or in the first six months of 1914. The excep-
tion is Monsieur Pierre, the last work from the pen of the late
Lieutenant-Colonel Patrice Mahon. The gallant officer commanded
the artillery of the 71st Division, and was killed in action, 22nd
August, on the Col de Sainte-Marie-aux-Mines in Alsace. The
novel made its posthumous appearance late in 1916.

Lieutenant- Colonel Mahon was a thinker, a philosopher. He
had travelled much, particularly in Russia. He was a distin-
guished and facile writer on military subjects, but occasionally,
and to the no small delight of general readers, for he had an
agreeable style and great powers of description, he sought relaxa-
tion in pure fiction, which he wrote under the pseudonym of
Art Roe.

Monsieur Pierre is a story of the days of the Franco-Prussian
war of 1870. The first scenes are laid in the hill country of the
Jura, and the drama opens in the old chateau of the family of
De Persanges. There is no suspicion of the coming war. Subtle
brains in far-away Berlin may be weaving schemes of conquest.
In Paris some, wiser than their fellows, may have an inkling of
future trouble. But here in the ancient province of Franche-
Comte things are so peaceful that the youthful follies of a student
are enough to cause worry and disturbance.

Pierre de Persanges, the only son of the house, a young man
of nineteen years of age, has been studying at a Jesuit College
in order to prepare himself for entering the Ecole Polytechnique,
He is a brilliant student, being particularly clever in mathematics.
Probably, like many youths of his age, he suffers a little from
a swelled head. He develops philosophical ideas not at all in
accordance with the notions of the good fathers. They do not
know in the least what to do with a young fanatic who is only
occupied in propagating a revolution in their educational estab-
lishment. In their despair they send the young man home to
his mother, to whom they write a letter in which they inform
her that Pierre is suffering from insomnia, want of appetite, and
certain hysterical symptoms — all of which are true. Naturally,

238 y. Barfield Adams

the writers' abhorrence of their pupil's socialistic and almost
atheistical ideas finds expression in the epistle, but it is cleverly
veiled by sentiments of admiration for his remarkable mental
gifts.

An intensely religious woman, Madame de Persanges is
grieved by certain passages in the letter, but she is a mother,
and for the moment she is more alarmed by the account of her
son's health than by anything else. The morning after Pierre
arrived at the chateau the family doctor — he is a friend as well
as a physician — is called in. He is a little man with a rosy face,
fair hair, and short side whiskers. He has a private interview
with Madame de Persanges, who acquaints him with the contents
of the Jesuit fathers' letter.

Then the patient enters. The scene that follows is homely
and commonplace enough, but the author's skill has invested it
with a singular charm.

The doctor has known Pierre from a child. He treats him
affectionately, familiarly. It does not look as though there were
much the matter with the young man, but the physician leaves
nothing to chance. He examines the case thoroughly, going
through the usual routine of palpation, percussion, and
auscultation.

"Nothing, nothing," he remarks, as he carries out his
researches. "I find nothing wrong here. The heart beats a
little quickly, it is true. The tongue is clean. The teeth are
healthy."

The worthy doctor knows his work. He resumes his seat,
and for a moment or two regards the patient in silence. Possibly
the letter from the college authorities has raised suspicions in his
mind that the immorality which haunts even the best schools lay
at the root of the trouble. Adroitly he satisfies himself that that
is not the case.

The physician is content with the results of his examination.

"Too much mental work," he says to himself, "too little
physical exercise, wild, tout ! "

" Yes," he remarks aloud, " I am certainly of the opinion that
it would be wise to interrupt the preparation for the Ecolc
Poli/technique."

Then he sketches out the treatment. Pierre is to take plenty
of exercise in the open air, to have abundance of substantial
nourishment, and if he wishes to continue his mathematical
studies — well, he can do so in reason.

The Doctors in some Modem French Novels 239

The scenes change rapidly. The war has broken out. The
tragedy of Sedan has taken place. Bazaine has played the
traitor at Metz. France lies bleeding and exhausted beneath
the brutal heel of the invader. Aux amies! La Patrie est en
danger! Pierre has enlisted as a volunteer in a regiment of
Lancers. He is now in the army of the Loire — the army on
which so much depended, which was within an ace of relieving
Paris, which might have changed the whole history of the last
forty-eight years, which might, perhaps, have prevented the awful
desolation and slaughter of the present war. Oh ! if a Clemenceau
had only been at Tours and a Foch at Orleans in the winter
of 1870!

It is one of the last battles in the OrManais. Cavalry,
artillery, infantry, francs-tireurs, and half-armed peasants in the
confusion of retreat are hopelessly mixed up. The Bavarians,
the Prussians, are advancing always. Pierre's horse is killed
under him, and he himself is wounded in the side. He is lying
helpless on the ground. The guns, retreating at a gallop, come
thundering down the road, and the wheels of more than one of
them pass over and crush the wounded man's right leg.

Denis Stanislas, a camp follower, a man who had received
some kindness from Pierre, and who had acted as his servant,
found the young soldier lying half-unconscious in the mud and
snow. It was impossible to leave him there to die. Stanislas
searched for some means of conveying the wounded man to the
nearest ambulance. He found a wheel-barrow.

A cry of agony escaped from Pierre's lips when the servant
tried to raise him from the ground.

" Leave me alone ! " he exclaimed. " Do not touch me. It is
useless. I am dying."

Undeterred by cries and protestations, Stanislas lifted the
sufferer on to the barrow, and bound the injured limb to one of
the long handles of the vehicle.

" It is for your good," he said. " Don't be afraid. They will
cure you."

It was a long and weary journey to the nearest place where
surgical assistance could be obtained. Once they had to pass a
Prussian outpost. The moon inopportunely broke through the
clouds at the moment. Pierre had swooned away, and Stanislas
told the soldiers that he was taking a dead body from the battle-
field to bury it. He was allowed to pass.

It was bitterly cold. Presently it began to snow. Stanislas

240 y. Barfield Adams

struggled on, and at last, when morning was breaking, he arrived
at Neuville, where help was to be found. The camp follower
wheeled the barrow into the quadrangle of the convent, which
had been turned into a hospital. He unfastened the broken leg,
and lifted the unconscious body, stiff and half frozen, and laid it
carefully on the ground, on which he had previously spread the
soldier's cloak.

A surgeon chanced to come to one of the doors. His hands
were red with blood, for he had been at work all night, and he
stooped to wash them in the snow.

"Monsieur le major, if you please," said Stanislas, "this is
urgent."

" What is it, then ? " demanded the doctor, continuing to rub
his hands and arms with the snow.

A sister of mercy at that moment came to the door, and
followed the surgeon into the middle of the court.

"It was yesterday that this misfortune happened," began
Stanislas.

But the doctor did not listen to him. He knew too well what
the story would be. He raised the twisted foot, which was
plastered with congealed blood. He put it down, surprised that
the wounded man had not groaned. For a moment he considered
the drawn, cadaverous face.

" His affair is well arranged," he remarked.

The sister of mercy approached, knelt down, and put her hand
on the forehead of the sufferer. The doctor tried to feel the
pulse; he could feel nothing. Perhaps it was because his own
fingers were wet and numbed with cold. He rubbed his hands
on his blouse to warm them. The sister took the other wrist of
the wounded man. She could feel no pulsation.

" There is no pulse, is there, ma sceur ? " asked the surgeon.

" None at all," was the reply.

The doctor opened the soldier's tunic in order to listen to the
heart. He saw that the shirt, soaked with blood, was glued to
the body. He did not search further. He made a gesture with
his hands which signified that all was explained.

" Is he going to die ? " asked Stanislas, plaintively.

"Where shall we put him ?" inquired the sister of mercy.

Before he replied the doctor put his spectacles on his nose
and took a last look at the sufferer. He would have liked to
have done something for him if it had been possible, and he
turned away with regret.

The Doctors in some Modern French Novels 241

" Put him where you will, ma scaur? he said. " He is lost."

Fortunately for Pierre, Stanislas, the rough but faithful camp
follower, would not accept the doctor's verdict. No doubt the
man's devotion touched the hearts of the good sisters. A bed
was found for the wounded soldier, and every means was adopted
to restore warmth to his body. When it was possible, stimulants
were administered, and in the end Pierre was brought back to
consciousness. But it was the consciousness of suffering. It was
necessary to amputate the right foot. There was much fever and
delirium, and the long and weary convalescence was marked by
constantly recurring delusions.

Among the closing scenes of the novel there is one beautiful
and tender episode — that of the meeting of the mutilated hero
with his sweetheart. The author tells the little story in few and
simple words. It would have been a pathetic picture had not the
pathos been swallowed up in the girl's deep love.

Gaston Eageot's novel, La voix qui s'est tue, appeared in
1913. It is a relief to read the book. There is nothing in it of
the deafening din and horror of war which have distracted our
minds during the last four years.

In working out the plot of his story the author has made
considerable use of the supposed influence of maternal impressions
during pregnancy on the future mental and physical development
of the child. It may be doubted whether anyone sceptical of the
theory would be convinced by the novel. Mere heredity would
probably explain everything. But the book is well worth reading,
for in it we are presented with a clever psychological and physio-
logical study of a slightly neurotic young woman in her first
pregnancy and, later, of a delicate and precocious child.

Madame Favelin, the heroine, receives a severe mental shock
within a few hours of her becoming conscious that she was
enceinte. Her jealousy was aroused ; her amour-propre was
wounded. If she had gone into a downright passion and
demanded an explanation, things might have been put straight
in a quarter of an hour, though, no doubt, it would have been
a bad quarter of an hour for everybody. But Madame Favelin
was not the sort of person to take that course. She was an
amiable, gentle girl, who inherited from her mother the habit of
keeping things to herself. She concealed her . real trouble, and
the agitation and nervous distress, which she could not altogether
suppress, were put down to natural causes.

The husband, however, was not quite satisfied with his wife's

18

242 ./. Barfield Adams

condition. He called in Dr. Leroudin, an old schoolfellow of his,
who was now on the staff of La MatemiU. The doctor's natural
jovial disposition was obscured by professional solemnity. This
solemnity, the author suggests, was increased by his speciality
bringing him constantly in contact " with beings troubled by
mysterious hopes or ill-determined fears ! " He also observes
that, as the majority of young husbands are not remarkable for
sangfroid, the physician found it useful to adopt a tone of
authority in speaking to them.

Leroudin visits the patient. He readily admits that she is
correct in her expectation of becoming a mother, and he simply
recommends that in the state of lassitude in which she finds
herself she should not commit any imprudence.

With a weary gesture Madame Favelin signifies that she has
no desire to do anything unwise.

The husband and the doctor return to the antechamber.

" You don't find anything unusual ? " asks Monsieur Favelin.

"Unusual ! No," replies Leroudin. "At least, not to-day."

Then he assumes more than ever his professional solemnity,
and begins to discuss the case with the objectivity of a savant.

" We find ourselves," he remarks, " in the presence of a young
woman extremely nervous, impressionable, and easily agitated.
In her present condition there is the risk of exaggerating these
dispositions."

"Her health has always been excellent," observes Monsieur
Favelin.

"That has nothing to do with it," says the doctor. "The
healthiest women are sometimes the most impatient of the trials
of pregnancy. In short, let us exaggerate nothing, and particu-
larly, mon ami, try not to be more nervous than your wife. With
prudence, calmness, and moral repose, there is nothing for the
present to make us uneasy."

As the pregnancy progressed one could not see that there was
anything in the patient's physical condition to worry about. The
symptoms were usual enough. But from a psychical point of
view it was otherwise. There was evident mental disturbance,
anxiety, mild depression, and a close observer might have
remarked coldness towards the husband.

Taking' it all round, Dr. Leroudin did not like the case, and
when the patient expressed a wish to pass some weeks in her
native air, he readily gave his consent.

Madame Favelin's home was some miles from Puy, in the

The Doctors in some Modern French Novels 243

heart of the mountains of the Cevennes, and almost under the
shadow of the huge volcanic mass, Gerbier-de-jonc, the rugged
cradle of the mighty Loire. Her father, a nouveau riche, had
poured out wealth without stint in order to soften with the
comforts of modern civilisation the asperities of a picturesque old
chateau. But the purity of the mountain air, the grandeur of
the scenery, and all the love and comfort with which she was
surrounded failed to produce any improvement in the patient's
mental condition. She brooded over her secret trouble night and
day, and made herself utterly miserable.

The husband became more alarmed than ever. On one of his
periodical visits to his wife he brought Leroudin with him.
The doctor was not at all pleased with the patient.
" The country," he said, " has not produced the benefit that we
expected."

"Without diagnosing anything precise or clearly abnormal, he
observed a general state of which his obstetric science could not
discover the cause, but which, as it was growing worse, threatened
to compromise not only the pregnancy but the young woman's
health.

He ordered the patient back to Paris. He deemed it absolutely
necessary to have her under his own eye.

But the poor woman brought her heartache back with her to
the city, and she continued to brood over it until she arrived at
such a pitch of misery that she looked forward to her accouche-
ment with pleasure and even with longing, because she felt certain
she should die.

The hour arrived.

After a night of suffering, Leroudin was sent for at the hour
•of dawn — " the hour of dawn, livid with insomnias, with love and
with death."

Madame Favelin refused chloroform. Still obsessed with the
idea of imminent death, she did not wish to die without conscious-
ness and will. There were hours of pain. Then there was a
moment of supreme agony, and the next the sufferer experienced
& wonderful sensation of well-being throughout her whole body.
She heard a child's cry.
" Un beau yargon ! " announced Dr. Leroudin.
The patient raised her head and extended her arms.
" Show him to me," she murmured feebly.
Madame Favelin made a good recovery. Her mental condition
improved, but the trouble, over which she had so long brooded,

244 y. Barfield Adams

though it was pushed by other interests out of the centre of the
field of consciousness, was not forgotten. It shadowed the whole
of the woman's future life.

However, now the story widens, and the child becomes of
importance.

He was nursed by his mother, and during lactation he thrived ;
but he did not do so well after he was weaned. He did not get
on with his food, he slept badly, grew very thin, and exhibited
certain symptoms which old nurses describe as "inward con-
vulsions." He was precocious. He spoke soon, and ran alone
very early. He was very restless, was always on the move, and
was unnaturally proficient in speech.

One easily understands how such a woman as Madame Favelin
would worry about her child. Dr. Leroudin, who understood
better how to bring infants into the world than how to rear them,,
declined the responsibility of treating the case. After many
specialists in children's diseases had been called in without much
benefit, Leroudin advised that a certain doctor, an old fellow-
student of his, should be consulted.

The new physician, Dr. Dennet, was one of those practitioners
who make their appearance more commonly in fiction than in
actual life, though they are occasionally to be met with on the
fringes of the profession. They endeavour to foist themselves
upon the public as geniuses. The majority of them are mere
quacks, but a few are honest men, who, without having the ability
to strike out new and sound ways for themselves, are too proud
to walk in the beaten track.

When such a person is introduced into a novel he is always
described as being a man of extraordinary talent, but his
instability mars the picture. Genius is remarkable for patience
and bulldog persistency of purpose. Our author, no doubt, felt
the difficulty. He intended to delineate a genius, but failed.
Consequently, although Dr. Dennet is one of the most important
secondary characters in the tale, his figure is feeble and all out
of drawing.

Even Dr. Leroudin does not seem to have thought very highly
of his old fellow-student, though perhaps the way in which he
brings his name before Madame Favelin is only the veiled
depreciation with which we sometimes speak of our best
friends.

" No career," he says, " has been more singular than Dennet's.
He has worked at all the sciences. He is psychologist, philosopher

The Doctors in some Modern French Novels 245

— anything you like. I did not propose him before because he
passes for being something of an original."

Madame Favelin hesitated to consult this new physician. She
had seen so many of these soi-disant specialists, who give a
different opinion when they are seen apart, and an identical one
when they meet in consultation.

Finally she decided.

• Let us see your friend," she said to Leroudin.

Whatever may have been Dr. Dennet's professional ability,
he had two great gifts. He was sympathetic, and he knew how
to gain the confidence of the patient and the patient's friends.
It is bad for the public when clever surgeons and physicians are
lacking in these virtues, but it is infinitely worse when ignorant
men are endowed with them.

In describing Dr. Dennet's first visit to the child there is
something pitiful, though amusing, in the picture that our author
draws of a little patient who has become accustomed to the
"ceremonies, almost sacramental, of medical examinations," and
who knows all the movements and the rites. He submits readily
to auscultation and percussion. When asked to do so, he coughs,
sneezes, and points with his finger to the spot where he feels or
has felt pain. Sometimes he laughs. He says he is tickled.
And all the time he observes the doctor with an air, comical,
mischievous. In reading the passage one is reminded of the scene
in Daudet's Les Rois en Exil, in which the poor little Prince Zara
finds himself in Dr. Bouchereau's consulting-room. But the
pathos of Daudet's picture is infinitely greater.

Of course the child's good humour pleases the mother, and she
begins to have faith in the new physician.

Dr. Dennet's visits are repeated. He comes to the conclusion
that the little patient is suffering from a nervous condition of the
liver. Whether he is right or wrong is no business of ours, but
his prescriptions and dietaries — and they are endless— do not do
much good. Finally, he makes up his" mind that the child is
neurotic. He looks around for the possible causes of such a
condition.

" During your pregnancy," he asks Madame Favelin, " did you
experience any excessive emotion — a fright, an agony, a chagrin ?"

At first Madame hesitates, but, being convinced that it is for
the good of the child, she admits having undergone a great mental
strain during the period in question. Naturally, she does not go
into details.

246 J. Barfield Adams

Although Dr. Dennet in his diagnosis had now got very close
to the mark, in his treatment he was as unsuccessful as before.
At last he took a step which most of us take when we do not
know what else to do with a patient. He advised change of air.

This proved the boy's salvation. He was brought up in
his mother's native air among the mountains of the Cevennes.
Although he was never robust, he was well and moderately strong
when he attained the age of manhood. He was clever — clever
with the showy, unsubstantial cleverness that one meets with
among the neurotic.

In considering the novel as a whole, one might be inclined
to say that it is a case of much ado about nothing. But, after
all, does not half the trouble in the world arise from a faulty
perspective, from a failure to appreciate the exact proportion of
things ? Are we not always mistaking molehills for mountains ?

In studying a man, in addition to his individuality, which is
often a comparatively minute portion of himself, we have to take
into consideration his ancestry, to think of his nationality, to
allow for errors of education, and for the influence exercised
upon him by his trade, profession, or calling. Finally, if he be
a. middle-aged or elderly man, we find that his corners are a
good deal rubbed down — sometimes even polished — by contact
with his fellow-men. It is in this rubbing-down process that his
individuality, however small it may be, is of importance — a hard
stone at the bottom of a brook is not so much worn as a soft one.

All these points of human natural history can be studied in
the case of Dr. Fumat, to whom Paul Bourget introduces us in
his excellent novel, Le Ddmon tie Midi. Look at the doctor ! He
is a broad-shouldered, massively built man with the brachy-
cephalic skull of a typical Auvergnat. He has the ruddy, highly
coloured face of one who lives much in the open air, and who
feeds well. His hair is already grizzled. He is probably nearer
fifty than forty years old, for we are told that he took his doctor's
degree in 1892, and the story opens in 1912. His profession
colours his thought and speech. His ancestors were peasants.
Indeed, he is not removed by more than one or two generations
from that class. His corners, of course, have been rubbed down
a trifle, but the grain of his individuality is too hard and rough
to take much polish. Although he has learned that it is well
to be all things to all men, his ill-nature and envious disposition
reveal themselves constantly.

Dr. Fuinat practised at Kochefort-Montagne, a town in the

The Doctors in some Modern French Novels 247

arrondissement of Clermont-Ferrand, in the departement of Puy-de-
Dome. There are beautiful descriptions of scenery in the novel.
"We are shown the country in early winter, when the mists make
the distances mysterious in the morning, when the delicate colours
of the sunset die among the mountains in the afternoon. The
dark and lonely lakes among the primaeval rocks are half frozen
over. Here, the snow lies lightly on the ground ; there, it drops
with a rustling sound from the bare branches of the oaks and
from the needles of the pine trees and the firs.

Eochefort is a small place of about 1400 inhabitants, and
naturally the doctor had to seek his patients as much in the sur-
rounding country as in the town itself. Those who know some-
thing of the Auvergne can imagine what sort of a neighbourhood
it was in which to practise.

No doubt, when Fumat commenced work, he made his rounds
in the saddle or perhaps in a hooded gig. To-day he travels the
steep and dangerous roads in a two-seated, second-hand motor
car, which is generally filthy dirty with the mud picked up in
the day's journey, and rattles along with the noise of a bundle
of rusty old iron. Still, the machine was a good hill-climber.
Once, when the doctor had been looking, not without secret envy,,
at the sumptuous automobile of one of his wealthy patients — there
are wealthy patients to be found even in the neighbourhood of
Rochefort-Montagne — he exclaimed, speaking of his own car :
" Ce vieux clou fait tout de mime du vingt-cinq a I'heure en
montagne."

There is no doubt that Fumat knew his work. From a profes-
sional point of view he was a good man. His patients trusted him
implicitly — even Monsieur Calvieres, the wealthiest among them,
although, in his moments of ill-temper, he applied the epithets
of bonesetter and quack to the doctor, had perfect confidence in
his skill.

Dr. Fumat had the trick of employing medical terms in general
conversation. Most of us have had the misfortune of meeting
such men, who not only practise medicine, but speak it. It is
a disagreeable form of pedantry, to say the least of it, and more
often reveals ignorance than knowledge. Dr. Fumat, for example,
talks about one of his lady patients suffering from " the classical
form of vertigo, a stomacho loeso, of Trouseau." This may have
been all very well, spoken in private to the lady herself or to her
husband, but it seems out of place before strangers. And surely
it was unnecessary, a little later, in conversation with a chance

248 J. Barfield Adams

acquaintance, to go into particulars about the condition of the
patient's heart and other internal organs.

But Fumat was not only indiscreet — he was ill-natured. He
was not above telling disagreeable stories about his patients. He
gossiped about family troubles, and often hinted at the reason why
the household machine functioned badly. On one occasion he
related a little story which was nothing better than a piece of
calumny. Then, when his dark brown eyes saw that he had gone
too far, he excused himself, falling back into his beloved medical
phraseology by saying that the good wine he had been drinking
had made his third left convolution too active.

One easily understands that the doctor was a politician. But
his politics never ran counter to his interests, and when the
wealthy Monsieur Calvieres changed his political views, those of
his medical attendant veered round on the same tack. When we
last see Dr. Fumat, he is seated at an electoral banquet, where he
is doing full justice to both his gustatory and oratorical talents.

Fumat is one of the secondary characters in the novel. He is
merely one of the crowd. Perhaps that is the reason why he is
so lifelike. In many of the best works of fiction the hero and the
heroine are so finely dissected that, although they are intensely
human, they lose something of humanity. In Le Dimon de Midi
Paul Bourget has made a remarkable psychological study of the
hero, Savignan. It is a wonderful piece of work. Every power
of the author's mind was bent to the task. But the details are
so minute that one loses grasp of the ensemble. In the secondary
characters it is otherwise. In drawing them, Bourget's genius
seems to have acted almost unconsciously, without effort, and the
result is that they catch the eye at a glance.

This remark applies especially to another doctor who appears in
the same drama, and whose silhouette is thrown only for a momeut
on the screen. This is Dr. Freundberg. His name gives him
away. He is a German, and, in spite of his degree, he is a quack.
There are plenty of qualified quacks in Germany, even in pro-
fessorial chairs, and before the war they penetrated peacefully
all over the world. They had the trick in those days of deceiving
the elect themselves. No wonder they deceived the laity.

Freundberg is a stout man with a serious, stolid face. He
looks over the brim of his spectacles with an air of immense
wisdom — an air which is accentuated by his huge, bald cranium.
His speech is slow and solemn, and he speaks French with an
atrocious accent. He is a professor of myotherapy — that is to say,

The Doctors in some Modern French Novels 249

he professes to cure every disease under the sun by muscular
exercise.

The patient, whom we are privileged to see undergoing a
course of myotherapeutic treatment, is as interesting as the
physician. He is an elderly man — a millionaire, who has made
his money in trade. Believing himself to be an intellectual of
the first order, he has nothing but contempt for all that is old-
fashioned. He is afflicted with modernism in its most virulent
form. Everything that he takes up — politics, medicine, piety —
is of the most recent pattern, and he prattles the newest physiology
and pathology as he prattles syndicalism and the jargon of the
latest travesty of religion. It is singular how quackery appeals
to vanity and imperfect education. It is always among the
"intellectuals" that the quack, be he homeopath, bonesetter, or
Christian scientist, seeks and finds his richest prey.

Paul Bourget draws a striking picture of this elderly millionaire,
attired in a khaki-coloured gymnasium costume of the newest
fashion, gravely, conscientiously carrying out the various exercises
under the surveillance of the German professor.

"More slowly. Eespire deeply," commands the latter in a
guttural voice. " Good. Don't bend the legs. Now, circular flexion
of the arms. Legs wide apart. Touch alternatively each foot with
the opposite hand. The other arm to be extended backwards."

When the story is drawing to a close, and the tragic threads
are gathered together and knotted into the catastrophe, medical
men again appear upon the scene.

Dr. Magdelin, ancien externe des hopitaux, as he described
himself on his door-plate, was a very young practitioner. He
had recently established himself in a not very fashionable quarter
of Paris, and he spent a good deal of his time in waiting for
patients. One Saturday, about two o'clock in the afternoon, he
was called to an accident in the neighbourhood. A young man,
he was told, was grievously wounded in the chest. He had been
fooling with a revolver, and the weapon had gone off unexpectedly.

The doctor hurried to the house where the misfortune had
occurred, and being a clever young fellow, fresh from hospital
practice, he immediately took in the gravity of the situation. He
concentrated all his powers of observation on the patient. A man
of more experience of life might have thought of other things
as well, and might not so readily have accepted the theory of
accident. There was the possibility of suicide ; there was the even
greater possibility of murder. However, Magdelin's suspicions

250 J> Barfield Adams

were not aroused, and later on he corroborated, with all honesty
as far as his knowledge went, the account of the affair given to
the civil authorities, and thus prevented a hideous scandal which
would have given the finishing touch to the catastrophe.

" Be silent, monsieur," he said when the injured man opened
his eyes and attempted to speak, attempted to murmur something
about the affair being an accident. " I know all about it. You
were playing with a revolver. You were not aware that it was
loaded. The weapon went off, and you were holding it with the
barrel pointed inwards. Et voilti ! But it is no good leaving the
plaything lying on the ground. Another accident may happen."

He picked up the revolver, examined it, and put it on the
table.

" It is unheard of," he remarked, shaking his head, " that they
are allowed to sell such things to the public. It is astonishing,
manufactured as they are, that they do not go off by themselves
as soon as they are touched."

The young doctor spoke pettishly. Not that he cared about
badly made revolvers. At the bottom of his heart he was annoyed
at the prospect of losing his patient — the first that he had been
called to since he had set up in practice. But the sentiment of
professional duty immediately corrected this selfish feeling.

"Now, monsieur, lie quiet. Don't move,". he said, speaking
earnestly, but with some roughness in the tone of his voice.

The man who had called him in and a young woman were
standing beside the couch..

"Naturally," remarked the doctor, "you have nothing here
with which to make a dressing — not even a sterilised solution,
I suppose. Have you a cordial ? If so, bring it to me."

He raised the pad which the young woman had previously
placed over the wound.

" Ah ! " he exclaimed. " At least this is not so bad. And the
wound has been well washed. You have studied at a dispensary,
madame — is it not so ? You see how useful it is to know something
about first aid."

A cordial having been brought, the doctor made the patient
swallow some drops.

" Now," he said, " support him, you two — you, monsieur, and
you, madame — that I may examine the back, to see if the ball has
passed through the body."

When he had made certain that the ball was still in the lung,
his anxiety increased. He carefully percussed the chest. He

The Doctors in some Modern French Novels 251

listened first in one place and then in another, seeking to hear the
pulmonary murmur and the beating of the heart.

" Ah ! well," he said, when he had finished the examination,
" I am going to fetch what is necessary. You, madame, will not
leave the patient until I return. I shall not be long. There is
a chemist's shop just round the corner in the Rue de la Tombe-
Issoire."

He wrote some words on his card.

" You, monsieur," he continued, speaking to the man who stood
beside him, " will go for a surgeon. With my card one will come
immediately. There are none in the afternoon in the public
hospitals, but you will find one in a private hospital — at Bon-
Secours or Saint-Joseph. It is the hour that they operate in those
huuses. And you, monsieur," he added, turning to the injured
man with that affected joviality which medical men so suddenly
assume in the midst of their most serious consultations — a naive
proceeding which, however, succeeds in nine cases out of ten in
reassuring the patient, so keen is the instinct of life in seizing on
the faintest straw of hope — " after all, it is a mere nothing. We
will soon get you out of your trouble."

But when the door closed behind the doctor his manner
changed.

"Run, monsieur," he said to the man who accompanied him,
" or, better still, take a taxi. The case is urgent. An immediate
operation is necessary. If it be possible. Do it here ? What do
you mean ? Take him to a hospital ? Out of the question. The
ball has made a wound in the lung. There is abundant internal
haemorrhage. The lung is compressed. The heart is compressed.
The pericardium may have been touched. The case is grave, very
grave. However, we can but try. Go and return quickly."

A little later, when Dr. Magdelin returned to the house, he
found that the messenger had arrived with a surgeon. The latter
was a spare, elderly man with a hard-featured, strongly marked
face. His manner was abrupt and rough to a patient's friends
and prying acquaintances, but to the patient himself he was as
gentle as a woman. We all know that sort of man.

" Madame," said Dr. Magdelin to the young woman, " we
have brought all that is necessary for the present — and for
an operation, if it be possible. But you know my fears.
I don't know, mon cher confrere," he added, turning to the
surgeon, " if it will be possible to operate. However, it will
be for you to judge."

252 y. Barfield Adams

"Then you find him very ill, monsieur," said the patient's
father, who was now present.

"We cannot speak positively without another examination,"
said the young doctor; "but your son is young, monsieur. At
his age Nature has great resources."

" Ah | yes, but it is necessary to aid Nature," interrupted the
surgeon roughly, " and from what you tell me, Magdelin, we have
no time to lose."

The doctors did their best, but there was little to be done, and
the patient died with the noble lie upon his lips.

There are some lies which carry with them their own absolution.

Sinuses Persisting after War IVounds 253

THE TREATMENT OF SINUSES PERSISTING . AFTER
WAR WOUNDS.

By ARTHUR J. TURNER, Capt., R.A.M.C., M.B., B.S.(Durh.),
M.R.C.S., L.R.C.R

The majority of sinuses persisting for any length of time lead
to the surface from bones which have been damaged by one or
other kind of missile. Sometimes they do not, and then it is
usually a metal fragment or a piece of cloth or some other foreign
body remaining in the tissues which is responsible for non-
healing. In cases where bone is involved, it may be a small
splinter of bone from the external surface, or soft necrosing or
necrosed bone-tissue of greater or less depth into the structure of
the bone, or a sequestrum lying within the bone which keeps the
sinus open by a constant discharge of pus.

In dealing, therefore, with the problem of such sinuses, with
the object of bringing to a speedy termination this discharge of
pus and the prolonged series of frequent dressings usually
employed in these cases, it is of first importance, as in fresh
wounds, to remove as completely as possible any foreign body,
diseased or dead tissue as may be concerned in producing and
perpetuating the sinus. In a series of cases recently passing
through my hands in which the sinus had persisted from two to
seventeen months from the date of the wound, an operation was
performed in the great majority for the purpose of thoroughly
laying open the track, and exposing the bone in such a manner
that every particle of diseased bone could be scraped away, and
every fragment of loose bone, metal, or other foreign body removed
as a preliminary to the further specific system of treatment with
special dressings outlined below. In some of those cases where
the sinus had become by reason of age considerably fibrosed, the
operation included in addition a carving out of this fibrous wall
and the removal of thickened periosteum.

I have up to date dealt with 110 cases. For the very
successful post-operative treatment in these I am deeply indebted
to the illuminating article of my former teacher, Professor Morison,
on " The Treatment of Infected, especially War, Wounds," in the
British Medical Journal of 20th October 1917. The paste used
by me differs from that described by Professor Morison as " Bipp "
in more than one detail, but that is partly due to my dealing with
operated wounds where circumstances made it impossible to draw

254 Arthur J. Turner

the tissues together with sutures, and where, moreover, I was
anxious to obtain granulation from the bony surface outwards to
avoid leaving a cavity within, which one could not feel certain
was being filled up. With this object, therefore, I added to my
paste a small amount of scarlet red powder, the property of
which in stimulating the growth of granulation tissue is familiar
to most surgeons and which I have found of the utmost value for
this purpose. But I have adopted Professor Morison's technique
•of drying out the wound with gauze, applying to every cavity and
crevice methylated spirit, and then gently rubbing in my paste
very thoroughly over the whole surface of the wound; finally,
applying a dressing of gauze, either dry or moist with spirit, after
having painted the surrounding skin with tincture of iodine made
with 70 per cent, alcohol.

My earliest attempts were made with a paste composed of
iodoform, boric acid, chalk, scarlet red and paraffin based upon
the experiences given (in the same number of the British Medical
Journal as Professor Morison's article) by my friend Captain
Eendle Short. I found, however, that the use of this paste
necessitated a change of dressing in three or four days owing
to non-elimination of smell, and I therefore made the following
combination, which has exceeded in its antiseptic, cleansing, and
stimulating properties my highest hopes : —

Iodoform . . . . . \ oz.

Acid salicylic . . . . . \ oz.

Scarlet red powder . . . .25 grs.

Liquid paraffin . . . about \ oz.

If found a little too dry on rubbing into the tissues with dry
gauze, a little additional paraffin may be poured on to the gauze
so used.

In some cases a single dressing has been sufficient and has
been left on three weeks and in certain cases four weeks, without
the least smell being noticeable. Sometimes there is a faint oily
odour outside, which is not found to exist inside the dressing when
opened, and which may, therefore, be neglected. Sometimes blood
or slight pus 'has mixed with the paste and exuded below the
dressing : the wool and bandage have then been removed and the
dressing replaced with fresh dry, spirit-moistened or carbolic (1 in
20) gauze, or additional gauze, wool and bandage added below to
cover the discharge — the results are equally good in either case.
Most of the cases have been found at the end of three to four

Sinuses Persisting after War Wounds 255

weeks to have become completely filled up with granulation tissue
to the level of the skin : where this has been exuberant, it has
been touched with nitrate of silver stick and a daily fomentation
applied, the epithelium then rapidly growing over. In a few a
narrow sinus of varying length was found to persist when, as a
rule, the insertion of a small spoon has discovered and evacuated a
tiny piece of loose bone, or metal, or a tiny area of soft bone ; this
removed, healing has taken place at once.

Sufficient emphasis perhaps has not been laid on the desir-
ability of Professor Morison's method of treatment from the point
of view of economy. At a time when surgeons, nurses, and
orderlies were greatly overworked, and when the demand for all
kinds of dressings was so extensive and so imperative, it was of
the utmost importance that greater use should be made of a
method by means of which, I have no hesitation in saying, the
time given to dressing wounds and the expense of the dressings
themselves might be reduced to a fraction of what is employed
in the old way.

I found that there was by the introduction of the paste method
a saving in my hospital of over 44 per cent, of gauze, 18 per cent,
of boric lint, 41 per cent, of plain lint, and 31 per cent, of
cotton-wool. There was also a saving of 49 per cent, of
bandages, but this was partly due to the sterilisation and repeated
use of all bandages, however soiled; so that none were wasted
except such as out-patients failed to bring back.

I have alluded above to one of the advantages of an antiseptic
paste such as mine, viz. the freedom from smell. Other advan-
tages are the rapid fall of temperature in cases where there has
been fever, and the absolute comfort of the patient after the
one somewhat painful dressing. With regard to the latter fact,
it is my custom not to paste the wound at the time of operation
on account of the haemorrhage, but to pack it firmly with sterile
gauze, and to apply the paste after removing this on the second
or third day. By this time oozing has usually ceased and the
wound is dry, while the gauze is slightly moist with the absorbed
discharge (the gauze does not stick so closely to the tissues on the
third day as on the second) and therefore its removal is attended
by comparatively slight pain. The application of the spirit is
the painful process ; if the gauze soaked in spirit is allowed to
remain in the wound a few minutes this painfulness becomes
gradually less, and the rubbing in of the paste is felt less. Of
course the dressing may be performed under chloroform, and if this

256 Arthur J. Turner

be done the patient will be spared all pain from the commencement
of the treatment onwards.

It should be borne in mind that the wounded patient suffers
from the effects of pain upon his nervous system, and of suppura-
tion sapping his strength by the drain of leucocytes from his
tissues and the absorption of toxins into his blood-stream. A
method, therefore, which does away with painful daily dressings
and reduces the flow of pus to a minimum serves the important
purpose of promoting a speedier restoration to health, and in
fact a quite noticeable improvement takes place soon after the
operation stage is over

Pathology 257

RECENT ADVANCES IN MEDICAL SCIENCE.

PATHOLOGY.

UNDER THE CHARGE OP

THEODORE SHENNAN, M.D., and JAMES MILLER, M.D.

Bone and Joint Disease in Relation to Typhoid Fever.

The subject of this paper has not received the attention it deserves^
to judge from the importance of the facts collated by Dr. Murphy
(Surg., Gynec, and Obstet., August 1916). He found that out of 18,840
cases of enteric fever, reported by fifteen authors, 164 cases were
complicated with periostitis and osteitis ; or 0*82 per cent, of all cases
showed metastatic bone disease.

In 108 out of 452 cases the spine was affected (92 males and 16
females), and other bones were attacked in 344 cases (238 males and
108 females).

It is difficult to determine what percentage of the cases of spinal
disease is due to osteitis and periostitis, or to perichondritis. The
ages of the patients varied from 10 to 69 years. Between 10 and
25 years the disease has much the same percentage-frequency as the
non-typhoid forms of osteomyelitis ; but before the age of 10 years
osteomyelitis septica preponderates, whereas typhoid osteomyelitis
preponderates after 25 years of age.

The typhoid bone lesions in 533 cases were situated in the bones
of the head in 22 cases; spine, 110 cases; thorax (ribs and sternum),
142 cases ; bones of the upper extremity in 57 cases ; in those of the
lower extremity in 183 cases, and the lesions were multiple in 19 cases.
The longer, more compact, bones were frequently attacked — humerus,
ulna, femur, and tibia. These, be it noted, are the bones which are
most exposed to slight traumas. The ribs, tibiae, and spine provided
70 per cent, of the cases. In the case of the long bones the shaft
rather than the metaphysis is involved, the reverse being the case in
metastatic pyogenic osteomyelitis.

The nature of the lesions in 454 cases was as follows : — Periostitis,
128 cases; necrosis, 110 cases; "typhoid spine," 110 cases; osteitis
(bone abscess), 29 cases; osteomyelitis, 27 cases; caries, 21 cases;
chondritis, 11 cases; perichondritis, 11 cases; exostosis, 4 cases; and
granuloma, 3 cases. The periosteum, moreover, was always affected
in the osteal disease, and the bone was frequently deeply involved,
when the diagnosis of periostitis was made.

Ninety-nine bone lesions were examined bacteriologically, and the
B. typhosus was identified in 71 ; B. paratyphosus in 3 ; B. typhosus
and B. coli in 1 case ; B. typhosus and pus organisms in 2 cases ; pus-
microbes only in 15 cases, and the cultures proved sterile in 7 cases.

19

258 Recent Advances in Medical Science

In 1 case, inoculation gave a pure growth of B. typhosus, even though
an open sinus had existed for six years. In another case pure cultures
of B. typhosus were obtained at first, but later only the staphylococcus
aureus. Mixed infection is apparently infrequent. Bacilli may persist
in bone lesions as long as twenty-three years after the primary illness.

The bone disease may arise during the actual attack of typhoid
fever, during convalescence, or not until after the lapse of months
or years.

The question arises, " Is the lateness due to latency of the bone
infection, or to late metastasis from the gall-bladder or intestine in
'carriers'?"

Pathological Anatomy. — The subperiosteal " medullary " layer is
most often involved, then the intracanalicular medulla, and the
central medulla. " The infarcts with typhoid metastases are from
arrests in the smaller branches of the osseous vascular tree, of which
the periosteal is the smallest."

When the medulla is attacked, the marrow is softened and more or
less congested. Its colour varies from bright to deep red, simulating
the hue of the marrow in children. The amount of fat is diminished.
The 'periosteum is thick and swollen, congested, and stripped up from
the bone. If suppuration ensues, a yellow or whitish fluid, sometimes
tinged red from effusion of blood, collects under the periosteum.
Sometimes it is creamy, and even if there be no apparent necrosis of
the subjacent bone it contains small osseous particles. When the pus
invades the medulla, the sequestra are more abundant as well as of
larger size.

In place of suppuration there may be hyperostosis from stimulation
of the osteogenic power of the deep layer of periosteum.

The bone is red and vascular, the Haversian canals being dilated,
and easily seen as reddish sinuosities or fine points. They are stuffed
with hyperaemic marrow surrounding the dilated vessels. •

Dupont describes a special change seen by Tidenat. Fluid blood
collects under the periosteum, and rarely coagulates. Suppuration
takes place very slowly, only after the lapse of months.

Pean found exostoses developed in a young girl after typhoid.
The bony tissue was hard, but the interior contained a cavity extend-
ing into the compact tissue, filled with a pink, very vascular, trans-
lucent material, resembling the fungus masses of a " white swelling."
The walls of the cavity were hard and eburnated, the periosteum thick,
and infiltrated with myxomatous granulation tissue.

The reason for the slowness of the pus formation is that the pure
typhoid infection causes a feeble or no response in the way of leuco-
cytosis, particularly of the polymorph variety, and therefore there is
no trypsin from dead polymorphonuclears, and consequently only a slow
inflammatory destruction of tissue of the nature of the "cold abscess."

Pathology 259

W. T. Longcope, in 26 cases of typhoid, found that the bone-marrow
showed changes resembling very closely those in the mesenteric lymph
nodes and lymphoid follicles of the intestine and spleen. It is possible
that these lesions are in some way nearly related to, and perhaps
responsible for, the hypoleucocytosis, characteristic of the disease.

In nine necropsies Quincke found typhoid bacilli eight times in the
rib-marrow, and once in the bones of the extremities.

Clinically, patients complain of pain, which has been likened to the
osteoscopic pains of secondary syphilis. The duration of the swelling
varies. There is, as a rule, entire absence of fever. The course is
chronic. When necrosis occurs, the pain becomes more severe, the
surface temperature raised, but there is no constitutional disturbance.

X-Ray Findings. — In the long bones the appearances may be those
of hyperostosis or rarefaction. There may be central erosion accom-
panied by cortical sclerosis and periostitis. The simplest process is
a localised bone abscess, sometimes three or four developing in the
cortex, just underneath the periosteum. They are usually of small
size, about the diameter of a lead pencil. The periosteum may become
involved. When opened, a sinus may persist, discharging for months
or years.

In the spine the dorso - lumbar and lumbar regions are most
commonly attacked. Occasionally symptoms point to compression of
the spinal roots at the spinal foramina, by thickening due to prolifera-
tion of the periosteum. Sometimes there is deformity, usually a mild
degree of kyphosis, which may persist after recovery. This indicates
that the anterior parts of the bodies are affected, Wullstein being of
the opinion that it is due to localisation of the bacilli in these parts,
with subsequent absorption of bone, but radiograms suggest that the
kyphosis is rather the result of periostitic changes, with softening of
the ligaments and disorganisation of one or more intervertebral discs,
leading to approximation and synostosis of the vertebral bodies above
and below. In the bodies of the vertebrae, also, destructive foci
may be seen. The milder cases of periostitis and perichondritis may
show no manifestations demonstrable by X-rays. The alterations may
resemble closely those of spondylitis deformans ; but they are circum-
scribed, and do not involve the whole of the spine, as in that disease.

Typhoid Arthritis. — According to Keen, most cases are encountered
in patients under 20 years of age. The lesions develop during early
convalescence. They are accompanied by pain and swelling, and the
inflammation in certain joints may result in pathological dislocation.

The pathological anatomy is similar to that of other forms of
arthritis caused by other organisms.

In addition to the general survey of the subject, an abstract of
which has been given above, the author supplies details of cases which
came under his own observation.

260 Recent Advances in Medical Science

The Bactericidal Action of Sunlight.

It has been generally accepted that sunlight has a marked
deleterious action upon bacteria ; that the direct rays have a stronger
effect than diffused sunlight ; and that of the different rays making up
the solar spectrum, the chemical rays, and especially the ultra-violet
rays, have the strongest bactericidal action. So much reliance has
been placed upon these as factors of value, both from a public health
and from a therapeutic point of view, that it is somewhat startling to
find doubt cast upon the accuracy of former conclusions.

Miramond de Laroquette {Ann. de Vlnst. Pasteur, April 1918) has
carried out a long series of experiments under favourable conditions,
exposing bacteria to sunlight through uncoloured glass, and also
through blue, green, yellow, and red glass. He has employed many
non-sporing bacteria in his experiments, either suspended in air, or in
various fluid and solid culture media.

He concludes that sunlight is bactericidal only with long or strong
exposure. Its most powerful action is on bacteria upon dry media, or
in the air, provided the bacteria are also exposed to drying.

When in liquid media they are destroyed only when acted on by
direct, intense sunlight, and in very thin layers of the fluid.

White sunlight is much more effective than its separate con-
stituents. Diffuse sunlight has only a slight action. Blue light is
slightly more effective than light of other colours, but much less so
than white light. After blue comes the yellow, then the red, and lastly
the green, which, for bacteria as for plants, is most akin to black. The
most active part of the spectrum is the luminous part.

Ultra-violet rays have only a feeble action.

Filtration of sunlight through thick glass, which keeps back most
of the ultra-violet rays, does not sensibly diminish its effects. The
same holds with the infra-red rays. Filtration of sunlight through a
layer of water has not prevented its bactericidal action. (This is
apparently in contradiction of an earlier statement, though in this case
the bacteria acted upon may not have been suspended in the water.)

Heat plays a certain role. Cooling by ice during exposure retards
the action and the drying of the bacteria.

The bactericidal power of the rays appears to depend partly upon
chemical action and partly upon a dehydrating action ; and in the
case of liquid media is due to a sort of kinetic shock or intoxication
by excess of energy.

In the practical applications, in hygiene and in therapeutics, it
appears to be vain to count much (particularly in temperate climates)
on the direct bactericidal action of sunlight which cannot act deeper
than a few millimetres. In heliotherapy the bactericidal action of
sunlight is important only in treatment of superficial lesions. The
sun cure, however, affects also bacteria enclosed in the tissues, as has

Dermatology 261

been demonstrated clinically. All this points to its being an indirect
effect resulting from the biotic action of sunlight upon the living
tissues, an active, general, and local action, an exciting, energetic
influence of which the therapeutic importance has not been exaggerated,
which is caused by all the rays, and is demonstrated by an increased
circulatory and functional activity of the organs, and by an augmenta-
tion of the powers of defence.

The results of these experiments after all do not disturb our faith
in the efficacy of sunlight and fresh air as bactericidal and deodorising
influences, especially in home hygiene, seeing that they act in a
manner demonstrated as effectual by Laroquette, that is, by the direct
action of the sunlight assisted by desiccation. T. S.

DERMATOLOGY.

UNDER THE CHARGE OP

R. CRANSTON LOW, M.D., and F. GARDINER, M.D.

Pigmentation of the Skin.

This has long been a subject of controversy and research, and Whit-
field {Brit. Journ. of Derm., January 1918) gives an interesting rdsumd
of recent German literature on the subject. Bruno Bloch has dis-
covered a staining reagent, which he calls "dopa," obtained from
c ertain plants such as " vicia faba," or synthetically from vanillin and
hippuric acid. More elaborately it is called 3*4 dioxy phenylalanine,
and is a combination of orthodioxybenzene (pyrocatechin) with
a-amino-propionic acid.

An oxidation of the dopa takes place by means of a ferment
called dopa-oxidase. This ferment is not affected by prussic acid,
chloroform, acetone, benzole, or alcohol, but is destroyed by reducing
and oxidising agents — sulphuretted hydrogen, toluol, heat, drying, etc.
The skin is therefore obtained fresh, embedded in agar, and cut by
the freezing microtome. The sections are placed for twenty-four hours
at 37° C. in a 1 per cent, watery solution of dopa, then washed well,
and stained with Unna's Pappenheim stain. The result shows dark
staining of the basal layers of the epidermis, and the cutis vera is little
affected. In the stained cells the nucleus is unaltered and the proto-
plasm alone stained. In animals the ferment is not found in the white
patches of the skin; but only in the pigmented areas. Destruction or
damage to the suprarenals produces increased supply of the substance
from which the ferment is made, but the quartz lamp, X-rays, and
thorium increase the action of the ferment. In the presence of
leucoderma the dopa oxidase disappears, but in the hyperpigmented
area around it is in excess.

262 Recent Advances in Medical Science

Psoriasis.
Heidingsfeld (Urol, ind Cut. Review, May 1918) discusses this in a
thoroughly practical manner, giving it as his experience that, while
every new form of treatment brought an increase of clientele at first,
as certainly the patients disappeared when the results of treatment
became evident. The host of remedies proposed is a natural outcome
of our ignorance of the etiology of the disease, and the writer's state-
ment that "few of these are without virtue, but none are specific," is
generally accepted. " The psoriatic is prone to be the most disappointed
of all dermatological patients. Like all patients he desires results,
and results not at the cost of too disagreeable personal experience."
Balm of Duret, which is a swan-shot preparation containing coal tar,
chrysarobin, pyrogallic and salicylic acids, sulphur, green soap, resorcin,
acetone, camphor, and guaiacol cleared up old inveterate patches, but
was too disagreeable. White precipitate ointment 10 per cent., with
1 to 3 per cent, of chrysarobin, is still, he considers, very valuable in
generalised cases. In 1914 human serum injections were commenced,
and are of undoubted value; 5 to 10 c.c. of heterogenous serum from
a non-psoriatic patient are given semi-weekly. X-rays are useful when
given in moderate and infrequent doses, more especially for chronic-
patches. Other forms of radiotherapy are well adapted for psoriasis.
The fact that the eruption affects the face and hands less frequently,
that it disappears with sea-bathing and outdoor sports, and that the
worst attacks occur in winter, when the helio-activity is lowest, is
probably related to this. The disease being classified by the writer
as a localised acidosis, he employs the following lotion successfully : —
R Tinct. benzoin, 5 parts.

Alcohol, 25 parts.

Glycerin, 15 parts.

Aq. calcis, 30 parts.
M. ft. lotio, A.

R Potas. sulphurat., 1 part.

Aq. dest., 100 parts.

Zinc, sulph., 1 part. 4

Acid, carbolic, 4 parts.
M. ft. sol. B.

Sol. A, plus sol. B, add aqua dest., q. s. ad 200.
The above lotion is to be applied locally several times daily.
When the disease occurs in large, thickened, and resistant patches,
he applies the following several times weekly : —
R Acid, salicylic, 1 part.
Resorcin, 2 parts.
Alcohol, 50 parts,

to which, if necessary, 2 per cent, of pyrogallic acid can be added.
Pi oceeding from the hypothesis, very generally held, that psoriasis

Dermatology 263

is due to a combination of etiological factors, the author then takes
up these points as affecting treatment : —

1. Infective Theory. — This being well known in psoriatic individuals,,
the use of chrysarobin and sulphur as parasiticides is sound.

2. Nervous 'Theory. — This he does not believe in, but admits that
some of the well-defined attacks and relapses have been ushered in by-
nervous exhaustion and worry.

3. Diet is very important, but treatment based on it is empirical —
the elimination of substances which have a deleterious effect on the
skin in general, and more particularly sweets and acid substances.
Since intestinal intoxication cannot be ignored, he prescribes 4 to 16
minims of a 2 per cent, solution of phenol well diluted with water.

4. Rheumatic Theory. — Both diseases may have the same intestinal
or obscure local infection as a factor.

5. Lastly, the clinical appearance is of important prognostic value.
" As a rule, the smaller the lesions, the more favourable ; the larger
the lesions, the less favourable is the therapeutic outlook. Of much
greater prognostic import is the tendency, or lack of tendency, of the
lesions to undergo spontaneous central involution. Psoriasis annulata,
or gyrata, even when abundantly present and covering a wide area,
offer a favourable prognosis for prompt and early disappearance with
treatment. On the other hand, lesions with diffused erythematous
infiltration, scaly bases, and slowly spreading borders, which show no-
central retrogressive changes offer the least favourable prognosis from
a therapeutic standpoint."

KlNGWORM OF THE GROINS.

Saboraud (La Presse MM., 20th May 1918) reiterates the import-
ance of this condition at the present time in the Army. Very few
realise that the disease may simultaneously affect the toes. As a
result of this the eruption is half cured, and when marching is
resumed there is a rapid spread, and the soldier has to be returned
to hospital. All the interdigital spaces may be infected, and even the
dorsum of the foot, but most commonly it is the fourth and fifth inter-
spaces. The epiderraophyton is easily killed, but it is hidden in
masses of thickened epithelium. Thorough scraping with a sharp
spoon to the extent even of producing oozing and bleeding is the most
important item, and after this the parts are firmly rubbed with a
20 per cent, solution of iodine in alcohol. A zinc paste is now applied,
and the whole process is repeated daily for eight days. This generally
removes all the trouble, but, if not, then 10 per cent, of chrysarobin
in lard is recommended.

Dermatitis Venenata.
Strickler (Amer. Joum. of Cut. Dis., June 1918) sounds a hopeful
note when he discusses the question of the treatment of these by

264 Recent Advances in Medical Science

vegetable toxins. The active principle of poison ivy is of a glucosidal
nature, yielding on analysis gallic acid, fixtin, and rhamnose, and is
non-volatile. It is obtained from the leaves by extracting with alcohol,
and subsequently filtering and precipitating. The precipitate is dried,
then extracted with Soxhlet's extractor for ten hours. This extract
is then dried at low temperature, weighed, and dissolved in absolute
alcohol and water. Poison ivy, sumac, and nettle were all treated
thus, and used in the experiments. When a case came under
observation, -£$ c.c. of each of these was injected endermically, and
the case examined at twenty-four and forty-eight hours' interval.
A positive reaction was indicated by the formation of a papule,
erythema, and tenderness, and a patient so differentiated was then
used for treatment. Twelve patients suffering from dermatitis
venenata, whose history indicated plant irritation, were given 0*3 to
0'7 c.c. of the toxin intramuscularly, and all were cured after one or
two doses. Unfortunately, the immunity was found to be very
fleeting. The possibilities of this method are manifold if subsequent
experience gives as good results.

Staphylococcal Dermatitis.

Cases are always numerous, more so in war time, and many are
very resistant to treatment. The use of tin salts, an old method
revived, is often satisfactory. Burnier (La Presse MM., 2nd May
1918) finds that the root of bardane (lappa officinal.) is more useful
for furunculosis in the cases under his care, although he still prefers the
tin salts in folliculitis. The root must be collected in spring, dried at a
low temperature, and 0*60 gr. of the soft extract is given in pills thrice
-daily. He states that in twenty-four to forty-eight hours the pain ceases,
and that in three to four days the abscess evacuates spontaneously.

M'Donagh (Med. Press and Circ, 5th December 1917) has been
investigating the colloidal metals in this connection. Colloidal copper
intravenously and intramuscularly did no good. Colloidal manganese
given intramuscularly in 3 c.c. doses cleared up boils in three days.
Smaller doses cause no inconvenience, and larger doses may cause a
severe reaction, therefore he prefers to commence with 1-5 c.c. and
then go to 3 c.c. in a few days if necessary. Out of 100 cases
50 had the usual treatment with vaccines, etc., and the rest were
treated with manganese alone ; the first took fifty days on the average
to be cured, and the latter only seven days.

Auld (Brit. Med. Journ., 16th February 1918) is not so satisfied
with the efficacy of the colloids. Manganese given intravenously was,
in his opinion, more reliable in its action. Gold, silver, and copper in
doses of 2 to 10 c.c. gave favourable results, especially if followed by a
rise of temperature. In conclusionhe states that the protective solution
is an active ingredient in all the preparations. F. G.

New Books 265

NEW BOOKS.

Physiology and Biochemistry in Modem Medicine. By J. J. R. M'Leod,
Professor of Physiology, University of Toronto. Assisted
by Roy G. Pierce and Others. Pp. xxxii. + 903. With
233 Illustrations. London: Henry Kimpton. 1918. Price
37s. 6d. net.
We have a special satisfaction in reviewing this work from the fact
that it adopts an attitude towards medical teaching which has recently
been elaborated in our pages. In the inquiry by the Edinburgh
Pathological Club into the medical curriculum the importance of co-
relating the teaching of the earlier scientific subjects with that of the
more advanced clinical subjects was strongly emphasised, and here we
have a text-book specially designed to give effect to this idea in relation
to physiology and clinical medicine. In his preface, Professor M'Leod
comments on the disadvantages of the water-tight method of teaching
the various subjects embraced within the curriculum. "When the
clinic is reached," he says, "the methods of the scientist are not
infrequently cast aside, and an understanding of disease is sought for
largely by the empirical method." The blame for this state of affairs
must be shared by both groups of teachers. The author frankly
admits that " the laboratory courses are frequently given without any
attempt being made to show the student the bearing of the subject in
the interpretation of disease, or to train him so that in his later years
he may be able to adapt the methods of investigation which he learned
in the laboratory to the study of morbid conditions." We must be
equally candid and confess that the clinical teacher is too often content
to accept certain groupings of symptoms as evidence of a particular
disease, without insisting that the student shall take the trouble to
interpret them in terms of disordered physiology. "But," to quote
the author again, "the chief remedy of the evil undoubtedly lies
partly in the continuance of certain of the laboratory courses into the
clinical years, and partly in the study of medical literature in which
the application of physiology and biochemistry in the practice of
medicine is emphasised." The first of these proposals was recom-
mended as a result of the investigations above referred to, and the
work before us is an excellent example of the kind of medical
literature which will be in demand when this most desirable change
in the curriculum has been put into operation.

This work is in no sense a text-book on physiology. It is rather
an exposition of those physiological problems which have a direct and
practical bearing in diagnosis and therapeutics.

After a brief, but illuminating, section on the physico-chemical

266 New Books

basis of physiological processes, in which osmotic pressure, electric
conductivity, acidosis, colloids, enzymes, and other allied subjects are
dealt with, the circulatory fluids are fully discussed. Then follow
sections on the circulation of the blood, respiration, digestion, and so
on through the various functions. Space does not permit of a detailed
consideration of each section of the work, but the scope of the discussion
may be indicated from the chapter dealing with digestion, which
begins with a general description of the microscopic changes in the
digestive glands during activity, followed by an explanation of the
mechanism of secretion, and of the nervous control and also the
hormonic control of glandular activity. Each digestive gland is then
taken up separately, the normal physiological action being fully
discussed, as well as the disordered activity which gives rise to
" symptoms " in disease. A consideration of the mechanisms —
mastication, deglutition, the movements of the stomach, intestinal
peristalsis, and anti-peristalsis — follows, and is particularly instructive
to the clinician. After hunger and appetite have been dealt with, the
general biochemical processes of digestion in each segment of the
alimentary canal are succinctly yet clearly described. Throughout,
the authors succeed in maintaining the clinical rather than the
laboratory point of view, with the result that the whole discussion
assumes a peculiarly practical aspect. The style of the writing makes
easy reading, and it is occasionally lightened up by such passages as
the following which occurs under the heading "Mastication." "The
benefit to digestion as a whole of a large secretion of saliva, brought
about by persistent chewing, has been assumed by some to be much
greater than it really is, and there has existed, and indeed may still
exist, a school of faddists, who by deliberately chewing far beyond the
necessary time, imagine themselves to thrive better on less food than
those who occupy their time with more profitable pursuits."

Our only regret with regard to this work is that it is rather large
for the already over-burdened student. A condensed version, which
could be studied as a supplement to clinical medicine, would be
invaluable. For the practitioner and for the teacher of the clinical
subjects of the curriculum it meets a need which has long been felt,
and meets it in an entirely satisfactory manner. It is well published,
abundantly illustrated, and fully indexed.

Forced Movements: Tropism and Animal Conduct. By Jacques Loeb,
M.D. Pp. 209. With 42 Illustrations. Philadelphia and
London : Lippincott Co. $2.50 net.

It is a pleasure to introduce this new series of American Biological

Monographs to British readers. The series, which is edited by Messrs.

Loeb, T. H. Morgan, and W. J. V. Osterhout, aims at emphasising the

New Books 267

value of exact quantitative experiments in biological research, and at
explaining life from the physico-chemical constitution of living matter.
The present attractive volume, which is well printed on good paper
and clearly illustrated, is the first of the series. Amongst others in
preparation are volumes -on Tlie Chromosome Theory of Heredity and
The Permeability and Electrical Conductivity of Living Tissue by the other
editors already named.

Dr. Loeb in this volume works out in detail the tropism or forced
movement theory of animal conduct, upon the study of which he has
been engaged for thirty years. " Motions caused by light and other
agencies appear to the layman as expressive of will and purpose on the
part of the animal, whereas in reality the animal is forced to go where
carried by its legs. For the conduct of animals consists of forced
movements." Amongst the forces which compel these movements, and
which have been studied experimentally by methods clearly described
in successive chapters, are electricity, light, gravitation, heat, and
chemical force. Various instincts are explained as due to heliotropism,
chemotropism, or stereotropism, while others are forced movements due
to hormones or to the influence of memory images. With regard to
human conduct, we are told that " our conception of the existence of
'free will' in human beings rests on the fact that our knowledge is
often not sufficiently complete to account for the orienting forces."

Dr. Loeb's book is decidedly interesting and is a valuable addition
to the descriptive side of biology ; whether it can be accepted as a
satisfactory contribution to the interpretative side will depend upon
the extent to which the reader is willing to accept a mechanistic theory
of life and a materialistic conception of evolution.

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, E.A.M.C.
Pp. xiii. + 136. With 13 Illustrations and 4 Charts. London :
Henry Frowde and Hodder & Stoughton. 1919. Price
7s. 6d. net.

Mr. Lloyd deals in a concise manner with the structure (the " stomach"
is labelled fore-gut instead of mid-gut), life-history, habits, and dis-
semination of lice and with methods of disinfestation, and there are
short chapters on relapsing fever, typhus, and trench fever — the three
diseases known to be louse borne.

During observations on the migrations of body lice from the host
it was found that an increased shedding of lice occurred when the host
was febrile, and it is suggested that this may account, partially at any
rate, for the rapid spread of louse-borne epidemics.

268 New Books

Kala-Azar : its Diagnosis and Treatment. By E. Muir, M.D. Pp. 37.
With 5 Plates. Calcutta: Butterworth & Co. 1918. Price
lis. 2 net.

In this small book the diagnosis and treatment of this affection are
discussed, especially in relation to the results obtained by the intra-
venous injection of soluble antimony salts.

It is intended for the use of practitioners in villages and small
towns, and to this class the practical hints regarding diagnosis,
especially the technique of splenic puncture, and the system adopted
for intravenous injection, should prove of value.

Before the introduction of the antimony treatment the mortality
in this disease was over 90 per cent, in 150 cases treated by the author
during a period of twelve months, death resulted in only 12 per cent.

There are several palpable errors to which the attention of the
author may be invited — for example, the word azar signifies disease —
but on the first page it is translated as ''fever" — the directions for
preparing Leishman's stain, 1 c.c. is evidently a misprint for 10 c.c,
and the statement on page 7 regarding the rapid pulse is not in
accordance with the experience of others.

The Epidemics of Mauritius, with a Descriptive and Historical Account of
the Island. By Daniel E. Anderson, M.D. Pp. xvi. + 312.
With Maps and Illustrations. London : H. K. Lewis & Co.
1918.

As the title implies, this work deals not only with medical matters
but also with the history of the island, giving lists of former governors,
various reminiscences, and other varied information, including a graphic
description of a cyclone — this portion, about 100 pages, should prove
most interesting to those having associations with Mauritius.

Regarding the present methods for the diagnosis and treatment of
leprosy, cholera, malaria, etc., the author has little to add to the
ordinary text-book information, but the descriptions of the various
cholera epidemics in the island from 1745 onward, detailing the
measures formerly adopted for the treatment of the disease (some of
them very quaint) and for its prevention, are well worth perusal.

It is interesting to note that in 1854 the physicians recognised that
during the acute stages of cholera intestinal absorption is in abeyance?
a fact often overlooked in the present day.

On the whole, the illustrations are good, but some, including those
supposed to represent the bacilli of leprosy and cholera and the various
forms of the malarial parasite, are very crude.

New Editions 2G9

NEW EDITIONS.

Manual of Bacteriology. By Robert Muir and James Ritchie.
Seventh Edition. Pp. xxiv. + 753. With 6 Plates in Colour
and 200 Illustrations. London : Henry Frowde and Hodder
& Stoughton. 1919. Price 16s. net.

This well-known manual makes a welcome reappearance in its seventh
edition. The numerous advances made in bacteriological medicine
during the last few years have necessitated extensive alterations and
additions in a large number of departments, and it is evident that no
time or labour has been spared in bringing the manual completely up
to date.

Improvements in technique, advances in our knowledge of the
pneumo-streptococcus, the meningococcus, and the typhoid-dysentery
groups; recent work on tetanus and other wound infections, on
spirochetal jaundice, on trench fever, on epidemic encephalitis and
poliomyelitis — in all these and in other directions the teaching of the
manual has been brought into line with the most recent investigations.

The fine critical faculty which the authors display and their
recognised ability in sifting the grain from the chaff render the
book one of great value to the bacteriological worker and to those
clinicians who take a wider interest in disease processes, the excellent
bibliography being not its least useful part.

The volume has in some magical fashion retained approximately
its former convenient size, and we are glad to notice that war con-
ditions have not produced any deterioration in the quality of paper
and illustrations.

The Intensive Treatment of Syphilis and Locomotor Ataxia by Aachen
Methods. By Reginald Hayes. Third Edition. Pp. viii. +
92. With 4 Plates. London : Bailliere, Tindall & Cox. 1919.
Price 4s. 6d. net.

It is universally admitted that, in the treatment of syphilis and its
manifestations, the use of mercury is an essential adjunct to the
injection of the arsenical compounds. The inunction method of
introducing the drug is not popular in this country, but the author
is a whole-hearted supporter of this method. He claims for it " safety,
potency, and painlessness, with exemption from most of the drawbacks "
of other forms of treatment. He admits, however, that inunction
requires properly selected cases, skilled rubbers, and careful super-
vision. This little book gives a useful account of the Aachen treatment
and the arguments in its favour.

270 New Editions

Hughes? Nerves of the Human Body. By C. R. Whittakek. Second
Edition. Pp. 73. With Diagrams. Edinburgh: E. & 8.
Livingstone. 1918. Price 3s. 6d. net.

This handbook gives a lucid though somewhat brief account of the
anatomy of the peripheral nerves and of the sympathetic nervous
system. The diagrams are clear and easily understood, and the book
should be of value to the student of anatomy who has not the time to
obtain his knowledge from the larger text-books. The author has
preferred to adhere to the old terminology throughout, giving the
B. N. A. nomenclature occasionally in brackets. The result illustrates
very well the confusion that will inevitably result in a few years in
anatomical and surgical text-books unless a definite position is taken
up with regard to terminology. Thus, we read on one page of the
"crus cerebri" and on the next of the "cerebral peduncle," and again
we find branches of the radial nerve, which used to be called the
external cutaneous branches of the musculo-spiral and which are now
known as the dorsal antibrachial cutaneous nerves, described here as
the lateral cutaneous nerves — a name which means nothing. In the
B. N. A. terminology we have a scientific nomenclature which cuts
down anatomical terms by one half — an advantage which alone is
sufficient to justify its adoption. In addition, although the terminology
still requires revision, the terms convey a definite meaning to the mind
of the student and are therefore easy of remembrance. This system
has been almost universally adopted outside the British Isles and
there can be little justification for any further delay in its general
acceptance.

A Manual of Elementary Zoology. By L. A. Borradaile, M.A.
Second Edition. Pp. xiv. + 616. With 419 Illustrations.
London: Henry Frowde and Hodder & Stoughton. 1918.
Price 16s. net.

This edition contains new chapters on protozoa (entamoeba, trypano-
soma, malaria), on nematodes and on cold-blooded vertebrates. A
few slips have escaped attention, e.g. the larvae of Filaria bancrofti
escape from the mosquito by way of the labium (proboscis) and not,
as stated, via the salivary glands. The labelling of the figure
showing the cranial nerves of the skate requires revision. The book
is excellently illustrated and clearly written, and takes rank among
the best text-books for the junior student of zoology.

Notes on Books 271

NOTES ON BOOKS.

The fourth edition of Dr. E. R. Morton's Essentials of Medical Electricity
rewritten by E. P. Cumberbatch, M.B. (Henry Kimpton, price 7s. 6d.
net), has been thoroughly revised and brought up to date. At the
present time, when there are so many in our midst who will benefit
from electrical treatment, its study will prove especially valuable.
The author deals in a clear and practical manner with his subject, and
describes the different methods used and how to apply them in order
to obtain the best results. Above all, he realises the limitations of
this form of treatment and recommends in all cases that it should be
combined with other general or local treatment.

Dr. Koll has written Diseases of the Male Urethra (W. B. Saunders
Co., price 14s. net) in response to the need which he has long felt for
a " comprehensive monograph " on diseases of the male urethra.
Without considering what justification there may be for a book
dealing mainly with gonorrhoea which omits all reference to gonorrhoeal
arthritis, we take the work as it stands and find that it contains no
oareful record of personal observation or investigation, and no
information of value which the student or practitioner cannot find
in any standard text-book on surgery. Many different causes are
alleged to give rise to non-gonorrhceal urethritis, among them con-
stipation, and in considering the pathology of this condition Dr. Koll
states that "it is not rare to find pathologic involvement of the
epididymi, the origin of which can be clearly traced to one of the
strains of saprophytes which has become pathogenic from some
idiopathic stimulus." This nebulous statement gives an indication of
the character of a good deal of Dr. Roll's writing.

Eeports, Transactions, etc. — The fourth volume of the Reports of
the Episcopal Hospital, Philadelphia (Wm. J. Dornan), contains a selection
of excellent short paper on subjects of general interest, well illustrated.

The Surgical Board of the Women's Hospital in the State of New York
has followed a prevailing American practice of collecting papers
published by members of the staff and issuing them as a separate
volume. The initial volume augurs well for the success of the venture.

The St. Thomas' Hospital Eeports, of which we have received the
forty-fourth volume (1915), is mainly of interest to statisticians.

The present issue of the Transactions of the American Gynecological
Society (vol. xlii., 1917) derives a special interest from the series of
papers dealing with the relation of the glands of internal secretion to
gynecology and obstetrics.

272 Books Received

BOOKS RECEIVED.

jji.ake, Joseph A. Fractures : Monograph on Gunshot Fractures of the Extremities

(D. Appleton £ Co.) 7s. 6d.
Bolduan, Charles Frederick, and John Koopman. Immune Sera. Fifth Edition

(Chapman & Hall) —
Cunning, Joseph, and Cecil A. Joll. Aids to Surgery. Fourth Edition

(Bailliere, TindaU £ Cox) is. M.
De Chambure, A. Quelques Guides de l'Opinion en France pendant la Grande Guerre

(Celin, Mary, Elen £ Cie) frs. 4.50.
Dumas, J., and Anne Carrel. Technic of the Carrel Method

(Wm. Heinemann (Medical Books), Ltd.) 6s.

Elmslie, R. C. The After-Treatment of Wounds and other Injuries . (J. £ A. Churchill) 15s.

Ghosh, J. C. Indigenous Drugs of India . . . (Butterworth £ Co. (India), Ltd.) Is.

Gould, Sir Alfred Pearce, and Eric Pearcb Gould. Elements of Surgical Diagnosis.

Fifth Edition (Cassell £ Co., Ltd.) 12s. 6d.

Jones, Ll. J., and A Bassett Jones. Pensions and the Principles of their Evaluation.

(Wm. Heinemann (Medical Books), Ltd.) 30s.

Maps, Catalogue of Small Scale Ordnance Survey (T. Fisher Unwin) —

Marshall, A. Milnes, and C. Herbert Hurst. Practical Zoology. Eighth Edition

(John Murray) —

Martinet, A. Diagnostic Clinique (Masson et Cie) frs. 30+10%

Paterson, A. Melville. The Anatomy of the Peripheral Nerves

(Henry Frowde, Hodder £ Stoughtori) 12s. 6<L

Reveille. Edited by John Galsworthy. February Number 2s. 6d.

Sequeira, James H. Diseases of the Skin. Third Edition . . (J. <t A. Churchill) 36s.

Shears, G. P., and E. E. Shears. Obstetrics: Normal and Operative. Second Revised

Edition (•/. B. Lippincott Co.) 30s.

Smith, E. Carlton. Chemistry for Dental Students. Third Edition (Chapman £ Halt) 13s. 6d.
Stewart, Sir James Purves, and Arthur Evans. Nerve Injuries and their Treat-
ment. Second Edition (Henry Frowde, Hodder & Stoughton) 12s. 6d.

Tweedy, E. Hastings, and G. T. Wrench. Practical Obstetrics. Fourth Edition

(Henry Frowde, Hodder £ Stoughton) 21s.

Wingfield, Hugh. The Forms of Alcoholism and their Treatment]

(Henry Frowde, Hodder £ Stoughton) 5s.

MAY 191».

EDINBURGH
MEDICAL JOURNAL.

EIMTOiilAL NOTES.

The establishment of a lectureship in ortho-
Orthopaedic Surgery. ,. ,. ... . . r e

paedics in connection with the department ot

surgery in the University raises again the much-debated question —
What is orthopaedic surgery? Much has happened since Nicholas
Andre, who coined the word " orthopaedics," in his treatise of 1741
defined the scope of his work as "the art of preventing and correcting
deformities in children," and Jean-Andre Venel founded the first
orthopaedic institute at Orbe in 1780, and we are no more called upon
to accept the limitations set by the one than we are to adopt the
methods followed by the other. Like every similar offshoot from the
parent stem of general surgery, orthopaedics has gradually tended to
spread itself out over a wider and wider area. The earliest efforts of
the "orthopaedist" were confined tp the use of mechanical appliances,
in the devising of which he exhibited an almost uncanny ingenuity.
Later he took to the knife, and by performing subcutaneous tenotomy
graduated as an " orthopaedic surgeon." The subcutaneous operation
in time gave place to the open one, and from that to the shortening,
lengthening, and grafting of tendons was a natural step. The inventive-
ness and dexterity inherent in the true disciple of the art have found
ample scope in the varied problems that come under his notice, and
with modern facilities he now carries out with infinite skill plastic
operations upon bones and joints which are veritable triumphs in
artistic carpentry.

The orthopaedic surgeon has long since broken his etymological
bounds, and no longer confines his attention to children, nor does he
limit his activities to dealing with deformities, potential or established.
Yet he is curiously selective in his predilections, for while cleft palate,
hare-lip, extroversion of the bladder and hernia, which are certainly
deformities of childhood, do not come within his ambit, he has annexed
spina bifida as his peculiar province. Beginning with the spinal

E. M. J. VOL. XXII. NO. V. 20

274 Editorial Notes

column he took tuberculous disease under his care, and gradually he
has laid claim to all tuberculous affections of bones and joints.

The boundary line between general and orthopaedic surgery has
been still further obscured by the peculiar circumstances arising out
of the war. In the process of recovery many of our wounded soldiers
reached a stage at which the methods of treatment employed by ortho-
paedic surgeons were those best calculated to ensure restoration of
function to damaged limbs. The military authorities wisely decided
to establish special hospitals where these methods could be efficiently
employed. The exigencies of the situation and the personal pre-
dilections of those entrusted with the work prevented any limiting
landmarks being set up between the spheres of the general and the
orthopaedic surgeon, with the result that there has been considerable
doubt as to where one ends and the other begins. The line is purely
arbitrary, and the principle on which it has been drawn not always
easy to recognise. Although the military phase of orthopaedic surgery
is, we hope, a passing one, it has served to establish claims on the part
of its votaries which are likely to be permanent.

It would appear, then, that we cannot with any degree of precision
answer the question — What is orthopaedic surgery1? Even in its
application to civilian work the term must be an elastic one, and the
line demarcating the specialty must remain arbitrary.

Our immediate concern, however, is not to arrive at an academic
definition but to find a means of utilising to the best advantage the
opportunity which has arisen of improving the teaching of an important
branch of practical surgery. That it has not hitherto received in our
curriculum the attention due to it is generally admitted. The chief
reason for this state of things probably lies in the fact that our
teaching hospitals have not included an organised department, fully
equipped and under the direction of a specially qualified surgeon, for
dealing with such affections as fall within even the restricted meaning
of the term orthopaedics. If the new lectureship is to add to the
teaching capacity of the school, this defect will require to be remedied.
To make a beginning, ample scope would be found in an out-patient
department furnished with the necessary staff and apparatus for
carrying out treatment by mechanical appliances, massage, and physical
exercises, under the direction of the lecturer on orthopaedics. Other
contingent developments in the school will, we trust, at no very
distant date make it possible to assign, for such patients as require
prolonged indoor treatment, a sufficient number of beds to complete the
equipment of a full orthopaedic department.

We offer our congratulations to Lieutenant-
Honour. Colonel Joseph M. Cotterill, C.M.G., F.R.C.S.,
K.A.M.C.(T.), on his receiving the honour of knighthood.

Editorial Notes

275

Appointment.
Children.

Dr. Lewis Thatcher has been appointed Extra-
Physician to the Royal Hospital for Sick

CASUALTIES.

Killed in action on 19th March 1918, Captain William Charles
Davidson Wilson, R.A.M.C.(T.F.).

Captain Wilson was educated at Aberdeen University, where he
graduated M.B., Ch.B. in 1915.

Died on service, Captain John Warnock Bingham, R.A.M.C.

Captain Bingham graduated M.B., Ch.B. at Edinburgh University in
1907.

Demobilisation of
Nurses.

The Minister of Labour has appointed a sub-
committee for Scotland of the Nurses' Resettle-
ment and Demobilisation Committee (London).
This sub-committee will deal with the resettlement of Scottish nurses
in civil life, with special reference to those who desire to find post-war
employment or to undertake some form of training. It will also
control the register of Scottish nurses who desire work in Scotland.
The register will be kept at the office of the Employment Department,
Ministry of Labour, 112 George Street, Edinburgh, to which all
inquiries should be addressed.

276 Francis D. Boyd

EXPERIENCES OF A CONSULTING PHYSICIAN ON-
DUTY ON THE PALESTINE LINES OF COM-
MUNICATION.

By FRANCIS D. BOYD, C.M.G., Colonel, A.M.S.

The life of a consulting physician on the Palestine lines of com-
munication was arduous, but was full of interest and variety.
With an area of duty extending from behind the front line to
Suez and Port Said, and upwards of ten thousand beds in charge,
there was no lack of clinical material. Nor was there want of
variety in scenery — from the sandy desert at El Arish and Kantara
to the fertile orchard groves of Ludd and Jaffa and the " stony
ground " of the hills about Jerusalem. Each had an interest of
its own. One had to be perpetually on the move. Motoring in
the desert and in the Jordan valley was an experience which
could never be forgotten. The rabbit wire track laid by the
engineers over the sand, the dust, the light Ford car which leaped
obstacles and rushed wadis, going through places that in pre-war
days one would have gone 20 miles round to avoid, all added
spice to the daily round. Nor must the insect life be forgotten ;
day and night it was ever present — the mosquito, the eternal fly,
the sand-fly, the scorpion, the centipede in the bath sponge — all
demanded consideration, if not respect. The house-fly nothing
seemed to daunt. The mosquito is a vital problem that will have
to be considered by those responsible for the health of Palestine
in the future. Give Palestine a water supply and abolish wells
for irrigation and the mosquito danger will be simplified. The
Nile water has been brought up in pipes as far as Gaza, thus
fulfilling an old prophecy that when the Nile water flowed into
Palestine Jerusalem would again fall. Much has been done, but
much remains to do, to make the country, beautiful as it is, a fit
habitation for a white man.

The sickness incidence amongst the troops of the Egyptian
Expeditionary Force in Palestine was high. Malaria, dysentery,
relapsing fever, typhus, enterica, sand-fly fever, and pyrexias of
doubtful origin, all were responsible. To these in the autumn
was added the influenza which has been epidemic throughout the
world. Though the sickness incidence was high, it can be claimed
that, until influenza .became epidemic, the mortality was not at

Experiences of a Consulting Physician 277

any time serious, if due consideration be given to the grave
character of several of the diseases affecting the troops.

Malaria. — A large proportion of the medical casualties resulted
from malarial infection. While the benign tertian and quartan
varieties occurred, the predominant types were primary malignant
tertian and relapsing malaria amongst the troops who had been
infected in other fronts, especially Salonica. By far the most
important as affecting lines of communication was the malignant
tertian malaria, for, if diagnosed early and promptly treated,
satisfactory results were obtained, while any delay or inadequacy
of treatment frequently led to a fatal result. The onset in these
cases was insidious ; the patient complained of headache, back-
ache, and malaise with some fever. On examination there was
tenderness in the splenic region. The spleen was not always
palpable, but usually showed some enlargement to percussion.
The tongue was dry and coated, and there was frequently a
history of vomiting. The conjunctiva showed a slight tinge of
jaundice, while the face was flushed, the pulse frequent, and the
patient appeared ill. Examination of the blood usually gave a
positive finding, but by no means always so. Cases have occurred
where as many as five examinations have had to be undertaken
before the parasite was finally discovered. The temperature in
these cases was usually of a remittent type, ranging from 104°
to 102°. A large proportion of the cases showed complications
of the most varied description.

Cerebral phenomena were common, varying from slight con-
fusion to an acute maniacal state, and passing rapidly into coma,
A man might walk into a casualty clearing station complaining of
malaise and headache, and unable to give a clear account of himself
and be comatose in a few hours. The skin was hot and dry, the
face flushed, the pulse full and frequent, and the pupils sluggish.
At times there was some rigidity of the neck. Trismus of the
muscles of the jaw was noted in several cases ; in some, epileptiform
convulsions occurred. Hyperpyrexia was only occasionally met
with. In one case the temperature reached 109°, but was reduced
by packs and intravenous quinine ; in several other cases, however,
it proved the harbinger of coma and death. Of the remoter effects
of malaria upon the central nervous system it is more possible
for the workers at the base to speak, but on the lines of com-
munication a number of cases of multiple neuritis were noted,
and at least three cases of transverse myelitis with paraplegia
and implication of the bladder and rectum.

278 Francis D. Boyd

Abdominal manifestations of malignant malaria were relatively
frequent. Disturbance of digestion, with a dry coated tongue,
vomiting and jaundice of varying degrees, were fairly constant
phenomena. The liver was usually enlarged and at times tender.
Not infrequently the disease assumed the bilious remittent type
which text-books say is " the most common and the least dangerous
of the pernicious manifestations." This was not our experience
in Palestine. These cases showed marked jaundice, a dry coated
tongue, constant vomiting and frequent hiccough, epigastric
distress, and an enlarged and tender liver. The condition was
very resistant to treatment and frequently fatal. Diarrhoea with
blood and sometimes mucus, which was fairly common at times,
made the differentiation of malignant tertian malaria from
dysentery a matter of considerable difficulty in the absence of
a pathological report, while a combined infection with malaria
and dysentery was by no means uncommon.

The algid type of malignant tertian malaria at times gave rise
to anxiety till a definite diagnosis was established. For example,
cases were admitted from a transport to the stationary hospitals
at Kantara, the first with a diagnosis of " acute abdomen-perfora-
tion ? " The clinical phenomena were suggestive of cholera —
intense collapse, cold blanched extremities, the skin dry, and the
abdomen retracted. Shortly after admission a copious rice-watery
stool was evacuated. Blood examination, however, established
the diagnosis of malignant tertian malaria, and under appropriate
treatment recovery took place.

Malignant tertian malaria, from the varied guise in which its
clinical manifestations may be presented, is not only of interest
to the physician but is a disease which the surgeon can never
afford to forget in the study of certain acute abdominal conditions
with a view to operation, particularly when they occur in a
malarial area. Cholecystitis, appendicitis, and other similar con-
ditions have been closely simulated. For example, a man was
admitted to the 76 C. C. S. complaining of abdominal pain. There
was a history of a former attack of appendicitis. The patient
looked ill. The tongue was coated; there was vomiting. The
movements of the abdomen were restricted, especially in the
right lower quadrant, where there was marked tenderness. The
temperature 103°, the pulse 80. The spleen was not enlarged,
but was tender to palpation. Operation was discussed, but it was
decided to wait till a blood report could be obtained. This proved
to be positive malignant tertian malaria. Intramuscular quinine

Experiences of a Consulting Physician 279

was administered, followed by intravenous, and in twenty-four
hours vomiting had ceased, and pain and tenderness diminished.
Eecovery was uninterrupted.

The 'pneumonic type of malaria was fairly common, both
amongst British and Indian troops. Amongst the British the
physical signs were frequently those of a croupous pneumonia.
The temperature was irregular, and blood examination showed a
malignant tertian infection. Under quinine the temperature fell,
but the physical signs in the lung persisted after the fall in the
temperature, and took a considerable time to clear up. Amongst
the Indian troops the common form of pneumonic malaria was of
a broncho-pneumonic type, with marked remittent temperature,
and was always grave. When influenza became epidemic amongst
the troops, pneumonia following on influenza and accompanied by
a malignant tertian infection assumed a pronouncedly septic type,
and was exceedingly fatal. Too much stress cannot be placed
upon the profound influence which the malignant tertian toxaemia
has upon the myocardium. During the acute attack the blood-
pressure may fall low and the heart become dilated, and a certain
amount of oedema of the lungs was common. In grave cases air
hunger with cyanosis was a prominent feature, but since there
was no evidence of acidosis — no diacetic acid or acetone in the
urine — the phenomena seemed purely due to myocardial toxaemia.
During convalescence the influence of the toxaemia on the
myocardium had always to be considered. Any exertion or too
early return to duty inevitably led to cardiac dilatation and a
circulatory breakdown, necessitating prolonged and careful treat-
ment. To hurry a man who had suffered from malignant tertian
malaria back to duty was an economic blunder.

Renal haemorrhage in the course of malignant tertian infection
was rare on the lines of communication. A few cases were noted,
one so severe as to endanger life from the profound anaemia which
resulted.

Blackwater fever was exceedingly uncommon. The few cases
seen could almost without exception be traced to an original
infection on one of the other fronts, especially East Africa. The
Palestine type of malignant tertian infection did not seem to
favour the production of haemoglobinuria.

Nephritis following on malarial infection was noted in a
number of instances. The urine contained albumin, cell elements,
and a small number of tube casts, but rarely blood. The cases
did well under treatment.

280 Francis D. Boyd

The Diagnosis of Malaria. — The first and most essential point
in the diagnosis of malaria is the proof of the presence of the
parasite in the blood, and in this important point the work on the
lines of communication was greatly aided by the establishment,
under direction from the D. M. S., of advanced diagnosis stations.
It then became the rule that in every case of pyrexia a blood-film
should be taken before any medicinal substance was administered.
The blood-film was then either sent to the diagnosis stations or
nearest laboratory for report ; or, if this was not possible, accom-
panied the man to the casualty clearing station. It was thus
possible to start quinine medication early without necessarily inter-
fering with the subsequent diagnosis. The question arises, failing
the finding of the parasite, Is one justified in the diagnosis of
*' clinical malaria " ? Experience on the lines of communication,
where one was dealing with a large number of malignant ter-
tian infections, would force one to answer the question in the
affirmative. We know that several blood examinations are often
necessary before the presence of the parasite can be proved, and
if the clinical factors point to malaria, to withhold quinine is to
endanger life.

A clinical diagnosis may be fairly based upon — (a) Response
to quinine therapy ; (b) the character of the pyrexia, with splenic
tenderness and possibly enlargement; (c) the blood-film picture,
with the presence of hsemozoin-laden leucocytes or a high, large,
mononuclear percentage. Given one of these factors present and
the exclusion of other known causes of pyrexia, such as relapsing
fever, the diagnosis of malaria seemed justified under conditions
where infection was so common.

Prognosis. — In considering prognosis it must be borne in mind
that the European troops were, for the most part, young adults
infected for the first time, and the infection was therefore corre-
spondingly severe. Taking this into consideration, one may with
justice state that if the diagnosis were made early and the treat-
ment energetically carried out, the prognosis was relatively good.
The disease responded well to treatment.

It is interesting to consider the causes of death in fifty cases
of malignant tertian malaria which occurred before the influenza
epidemic caused an increase in the proportion of pneumonic cases.
The table shows the figures.

Experiences of a Consulting Physician 281

Fifty Cases of Fatal Malignant Tertian Malaria.

Toxaemia with cerebral symptoms

Toxaemia with cardiac failure ....

Bilious remittent type .....

Hyperpyrexia ......

Pneumonia

Complicated with quartan malaria and bacillary dysentery

Complicated with amoebic dysentery

Complicated with myelitis ....

Imperfectly treated .....

10
10
7
3
13
1
1
1
4

50

Toxaemia with cerebral or cardiac phenomena was the cause of
death in no less than twenty of the series. Pneumonia occurred
as a complication in thirteen ; in one of this group coughing led
directly to a rupture of the spleen which determined the fatal
result. The bilious remittent type accounted for seven deaths,
hyperpyrexia for three. Amoebic dysentery, bacillary dysentery,
and myelitis occurred each once as a complication. Four are
shown as imperfectly treated — owing to the exigencies of war
they had been ill for some days before coming under treatment —
men taken ill at outlying posts, and treatment, when possible,
was unavailing.

In a study of the post-mortem findings it is interesting to
note how seldom parasites were found in smears from the spleen
or bone-marrow if the patient had been efficiently treated. It is
usually held that when parasites disappear from the peripheral
circulation they lie dormant in the spleen and bone-marrow, to
become active again when treatment is intermitted, and so
relapses occur. This may be so, but apparently the number of
parasites is so small as to escape detection on the most careful
and exhaustive examination. In thirty-seven consecutive post-
mortems in which a search was made for the parasites they were
found in only nine cases ; in all nine the period of treatment was
very short, averaging in eight of them 1*9 days, while one was
treated with oral quinine only — a method which we know has
little influence on the malignant tertian parasite. In twenty-
eight cases where treatment had been more prolonged no
parasites were found.

The table also shows the occurrence of mixed infections.
These were by no means uncommon. When malignant and
benign tertian occurred in the same individual, the clinical picture
was that of a severe malignant tertian infection. Where the

282 Francis D. Boyd

pathological report was that of benign tertian, and the symptoms
were severe, especially if they were cerebral, it was always
justifiable to postulate a mixed infection and carry out energetic
treatment as for malignant tertian.

Treatment. — In malaria there is constantly a profound dis-
turbance of the whole digestive system, and quinine treatment
may fail unless preceded by the administration of a dose of
calomel followed by a saline aperient. During the course of
quinine treatment this procedure should be repeated at intervals.
In every case of malaria the treatment should be controlled by
frequent blood examinations, so that the medical officer may be
kept informed of its efficiency. During the quinine treatment
the patient must be kept in bed rigidly during the first three
weeks of treatment.

In benign tertian malaria it was customary on the lines of
communication, after the initial purge, to prescribe quinine in
10 to 15 gr. doses three times a day, and to evacuate the patient
as a cot case if there were no urgent symptoms.

In malignant tertian malaria gastro-intestinal disturbance is,
as a rule, so pronounced that the oral administration of quinine,
in the early stages, is of little or no value ; and even if there be
not profound digestive disturbance, oral quinine does not appear
to be curative. Kecourse, therefore, was had to intramuscular or
intravenous administration. Given a case of average severity,
quinine bihydrochloride, 12 grs., was administered deeply into the
muscles of the buttock three times in the first twenty-four hours
and continued for at least three days. If by the end of three
days urgent symptoms had disappeared and the temperature had
fallen, oral administration was begun, 30 grs. being given in
twenty-four hours accompanied with arsenic. During the third
week of quinine treatment the daily dose was increased by 15 grs.,
as it was found that a certain tolerance to the alkaloid had been
established. In cases of graver severity treatment was begun by
intramuscular injection, followed in two hours by intravenous
injection of 6 grs. of quinine bihydrochloride. Before deciding on
the intravenous administration of quinine the medical officer was
advised carefully to consider the condition of the circulation. If
there was pronounced myocardial weakness with low blood-
pressure, the intravenous administration of quinine is associated
with the risk of sudden cardiac failure, and should be preceded
by the hypodermic administration of " pituitrin " or " adrenalin."
The dose of quinine should be administered in 1 to 2 pints warm

Experiences of a Consulting Physician 283

normal saline solution, the technique being that of an ordinary
transfusion. When the circulation was fairly maintained, quinine
was administered intravenously in fairly concentrated solution,
the dose, 6 grs., being dissolved in 20 c.c. normal saline solution.
The intravenous injection was given slowly, at least ten minutes
being expended in administration. In grave cases intravenous
injections were repeated every four hours till urgent symptoms
had disappeared. In cerebral cases, where there was profound
coma, it was usually accompanied by increased intrathecal pressure,
and benefit followed lumbar puncture. When the patient was
plethoric, venesection was found helpful. In the bilious remittent
type it was found essential to resort early to intravenous quinine
medication. This type was very grave, and it was found desirable
to administer 30 to 40 grs. of quinine by intravenous and intra-
muscular medication in the first twenty-four hours of treatment.
In cases of malignant malaria, when parasites had disappeared
from the peripheral circulation, and where there was evidence of
cardiac depression, with low blood-pressure and air hunger, benefit
sometimes resulted from intermission of quinine treatment for a
period of one to three days.

An interesting point arose through the frequent occurrence
of pneumonia along with a malignant tertian infection — Should
quinine treatment be carried out or should the patient be treated
as a pneumonia symptomatically ? Some medical officers are of
opinion that quinine should not be administered, but one has no
hesitation in concluding that, granted the malignant tertian
parasite in the peripheral circulation, this view is erroneous.
Benefit repeatedly followed the intravenous administration of
quinine in small quantities in these cases, as instanced by a fall
in temperature and pulse frequency, and the injection could be
repeated four -hourly without any undue disturbance of the
circulation.

Very early in the treatment of malignant tertian malaria it
was realised that transport had a most deleterious effect upon
the patient, and it was found necessary to detain the patient on
the lines of communication where possible till the end of the
third week of treatment, and then to evacuate as a " cot case."
No patient who had suffered from malignant tertian malaria was
to be evacuated as a " walker."

Dysentery. — As in all campaigns in the East, dysentery, both
bacillary and amoebic, has bulked largely as a cause of sickness
in the Army in Palestine.

284 Francis D. Boyd

In the bacillary type both the classical types, viz. true Shiga
and the Flexner-Y strains, being frequently isolated. The illness
began acutely, and, as a general rule, ran an acute course with
fever. It was possible clinically to distinguish the bacillary from
the amoebic by the presence of signs of toxaemia and the character
of the stools. The toxaemia was shown by the febrile reaction and
the effect on the circulation ; the pulse was accelerated and weak.
The stools were those of an inflammatory muco-purulent exudate,
of a somewhat milky appearance and streaked with blood.

The treatment adopted was — (a) dietetic ; (b) serum therapy ;
(c) the administration of salines.

The diet most suitable for those cases was found to be albumen
water, beef- and chicken-tea, meat-jelly, barley water, sweetened
tea without milk, and arrowroot. Milk did not seem to agree,
and was not used except in some of the Indian hospitals.

The serum treatment was undoubtedly successful, but two
factors are necessary for success — that it be given early and in
sufficient doses. So necessary did early administration appear to
be for success that an order was issued that all patients suffering
from diarrhoea with blood and mucus should be given a dose of
serum whenever they came under treatment, without waiting for
a laboratory diagnosis. The second factor essential to success in
serum treatment is a sufficient dose. Small doses were found
of little value, and accordingly an order was issued fixing the
minimum dose at 80 c.c. The saline treatment was undoubtedly
helpful, sodium sulphate being given in drachm doses, at first
every four hours, and diminished when the stool became feculent.
The infecting organisms themselves are thereby removed mechanic-
ally in large numbers by the saline treatment, with a correspond-
ing rapid reduction in the intensity of toxic symptoms.

It is sometimes stated that emetine has no influence on
bacillary dysentery. This statement is not absolutely correct.
In several cases where the disease had become subacute or
chronic, one or two doses of emetine had a considerable effect
in checking diarrhoea and hsemorrhage, even though several
pathological reports excluded the idea of a mixed infection.

Of the complications of bacillary dysentery, little was seen on
the lines of communication. Experience of neuritis was confined
to a very limited number of cases; in one there was complete
sensory and motor paralysis of the V-nerve.

Amoebic Dysentery. — While amoebic dysentery was not so
prevalent as bacillary, it yet led to a considerable amount of

Experiences of a Consulting Physician 285

sickness, especially among the troops reporting sick in the Jordan
valley. The commencement of the disease was much more
gradual; there was less toxremia and febrile reaction than in
bacillary dysentery, and, given a correct diagnosis, treatment with
emetine was very satisfactory. The doses of emetine employed
was usually \ gr. twice daily by hypodermic injection for thirteen
days. The patient, as a rule, commenced the treatment on the
lines of communication, and was passed to the base for completion
of the course.

Considerable interest attaches to the hepatitis which may
occur as the result of a previous amoebic infection, especially if
the original infection has been insufficiently treated. Some of
these cases closely simulated enteric fever. There might or might
not be a history of dysentery, but the liver was always enlarged
and tender, and treatment with emetine produced magical results.

A number of cases of abscess of the liver occurred in hospitals
on the lines, and were treated surgically. An interesting point
was that in most of the cases there was an entire absence of
any history of dysentery. The abscess occurred in " carriers "
who had not suffered from an acute attack. For example, an
R. 0. D. R. E. was admitted with a history of five days' illness,
complaining of epigastric pain and slight gastric disturbance.
There was no diarrhoea or intestinal disturbance of any sort, nor
could any history of previous intestinal disturbance be obtained.
In the epigastric region a tense fluctuating swelling was found.
The right lobe of the liver was normal to percussion. At
operation, typical chocolate-coloured material was evacuated from
an abscess in the left lobe of the liver.

Mixed infections of bacillary and amoebic dysentery were by
no means uncommon amongst the troops. The condition usually
began with the acute phenomena of bacillary dysentery, but did
not yield to treatment. Later, the presence of E. histolytica was
demonstrable in the stools. It seemed as if these individuals had
been amoeba carriers who had become infected with bacillary
dysentery, by which the intestinal resistance had been lowered
and amoebic dysentery developed.

Enterica. — The enterica group gave rise to a good deal of
difficulty in diagnosis. It was simple in the conscientious
objector who had never been inoculated, but in most of the cases
the clinical picture was modified by the effects of inoculation.
The majority of cases seen were of the paratyphoid variety. Help
in diagnosis was at times obtained from laboratory reports of high

286 Francis D. Boyd

agglutinating power of the blood-serum, or cultures from blood
and stools, but frequently these were entirely negative, or so
inconclusive as to be of little help, and yet one was forced to the
clinical diagnosis of enterica. Such a case, where all pathological
reports were a " wash-out," verified the diagnosis by perforating
three days after the diagnosis was made on clinical grounds.
The patient recovered after operation.

Relapsing Fever. — This accounted for a good deal of sickness,
especially during May, June, and July. Two types were seen —
the Egyptian and the Palestine. In the Egyptian type spirochetes
were plentiful in the peripheral circulation during the febrile
period. With the fever splenic enlargement was marked, to
recess again when the temperature fell. The pyrexial period, if
the condition were untreated, usually lasted about five or six days.
The blood usually showed a polymorphonuclear leucocytosis.

In the Palestine type spirochetes were frequently so scanty in
the peripheral blood that prolonged search might frequently be
necessary before even a solitary parasite could be detected. The
period of pyrexia was short, and the blood showed a marked
increase in the large mononuclear leucocytes very similar to the
blood picture in malaria.

In "karcivan" we have a specific for the treatment of the
Egyptian type. If given during the pyrexial period the tempera-
ture falls, and relapses after its use are uncommon. In the
Palestine variety the influence of " karcivan " is not so definite,
and relapses were more common, possibly owing to the shortness
of the pyrexial period, which made it difficult to administer the
substance while the spirochetes are present in the peripheral
circulation. The question of the dosage of " karcivan " is of
interest, for its administration during the pyrexial period causes
very considerable general disturbance. In two cases in hospitals
on the lines of communication the administration was followed by
a fatal issue which appeared to be attributable to the effects of
the medicinal substance. A dose of 0*3 grm. will control the
fever, but relapse may occur necessitating a second dose. A dose
of 0*6 grm. controls the fever, and relapse will not occur in the
Egyptian type. As, however, alarming symptoms have occurred
after the smaller dose in a limited number of cases, is the larger
dose justified in a clinical condition which in itself amongst
Europeans is seldom or never fatal ? It scarcely seems to be so,
though it must be admitted that 0-6 grm. has frequently been
administered without any apparent bad effects.

Experiences of a Consulting Physician 287

Typhus fever was a fairly common cause of sickness. The
type of the disease was not very severe as a rule, and the death-
rate was not high. Pulmonary complications seemed the most
to be dreaded. Much help was given in early diagnosis by the
pathological laboratories which carried out the proteus agglutina-
tion reaction. The reaction appears to be reliable, and, when
positive, may aid in the diagnosis before the rash has appeared,
and in the differential diagnosis between typhus and paratyphoid
with a very marked rash.

During the summer months cases of para-cholera were occa-
sionally encountered — for example, at El Arish a group of five
cases presented all the clinical features of cholera. They belonged
to the same regiment and had all drunk water from the same
pool. Here, again, the pathologist was of invaluable aid, for though
a vibrio was present in the stool it did not agglutinate, and true
cholera could be excluded.

Diphtheria and the Klebs-Loffler bacillus was at times some-
what prevalent, not only in the usual throat manifestations but
also in the form of septic sores, from which a pure culture of the
bacillus was frequently isolated.

Sand-fly fever was a considerable source of illness, important
more from the numbers affected than from the seriousness of the
clinical phenomena. True dengue was never observed. Malta
fever was a curiosity, only met in one instance. Among the
Indian troops leprosy was sometimes observed, but does not seem
to call for discussion.

The troops in Palestine did not escape the pandemic of
influenza. Pneumonia of a pronouncedly septic type was common
as a complication, and in a number of cases a further complication
in the form of malignant tertian malaria was present. This
serious disease complex led to a considerable mortality. It is
satisfactory to be able to report that hopeful results have been
obtained from the therapeutic use of a vaccine.

Pellagra amongst the Turkish prisoners of war formed an
interesting and instructive study, the results of which it is hoped
may be published at an early date.

288 James Young

A FIELD AMBULANCE IN GALLIPOLI, EGYPT,
PALESTINE, AND FEANCE.

By JAMES YOUNG, D.S.O., M.D., F.R.C.S.(Edin.),

Lieutenant-Colonel, R.A.M.C.

I. Off to Gallipoli.

In retrospect it seems a very long time since that day in early
June of 1915 when we set sail for "Service Overseas." It is only
a matter of three years and a half, but into this short interval,
which would ordinarily slip past in a man's life without much
comment, there have been crowded mingled experiences of trial
and triumph, pleasure and sorrow. Even to the youngest and
most unthinking the thrilling realities have worn right through
to the very core. We have known and we have felt, and our
knowledge and our feeling have been gathered amid the surging
tempest of war. We have lived our life under many skies and we
have watched the swaying fortunes of battle in several continents.
To a man we are different ; we may claim rightly and with pride
that we are veterans of war.

It was with bounding hearts after ten months' residence in
Stirling that we at last received the message to prepare to embark
for abroad. The ten months spent after mobilisation at home
tried us sorely, for we felt that we were ready for foreign service
long before the call came. The intense desire for work in foreign
fields and the burning spirit of adventure that overspread the
country during the early days had caught us in their net. We
drilled and we marched, we " carried stretchers " and we
" lowered stretchers " till our arms ached and our backs rebelled,
and we envied the men who were called early.

It came at last. We feverishly collected our new waggons
and harness from ordnance and our horses from remounts. , We
worked day and night and we were at last ready. It was to be
France. We knew it, for our equipment was of the pattern used
in France. And then we got orders to send it all back ! Instead
of heavy ambulance waggons we got light ambulance waggons,
and instead of horses we got mules. We knew now that we
were going East. What a pandemonium there was the night the
long procession of mules arrived ! Then there was the fitting of
harness and the endless arranging and rearranging of teams and
drivers. The mules were fresh from the ranches of Argentine

A Field Ambulance in Gallipoli 289

and our horsemanship was sorely tested. But the will was there,
and in a few days we stood by ready to move.

Two long trains took us south to Devonport. We found that
on the boat allotted to us there was room for only one officer, so
Captain Greer was elected to accompany the unit, as he was
Transport Officer and the main trials of a voyage always concern
the animals. The other officers, Lieutenant-Colonel Koss, Majors ,
Young and M'Intosh (Quartermaster), and Captains Brown, Walker,
Hunter, Stewart, Smith, and Linklater left on the 3rd June. The
remainder of the unit left the following day.

Looking back over it all, one of the greatest days we have ever
had was that day when we swept slowly down the estuary from
Devonport to the sea, accompanied by our two T. B. D. escorts,
silent wardens of our fate, with their funnels belching forth great
black clouds of smoke. Once outside, they aligned themselves one
on either side, and we were off.

These were intense days of pleasure and expectation. Nobody
knew where we were going. We whispered under our breaths
that it must be the Dardanelles, but the situation in the Eastern
Mediterranean was obscure at that time and we could only guess.
At times we feared it might be garrison duty in Egypt, but from
that unpleasant prospect our active spirits recoiled.

Every day of the voyage was full of interest. We were, most
of us, sailing strange seas and visiting ports that, save for the
fortune of war, we probably never would have seen.

We wanted to see Gibraltar, but we called there at night for
orders, and saw nothing but the lights of the town rising tier
upon tier from the water's edge in a great semicircle, and the
searchlights that turned on their blinding flashes as we approached
the shore.

We shall never forget the sight of Malta as we saw it bathed
in the early morning sun. We have seen some of the greatest
sights on this earth — the Pyramids of the Nile standing eternal
amid their desert of shifting sand ; Cairo with its minarets and
domes and the great panorama of colour as viewed from the
Citadel ; the temples of Thebes ; and Jerusalem as first seen in its
high mountain fastnesses, with the shadows playing over the
distant mountains of Moab. We have seen all these, yet we do
not think any of them ever affected us so much with a sense of
beauty and wonder as the first sight of Malta when we swept
round it that morning from the south. The island lay bathed
in the rays of the early morning sun and set in a sea as smooth

21

290 James Young

as glass and of the purest of blues. It looked for all the world
like an island of dreams. Though so far west it was the first
revelation to us of the enchantment of the East. What adorns
the long stretch of land and captures the senses and imagination
is the town of Valetta that crowns the summit. It extends in
irregular fashion over the higher land and down as far as the
cliffs of the purest of yellow sandstone, which catch and throw
back the rays of the morning sun. It is like a city of the Arabian
Nights. Fashioned out of the sandstone, it rises terrace upon
terrace to the summit, with here and there a spire thrusting its
head into the heavens. In the sun the whole is of a creamy-white
colour.

As we lay at anchor coaling we had an experience which
inspired us greatly. A French battleship swept past us at a few
yards' distance on its way to the sea. As it passed, the sailors,
with their red-tasselled caps, lined up in their hundreds and were
called to attention. A band struck up "God Save the King"
from a platform near the bridge. The French naval officers in
their blue surtouts saluted. After one verse of the National
Anthem they played " Tipperary." Our men, who were crowded
on the decks, could contain themselves no longer. They raised
cheer upon cheer as the monster glided by, and received answer-
ing cheers from the French sailors. Such incidents as these are
helpful and inspiring, especially in these days when war is so
much shorn of its glamour. We were in the mood and we
responded. We continued on our way the better for it.

We had thought that we were going straight for Gallipoli
and were a bit disappointed when we found ourselves heading for
Alexandria. The first party arrived there on 16th June, the
remainder on 18th June. Our sojourn in Egypt on this occasion
was destined to be short. We pitched our camp on the sands at
Aboukir, which is on the coast some miles east of Alexandria.
This short spell is chiefly noteworthy for the extreme heat which
we suffered. The day we arrived, as luck would have it, was the
hottest day that Alexandria had experienced (so the newspapers
declared) for forty years. The few days we spent at Aboukir
were like days spent in a furnace-room, and were passed by most
of us in a half-prostrate condition, in which exercise of any sort,
and even feeding, was a task. In a short time we should have
become baked into indifference.

But fate had its hold on us, and on 28th June we again
embarked at Alexandria. This time there was no doubt that we

A Field Ambulance in Gallipoli 291

were off to the Dardanelles. Again we were split up between
two ships, the Menominee and the Alnwick Castle, the Commanding
Officer (Lieutenant-Colonel Eoss) and the unit on the latter, the
other officers on the former.

Two days afterwards we dropped anchor in the bay of Mudros.
Then for the first time we began to feel the imminence of battle.
There was a constant bustle in the bay, which was crowded with
transports of all sorts and sizes. Ships were constantly arriving
with fresh troops or departing empty for a fresh load. From the
deck of our vessel we could see trawlers passing laden with
wounded men and we could see others with their load of death.

II. We Land on Gallipoli.

Whilst we were still at Aboukir we met officers and men
who had been at Gallipoli and who had been invalided to Egypt
sick or wounded. It was after meeting them that we began to
realise, though still only dimly, the fate that was awaiting us.
The stories we heard then were such as were calculated to damp
the ardour of all except the boldest or the ignorant. And we
were in the latter category. We learnt of the beaches that were
shell-swept by night and by day, and landing on them was at all
times a matter of considerable risk. And then we were told that
after you had landed your existence was a nightmare, for our
troops were " hanging on by their teeth " to a narrow strip round
the water's edge. So we were told by a staff officer who came to
see us and to advise us regarding the equipment we were to take
with us.

Colour was lent to all these tales when we received orders
that no horses or waggons were to be taken to the Peninsula.
They were all to be left behind in Egypt. All equipment was to
be man-handled after landing. Those who know the extent and
the tonnage of a field ambulance's equipment, as we did to our
cost, will not be surprised to learn that this announcement caused
consternation and dismay in our midst. But we had come out to
face the worst ordeals and this was no time for turning back.
We decided to leave fate to settle how a field ambulance could
work for even one day without horses and waggons. We had not
yet learned that spirit of calm submission and waiting for events
which later experience inevitably fosters in the Army, and, as
almost invariably happens, we found in this case that subsequent
events proved our initial fears to be largely groundless.

292 James Young

On the night of the 2nd July the first party, consisting of the
officers who had been split off' from the unit at Alexandria and
who travelled on the Menominee, set sail for Gallipoli. One of
the officers went ahead on a T. B. destroyer, which was carrying
a half battalion of infantry, to explore and prepare for the others.
The remainder of this officer's party transhipped to a trawler.
At this time, and throughout the campaign, all traffic to the
Peninsula took place on smaller vessels, chiefly because of the
added submarine risks run by larger craft. The larger transports
never came beyond Mudros. Here all troops and ammunition
and stores were transhipped to trawlers. A large fleet of this
class of vessel, which in all theatres of the war has played such
a great part, was kept running day and night between Mudros
and the various beaches at Gallipoli. The only large vessels
ever seen in the neighbourhood of the Peninsula were warships
and hospital ships. In the earlier days even hospital ships were
rarely seen, and the evacuation of the wounded was carried out by
means of returning empty trawlers.

The passage from Mudros to Cape Helles, where our lot was
to be cast for many months, was only a matter of an hour or two,
and we landed safely at V Beach before dawn on 3rd July. This
beach, which figures so prominently in the original landing in
April, is on the south side of the tip of the Peninsula. It was
here that the transport liner, the River Clyde, was run ashore.
Suddenly opening up her sides, she poured forth the men that
swarmed to the shore through the water or across the lighters
that were shoved in between the ship and the beach. The whole
operation was carried out under a constant and severe fusillade
from the Turkish machine guns placed on the neighbouring slopes.
One had only to see the place to realise the awfulness of the task
which these men faced and carried out, though it was only a
fraction of them that reached the shore.

It was here that our first officer party landed, just as dawn
was breaking on the morning of 3rd July. The wind had risen
and the sea was rough and it was no easy task. The trawler drew
alongside a bridge of lighters placed against the side of the River
Clyde. One had to clamber on to the lower deck of this vessel
and then along a swaying narrow plank bridge slung from the
port side. From this one you passed to another bridge of lighters
which conducted you ashore.

We were at last on the battlefield ! The Turks had not
commenced to shell the beach yet, but they would soon start

A Field Ambulance in Gallipoli 293

when they saw the troops landing, for we were under direct
observation from the Asiatic shore of the mouth of the Dardanelles.
As we learnt very soon, the Turk kept a very watchful eye on the
doings on this beach, and on W Beach, which was just round the
corner on the northern side of the toe of the Peninsula. This was
also called Lancashire Landing, in memory of the gallant Lancashire
Battalion of the 29th Division which here fought its way to shore
in the last days of April. The Turk could see movements, and he
was not long in sending across a salvo from Asia or from Achi
Baba to harass any traffic that he had spied.

So we were told to hurry off the beach as quick as our legs
would carry us. And we did. We climbed the banks that slope
on all sides down to the cove, and were soon breakfasting with a
field ambulance which had arrived some days before and was
meanwhile camped on the flat ground overlooking W Beach.

We had not been there more than ten minutes before we
experienced our first shelling. It was the morning straf of
W Beach from Asia, and the shells just missed our heads on the
way to the beach. We were hungry men, but we did not relish
our breakfast on that occasion. We had our first taste of modern
war and we didn't like it. The imminence of danger was so great
that I think few of us thought that morning that we would see
the day through. But time works wonders, and even shells create
indifference after a time.

Cape Helles was badly placed for shelling. It could be shelled
either from Achi Baba or from Asia. The Straits are only a
matter of three miles wide, and the Turk had many batteries
situated on the further shore to molest our flank. He was fond
of dodging guns about on the Asiatic side, so that you never
knew from which direction you were going to be shelled next. A
big gun that he used largely there went under the nickname of
" Asiatic Annie."

The solitary band of officers without a unit, for we had heard
nothing of the ambulance since we left Alexandria, dug themselves
in to await the turn of events. We spent the time in exploring
the neighbourhood. We saw the guns at the fort of Sedd-el-Bahr
which had been wrecked by our Navy in February and March.
We visited the crumbling buildings that had once been the village
of Sedd-el-Bahr, and we watched the frequent British and Turkish
artillery bombardments on the hill slopes of Achi Baba some
miles inland.

We chose a clear piece of ground about three-quarters of a

294 James Young

mile in from the shore for our ambulance, and we hoisted a Red
Cross flag to warn the Turks of our prospective arrival.

The commanding officer and the ambulance arrived on the
morning of 6th July. We could see from our vantage ground on
the shore the trawler pull in towards W Beach laden with its
khaki figures. Little realising the precious cargo it carried we
wondered, and we saw others wonder, when the Turks would open
on it. But we did not wonder long. When it had come close up
to the pier of sunken ships, which formed at once the landing-stage
at W Beach and the breakwater for smaller craft, a ranging shell
flew overhead and splashed into the water just beyond our incoming
trawler. Another and another fell in quick succession all round,
and we thought she was doomed. Then, to our relief, she pulled
out and the Turkish fire ceased. Later in the day she ventured
in again and discharged her load, which we now learnt was our
expected unit. They landed at W Beach amidst shelling, but we
had only one trivial casualty — Private M'Morran. This man, to
us all, will ever have a tragic association, for he was the only
man who was wounded at the landing, and when we went into
battle some days after he was the first man to be hit, and by a
bullet which killed him practically outright.

Our fears in Egypt regarding transport for our stores and
equipment, we now learnt, had been groundless. We managed to
charter some. Indian mule carts, which we had with us throughout
the rest of the campaign. These were subsequently to prove of
great value. They were small open carts drawn by a couple of
small mules and driven by an Indian driver. The cart we called
the "garry" and the man the "garry wallah." They did noble
service throughout, and the wallahs proved to be quiet, obedient,
uncomplaining, and daringly brave. During their work they
would chant their monotonous Indian dirge-like songs, and at
night, when their work was done, you would hear them play
their plaintive pipe to the moon.

Within a few days we were hard at work digging our camp.
We were novices then, and the remembrance of our early digging
efforts provokes a smile. We were adepts at pitching a camp of
tents, but our training had never taken into consideration the
prospects of a subterranean life. We were, however, anxious to
learn, and the dire necessity of protection against the enemy shells
that constantly pestered us made us apter pupils than we ever
thought to be.

We soon had funk holes for ourselves and patients, and our

A Field Ambulance in Gallipoli 295

camp gradually took shape. This was our main dressing station,
and here we remained during the whole six months of the
campaign. Throughout that time constant developments in our
premises took place, until at the end we had quite a large hospital
below the ground surface. There were five long deep trenches,
two of which were allotted to the hospital. These were covered
against the weather with corrugated iron resting on walls of sand
bags. Alcoves were dug forward from the trench and formed the
wards, and at the end we had a large bay fitted with doors and
glass windows for the operating theatre. But these were very
late developments. Our early efforts were carried out in face
of a constant shortage of engineering materials, such as timber
and corrugated iron, and, looking back on it, one wonders how we
ever managed to maintain an ambulance working with a decent
semblance of efficiency.

Throughout the larger part of the time the weather was good,
and waterproof sheets slung across the trench alcoves sufficed to
keep the blazing sun off the faces of our patients. But the rains
of October were on us before the long-promised engineer supplies
had arrived. With the first suggestion of broken weather we
held a council of war and decided to dare the Turks and pitch
our tents, which till that time we had refrained from doing for
fear of the consequences. But we found the Turk a sport on this
occasion as on others. He respected our flag, and our tents
remained from that day till the end, with additions now and then
as our patients increased. On no occasion did we ever find the
Turk disregard the Convention of the Red Cross, and several
times we have satisfied ourselves that he exercised special care
in steering his shells clear of our camp. We have often had
shells in our camp, but we have a strong belief that they were
accidental.

At the time we landed, and whilst we were settling down in
our new quarters, there had been a lull in the battle for Achi
Baba. But it flared up within a few days, and we were hardly
dug in when we found ourselves thrust into one of the fiercest
battles which it has been our lot to serve in during all these
years.

Our division was fighting beside the Eoyal Naval Division,
and it was decided that, to begin with, we should send up officers
and men to assist the ambulances of this division at their advanced
dressing stations, which were to serve the frontage of our division
and their own.

296 James Young

The advanced stations were situated in the Achi Baba Nullah
(or valley), the forward one about three miles from our main
dressing station, the nearer one about three-quarters of a mile
behind this. The former had been called the Whally Cross
dressing station by the East Lancashire men who first built it ;
the latter was called Skew Bridge dressing station, after the
fanciful title of a small bridge across the burn, which trickled
down the Achi Baba Nullah, to open into the Hellespont at the
broad, sandy inlet of Morto Bay.

To regain as far as possible the sensations of the moment,
which are preferable to a bare record culled from memory, the
next chapters are extracted from a diary written at the time, the
gaps of which are now filled in, in respect of matters which had
to be shrouded in secrecy when it was written. To those of us
for whom war has lost its edge, and whose original sensibilities
are somewhat dulled, these extracts may seem over-vivid, but I
prefer them because they are living. They were hammered out
hot on the anvil of reality.

III. Our First Battle — Achi Baba.

12th July 1915.

We are in the very thick of it. All day long there is the roar
of guns, interrupted only by short spells, when, by contrast, the
peace seems too profound for this world. At this moment the
roar and crash are greater than usual. Since the early morning
the guns around us have been hurling their message of hate into
the Turkish trenches. From my dug-out I can see the flashes,
repeated with awful rapidity, of a French battery that lies over
from us, just a few hundred yards away. Every now and then
there is a bang, a whiz, and a great cloud of earth and stones
thrown into the air, as the Turkish shell vainly tries to find the
guns that are concealed with wonderful ingenuity. Immediately
after there is a crash, as the earth's cry of agony reaches our
dug-outs.

For a short time earlier in the morning the guns suddenly
became quiet, and, from the slopes of Achi Baba that are exposed
to our full view, there arose almost immediately a terrific clatter-
ing of musketry and machine-guns. We knew then that our
gallant fellows had left their trenches, with set teeth, and their
Scotch faces glowing with the fire that on this battlefield meant
only one thing, as it had meant on many a battle-field in the past.

A Field Ambulance in Gctllipoli 297

It was to be death or glory. Even now we have heard, as we
expected it, of their success, though we shall have to wait till later
in the day to know the full proportion of the victory.

Our intense interest in the happenings on the hillside is
increased by the fact that many of the fellows taking part in it
are well known to us all, and also by the fact that the greater
part of our ambulance is up there taking part in its first action.
The three junior officers are out with them. We had to send
two officers to fill regimental medical jobs temporarily. I hope it
may be very temporary, for we are left very short-handed.

The spirit of our fellows is magnificent. Now that the time
has come they are keen to show themselves worthy. There was
disappointment in many hearts this morning when they found
they could not all go into action. Our eyes followed them as they
set off two at a time, with their stretchers and their surgical
haversacks towards the din of battle. They were soon lost to
sight in the mist of sand and smoke that by this time enveloped
everything. They knew what they were going to, and they went
with willing hearts. My heart is anxious for them. It is perhaps
too much to expect them all back scathless, but let us hope no
dreadful thing will overwhelm them. We will* know soon. The
inferno is as bad as ever. One wonders how anything could live
through it. The noise is terrible, and the earth seems to shake
to its very heart. God help them all !

The scene where the intensest conflict is raging looks quite
close to us. The roar of cannon now is constant, and is so
deafening that one even here can hardly hear oneself speaking.
Through it all one can see men and horses or mules and ammuni-
tion waggons crossing the country, or setting off in a panic when
a shell bursts too near. Our own men, who are left, are deepening
the trenches, stopping every now and then on their spades to see
how things are going. Just then, during a momentary hush, a
yellow-breasted bird flew by, chirping as if nothing were amiss.

13th July 1915.

I have been up at the advanced dressing station since early
morning to see how our fellows are faring for food and sleep, and
to lend a hand with the wounded. I found the men all working
with magnificent heart and will. Begrimed they were and fagged
out with their ceaseless and anxious work, but they had never a
murmur or complaint. They were out to do their task to their

298 James Young

utmost, and an inspiring task it is. The poor fellows were seeing
sights that this world, with all its madness, can show only on rare
occasions. They were seeing limbs shattered beyond repair, and
caked with blood and mud. They were seeing gashes that
shrapnel or shell had torn in the bodies of their fellow-creatures,
till even the practised eye could scarce recognise the original
parts. They were seeing long lines of livid forms pass on
stretchers that were as likely to be dead as living by the time
the dressing station was reached. Many were breathing their
last. Even the eye unused to death could see that. They were
seeing all these things for the first time, and yet there was no
sign on their faces, as I scanned them anxiously on my way up
towards the trenches, of panic or fear at the horrible thing they
had come to meet, but only a look of grim determination and
resolute self-control.

I knew the fellows well before, and I expected it, but I felt,
and feel now as I write, a great sense of pride in them. The
sterner types were toiling away in the scorching sun with their
tunics off and their sleeves turned up, with nothing but their
duty to exalt them. The gentler types were stopping every now
and then in their task to speak a word of cheer or comfort to
their wounded brother, or, with a smile, to re-adjust his wounded
limb or offer a drop of water to moisten his parched lips, for thirst
is a symptom almost as trying as pain.

The medical officers at the dressing station are working at their
gruesome job continuously, with a break now and then for a sleep
or a drink of tea. Tea without milk and slightly sweetened is
what one lives chiefly on here. Often it is the only thing you
can get, and right welcome it is at any time.

"War is a strange thing. On the one side you have all the
signs of excessive hate and unbridled passion that show the
innate madness that still lurks in the human soul. On the other
you have all the signs of unselfish devotion and kindliness of
spirit, even towards the man whom you have just struck in your
hate, that show that there is, somewhere, a reserve*of saving grace
that rescues mankind from utter degradation. All in all it is a
horrible jumble of inconsistencies. Meanwhile, let us cling fast
to the better spirit in us. We want it all. Thank God that our
task here is one of mercy and not of destruction. The realisation
of the horrors and sordidness of it all is impossible till you are
amongst the groans of the dying and the agonies of those that
were better dead.

A Field Ambulance in Gallipoli 299

I have truly seen some inspiring sights. I saw an A. and S.
officer with a shattered thigh whose chief concern, as he lay
stretched on the table, was that his men would be well supplied
with water, as the day was hot. He was carried out with" a smile
of absolute resignation on his face, and his last words to us were
of gratitude for what had been done for him. He was very
seriously hit, poor chap, and up there we could do very little for
such as he. I was badly upset for a time over one of our own
poor chaps. He was hit, mortally, I fear, close to where we were.
I had at the moment no time to look after him, and by the time
I was free he had been patched up and sent along the line. I
fear it is hopeless. The officers are all well and cheerful so far,
thank heaven.

\Uh July 1915.

Have been hard at it since I wrote last. I got back last night
and have just had a sleep, wash, and shave, and am off again.
Things are quieter now, but we have had two days of Hell. Our
poor fellows have been badly hit — killed and I don't yet know
how many wounded, the whole business happening just in front
of one's nose.

\Uh July 1915.

These last four days — Monday, 12th, to Thursday, 15th — were
days of awful strain and anxiety for us all. I shall never forget
Monday afternoon, when the affair reached a climax. The din
became incessant, and air and earth were shaken and torn in an
inferno of hate and destruction. . . .

Our bearers have worked with tremendous spirit, and under
circumstances of terrible hardship and strain, for, once the
casualties started, it was one unending stream. We placed them
in relays between two advanced dressing stations. Three of our
officers lent a hand at the front and another helped at the back
one. My % duty was directed between the two, and a general
supervision of the working of our own men, especially seeing that
they were fed and rested sufficiently.

Great credit is due to everyone for the way the work was

carried out, and our unit has been congratulated this morning

for its services. Congratulations mean little to anyone after

'an experience like that. The best reward is the sense of

duty done.

The officers worked with a will, and spared themselves nothing
whilst the stress was at its greatest. Sleep was impossible, or only

300 James Young

to be had in short snatches of exhaustion for a couple of days
and nights. The intense concentration demanded, with plentiful
supplies of tea, carried them safely through. "Tea, tea, tea."
That is the cry as the perspiration rolls from one and soaks
right through every garment after hours of toil under the
broiling sun.

The medical arrangements are as follows : —

Starting at the trenches each battalion has its regimental
medical officer. The sick report to him every morning, or, in the
case of an emergency, during the day. During an action the
wounded are carried to him by the regimental stretcher-bearers.
The work of the bearers is very strenuous when the casualties are
very heavy, and they are exposed to all the dangers of the front
line trenches. It is therefore not surprising that they often suffer
heavily themselves. When a big affair is on, they toil day and
night between the trenches and the regimental aid-post, where
the doctor and his orderlies wait beside their medical stores and
dressings to attend to the wounded before they are sent further
down the line.

The regimental bearers are themselves trained in first aid, and
whenever they observe a wounded man they apply the first field
dressing, which every soldier carries fixed inside the tab of his
coat. When the losses are heavy the soldier has to depend on
his neighbour to render first aid, and every soldier is instructed
in the use of the field dressing. The wound is exposed in the
quickest way possible and the dressing is rapidly tied on. It
prevents unnecessary infection whilst the man has to wait his
turn for removal to the doctor.

Not infrequently when there is no one near to lend a hand the
wounded man has to apply the dressing for himself. We saw a
man the other day who had a very severe fracture of both bones
of his leg. He cut up his trousers, pushed the fragments of bone
that were sticking out back into their position as far as he knew
how, and then fixed on his dressing. This is a type that one sees
fairly often — the man who won't kill. We had another such
who passed through our hands some time ago after a big action.
He had a large hole in his back, which he must have got far in
front of his fellows, for he lay out for a considerable time. An
ordinary man would have lain out for ever. He had the spirit
that brushes death itself aside. He crawled till, as he said, he
fell asleep, and crawled again whenever the din grew louder and
he wakened. We knew that it was no natural sleep that had

A Field Ambulance in Gallipoli 301

arrested his gasping efforts, but the collapse of exhaustion, and
haemorrhage.

These men have more than the mere animal will to live.
Through it all their hearts remain smiling and they make others
smile too. They are carried on their rude bed of pain and
exhaustion into a place that has kept company for many weary
hours with the tortured body and with death itself, and the walls
of earth and the roof of wood and sand became radiant with a
new spirit. The heavy-hearted catch up the cheerful strain.
Suffering would almost seem to be a joy. And no one knows
exactly how it has all happened, least of all the heroic and simple
spirit that itself lies prostrate and yet laughs in the face of death.
Their greatness is all unconscious, and is only great because it is
so. The doctor's smile and word of cheer and encouragement
seem puny and irrelevant before such a thing as this. The smile
and encouragement have found a thing immeasurably greater
than themselves, and they remain the better for the discovery.

When the regimental stretcher-bearers pick up a wounded
man they carry him to the regimental aid-post. This is close
behind the firing line, and is simply a hole extending from the
main communication trench, with ledges cut for the doctor and
his assistants, and any patients who are there, to sit or lie on.
Round about are arrayed the medical and surgical panniers that
are thrown open ready for use when an action is on.

It is imperative that the doctor be at some spot which all the
officers and men belonging to his unit know, and to which the
slightly wounded can walk and the severely wounded can be
carried. This arrangement is necessary, as it is impossible for
the medical officer to do good work in the firing trenches them-
selves that are scattered and cramped. The work done at the
regimental aid-post is always carried out under grave risks, and
the losses amongst medical men, who have died at their duty,
have occurred largely at these places. During an action the
shells and bullets may be falling like hail, and yet there is never
a lull in the work of mercy.

The patients sit or lie round waiting their turn. Every now
and then the bearers squeeze along the narrow trench leading to
the doctor's place carrying a man whose grave condition demands
immediate attention. The doctor turns aside from the broken
legs and arms and bends over the prostrate figure, his assistants
deftly cutting the clothes here and there till the wound is properly
exposed, and then after a few skilful touches, during which perhaps

302 James Young

a tourniquet is applied to -stem the red gush that carries life away
with it, the gauze, wool, and bandage are placed into position. A
ticket or " tally " with a red edge is torn from the book, the man's
regiment, number, name, wound, and treatment quickly jotted
down, and then the tally is fixed to the button of the tunic for
the guidance of those farther down the line. The red edge
denotes " danger," and that man will receive first attention where-
ever he may be.

The doctor turns again to the patients whose needs had to
give way before the greater danger, and one by one their wounds
are bathed and dressed, and they are carried off by the bearers
waiting near, or they are directed to walk if their wounds are only
trivial. If they require a helping hand, a bearer not engaged at
the moment with a stretcher is always there to aid them on their
way. Before sending them off the medical officer makes out the
ordinary or white tally for each, and they pass on, carrying the
label fixed over the breast that marks, better than any medal
will ever do, that they have fought and suffered in their country's
cause.

If you are to picture the scene at the medical aid-post during
an action, as indeed at all the more advanced places of medical
treatment, you must realise the awful circumstances of the time.
The air is torn with the din and crash of the heavy guns that
belch forth destruction on all sides, and with the constant crackle
of the rifles and machine guns. The bullets fly past with a hiss
and a hum. As the shells cross a hollow in the ground the sound
of their flight gathers volume into a roar, that is prolonged long
after they have passed overhead. It is as if a thunder-storm had
burst forth at your very ears, louder and more furious than earth
has ever known, and that seems as if it would never cease.

Every now and then the doctor and those around him stand
for a moment listening intently, and then duck suddenly as
a shell tears past with a scream and falls a few yards off,
shattering everything in its course. A few seconds later, perhaps
without a trace of warning, there is a terrific crash overhead,
as if the storm had concentrated all its fury for one supreme
moment. The shrapnel spatters the parapet and the trench with
its deadly charge, and the doctor turns again to his work of grace.
He feels a sharp twinge in his arm, where a maze of earth has
struck him, but that is nothing and his work is pressing. The
man on the ledge before him, whose hand he has just finished
dressing, sits for a moment gazing vacantly at the opposite

A Field Ambulance in Gallipoli 303

wall, and then rolls over heavily with a bullet through his brain.
He is carried out gently, and it is then seen that the same
shrapnel charge has found two of the other patients, who by
this time have begun to crowd round the doctor's trench waiting
their turn.

The bathing, dressing, and bandaging commence again through
it all. They must all be sent off down the line as fast as possible.
The doctor and his orderlies swab, and cut, and snip, and tie, until
the crush is well-nigh over.

The doctor's arm has been paining, but there was no time for
it, with so many that must be dressed and passed on, waiting by.
His orderly has seen the blood oozing through his shirt and
running down his arm, but there is blood everywhere, and who
minds blood on such a day ? With the lull that leaves a gap for
thought the doctor wonders if a lump of earth could really cause
so much pain, and there is a stream of blood trickling down after
all. He knows now, with a feeling akin to annoyance, that he
must have a dressing and bandage round his arm and join the
throng that is passing on down the line, with a tally fixed on his
breast. The bullet has gone right through the back of the arm,
and he knows the dangers and the dreary prospect before him.
He has been cheery from the beginning and his cheerfulness
soon returns. He makes the necessary arrangements, goes to see
about a man to carry on his work, and at length takes his place
in the line that is thinning down with the evening.

I know that man well,* and saw him two months later on his
way back to the line. He was sorry ab6ut the delays that had
kept him away so long, and he went off with an agile and happy
step to the front, where his men had again taken their places. I
think he is one of those men who do not know personal fear, and
whose sense of duty is always a keen, boyish pleasure. It may
be otherwise. It may be that acute sympathy is combined with
a timid heart, as is often so, but the hard needs of duty have ruled
down the fear in his breast, which is known only to himself.
Which is the better ? It is not easy to say. There must be
many of both at this time toiling unflinchingly and unselfishly
for their country.

We must again join the procession of the maimed and the
dying on their course along the line. From the moment when
they leave the regimental medical officer they are taken under

• Captain E. D. Gairdner, D.S.O.(and bar), Croix de Guerre, R.A.M.C. (T.),
Medical Officer, l/5th R.S.F.

304 James Young

the care of the field ambulance. The regimental bearers carry
the patient to the aid-post, and the bearers belonging to the field
ambulance take him over when the doctor there has dressed his
wound.

Our function starts here. The first relay of bearers carries
him or-supports him, if he is able to walk, for a quarter of a mile
or so along the trench, where the second relay takes him over.
Another quarter of a mile and the third relay takes over the
charge, and, in our case, these last bearers see him as far as the
advanced dressing station, another half mile or thereabout. Here
there are doctors and dressers working continually night and day
while there is work to be done. During an action the work may
be constant for days, but even during times of quiet there are
always cases passing through — sick men and men wounded by
the bullets and shells that fall in the trenches at any time of
the night or day.

IV. The Advanced Dressing Stations on Achi Baba.

On the 13th August we took over the evacuation of the sick
and wounded along the line of the Achi Baba Nullah. Our bearers
work backwards from the regimental aid-posts in the trenches
to the Whally Cross advanced dressing station. Stretcher cases
have to be carried the whole way.

The advanced station is far enough back to allow of surgical
treatment being carried out with a certain degree of comfort.
But a mile or less is not of much consequence in these days of
war. During the heat of an action it is only a little less storm-
tossed. If anything, the noise is greater, for we are nearer the guns
that blaze and crash on every side, and, being on the main line of
trench, the ground all round is frequently searched by the enemy's
shrapnel. There is hardly a moment when stray bullets may not
be heard whizzing past, to lodge in the scrub-grown bank opposite,
or to strike the road that runs in front. When they land they
give a sharp dull thud, and a fine cloud of sand rises to mark
the spot.

The bearers who ply to and from the dressing stations have
a task beset with dangers, and, as must happen, a gap is every
now and then made in their ranks. We had many such amongst
our own men during the last severe action. They tramped the
trenches during three weary, blazing days, and they tramped
them during the warm nights whilst the stress was at its height,

A Field Ambulance in Gallipoli 305

bearing down the wounded that still kept coming in. They
carried on the stream of men that had to be dressed and passed
on, and when they fell they were swept into the stream and
were passed on themselves.

The Whally Cross dressing station lies in a gully or nullah
that runs across the country for a considerable distance, There
is a space here of a few hundred yards where the trench is absent.
It is carried on by a narrow track that is protected on the
danger side by the bank. This has been undermined in places
to make dug-outs in which the passenger can crouch when the
rifle- or shrapnel-lire is falling thickly, and it has been raised in
places, where it is too low to afford cover, by means of loose earth
that has been thrown up to form a parapet. Farther down, the
track again passes into the trench. Along its side an extremely
dirty stream trickles, and notice-boards warn the passer-by against
using the water for drinking or even washing. It is infested by
frogs, as indeed are all swamps and streams in the place. On a
quiet evening their jarring croak fills in the intervals between the
outbursts of rifle-fire.

The station stands just within the sheltered bank of the nullah,
in a spot admirably suited for the purpose. The ground rises not
too steeply for about twenty feet or so, and when you stand on
the track and face the bank you are looking right back along the
line of fire.

The man who set out first to raise his Eed Cross flag in this
region must have seen that this was the very place for him. It
was an easy matter for him to dig the bank away to form an
entrance. You then mount a step into the dressing-room, a hole
about two yards square, dug into the bank and covered by some
corrugated sheeting supported on wooden beams. Boxes and
panniers lie round the sides, a plank is laid across behind by way of
seat, and coats, haversacks, and water-bottles hang round the walls
on nails driven into the wood. Beside it, to the right, you mount
by half a dozen rude steps to a narrow dug-out where the medical
officer eats and sleeps. Then behind these you have a whole host
of dug-outs lying just under the upper edge of the bank. To the
left there is another dressing-room where there is more room and
where urgent operations are done. Next to it is a broad dug-out
for urgent cases that require some hours of rest and treatment
before you dare send them farther down the line. Then you have
the holes where the other officers and men sleep.

It is all very primitive, but it is a very fascinating place. It

22

306 James Young

has stood the storm and stress of several months. Its wooden
beams have been drilled and grooved and splintered with shrapnel
and rifle bullets. A high explosive shell burst through the roof
of the patients' room the other night. It shook the sergeant who
was in it pretty badly, but that was all.

I could tell you tragedies of the road that runs by that would
horrify you, though they have long ceased to horrify us. It is a
place of tragedy, and yet we like its simple shelter of wood and
earth. The last men lived and worked there night and day,
through quiet and storm, for several months, and they were loath
to leave when we came to turn them out.

It is a haven on the road for those whose task is bearing them
down, and they come in for a little rest and comfort. A sapper
came in to-day, overcome with the heat and the unpleasantness of
a new job he had on at the front trenches. He sat and talked
and drank tea, and went away feeling better. He talked of the
fine Scotch fellows he had seen lying up there, though he did not
know I was Scotch. The other day a man came in on his way up
to the front line to find his brother who had fallen two days
before. He was strong and collected as he went off. But his task
proved hopeless.

As you sit in the dressing-room and look out between the
wooden props that form the door you may watch the regiments
passing from or to the trenches. As they pass in single file down
to the rest camp you can see, showing through all the dirt and
weariness of their days in the front line, a feeling of relief at the
prospect of quieter days and nights. Those that pass up swing
along with their heavy kit and rifle and spades, tired already with
the heat, but apparently regardless of the dangers they are going
to meet, although they are no strangers to the life of the front
line trench. It makes little difference if ' the Turks have spotted
them lower down and follow the thin line as it passes up with a
rain of shrapnel. They have had this experience often before, and
they continue on their way with a healthy indifference to danger.

If you climb a few steps leading from the dusty track, and
when half-way up the bank you turn sharply to the left for a
hundred yards or so, you come to our little cemetery. It has
steadily grown until, when we took it over, there were about sixty
mounds with their humble wooden crosses with the names of those
who have been called away from the noise and crash of the fight
written across firmly in indelible pencil. Like everything else, it is
all very primitive. A few of the man's company come down with

A Field Ambulance in Gallipoli 307

their spades, and the parson conducts a simple burial service. There
is little time for sentiment or regret. Two of our own men lie
there. Their place is marked with a simple wooden stick, but we
hope soon to have two crosses, which a joiner and a wood-carver
amongst our fellows are making.

The cemetery stands in an open piece of ground. The extra
height of bank which shelters the dressing station disappears just
before you reach it, and it thus stands on the top of the ordinary
low embankment that runs along the danger side of the track
below. It is not always safe to visit the cemetery, and accidents
have happened whilst a burial was in progress, for it has nothing
to shield it from the hill that rises slowly to the right, where the
entrenched armies face one another. Everything is quiet just
now, but you see the fresh bullets lying where they have struck
the mounds overnight, and even the wooden crosses are not saved
from the storm that breaks with the dark. It is a place exposed
to all the noise and clank of the fight, but the tempest's fury only
serves to accentuate the peace of those below. It is a true soldier's
burial-place.

In the early morning, before the haze of mist and sand has
settled over everything, you will find a pleasing view from this
flat piece of ground. In front, there is the gently undulating
slopes of hill rising ultimately to the summit that so far has
defied all attempts at conquest. It is a peaceful scene, with its
green growth of scrub and tree, and yet it is fresh from some of the
fiercest fights of history. Two big armies are there in front of us,
gathering strength for the final blow, and yet there is not a sign
of movement. There is nothing to mark the subterranean city of
the gathered hosts except the brown lines of earth, one behind the
other, that show where the trenches stretch across the hill.

Close at hand, a few hundred yards along the track that passes
by us and that carries on the communication trench, there is a
well — Romano Well — that gives the coldest and purest water on
the Peninsula. So the soldier will tell you. It is a favourite spot.
It is also well known to the Turk, and he every now and then
sends a shower of shrapnel amongst the men who gather round
waiting their turn. Many a man has lost his life while in pursuit
of a cooling drink, and it has now a sinister reputation. Its water,
however, is still as favoured as ever.

If you turn and look across the track that passes a few feet
underneath you, you see the opposite bank rising to a broad, flat
stretch of ground covered with a dark green shrub and some

308 James Young

trees. Beyond this the ground rises steeply to a height of
150 ft. or so. Down to the left the track runs along the
nullah, and a mile or so farther on this opens out on to the
Hellespont, with its strait of dark blue water intervening
between us and Asia Minor. Beyond the Hellespont and the
coast of Asia, some miles inland, but still only a short distance
away, we look along the plain of Troy.

This little station of ours has woven itself closely into the spirit
of war. It has seen and shared its horror and tragedy, its noise
and danger, its exaltation and inspiration. It is on the direct line
of things, and it knows the reality with a very intimate knowledge.
There is none of the flare of the trumpet nor the beating of the
drums here. There is none of the glamour of the dispatch. We
leave that to the commander and the journalist and those at home.
We only know the grim spectre that walks this countryside and
that lays his hand with a destroying touch on the manhood of our
race. We see the suffering and the death that are his work, and
when we pause to think, which we rarely do, we see behind it all
the tears and anguish of a sorrowing nation. But the spectre of
war is too near to us for his terror to remain long amongst us.
The horrors of the time have dulled our sensibility, and it is well
that it should be so. We have occasional spells of vision, when
we see through all the travail of these mad times the birth of
better things. But our imagination is for the most part dull, and
a drab determination carries us on our way.

Just now this nullah station has little to disturb its peace
during the day. When big things are going on in front, as
during the 12th, 13th, and 14th July, it is the centre of a
busy traffic.

On such a day there is a continual coming and going. The
wounded are brought down from the regimental aid-posts, and in
a majority of cases their wounds are dressed with more attention
to modern surgical needs than is possible further forward. The
bearers leave them lying outside on the track under shelter of the
bank, and they are brought in for treatment one after the other.
If they are very seriously hit, they may be taken to the dug-out
up the hill behind for observation. If not, other stretcher squads
take them over and carry them on the next lap of their backward
journey.

We have passed not a few wounded Turks through our hands.
Most of them are big fellows, large-limbed and broad-backed.
Truly a dangerous enemy. They receive exactly the same treat-

A Field Ambulance in Gallipoli 309

ment as our own fellows, and they have a pleasing way of exhibiting
their gratitude for the unexpected kindness shown them. One
big man positively beamed thanks when one of our bearers gave
him a cigarette and lit it for him. For them, as for our own men,
their greatest solace at such a time of pain is a cigarette clasped
between their lips. They are dirty and ill-kempt, as is every man
who has been long in the trenches. They are often hungry and
thirsty, and it is amusing to see them making friends with a thick
piece of bread and jam, as I have often seen. Their trench fare is
apparently very simple. In their haversack you will find only a
piece of black bread and onion. They are mostly well-clothed.
One man had the most beautiful underwear I have ever seen on a
man. He must have been of good social position, and it was
obvious that his needs had been the subject of fond care on the
part of those he had left at home. Kound their waist they all
wear a broad band several yards long, and it is a matter of no
slight difficulty unrolling it as they lie on the stretcher.

This little station is on the direct line of news, and we get
early first-hand information of what is going on in front. Every
man has his story to relate. You must first learn, of course, how
he himself was hit, how he had just climbed the parapet for the
charge, when he was nailed by the machine gun, or he had just
reached the Turkish trench where they were four-deep, or he was
forward in the bombing-trench or he was got by a sniper, when
going along one of the saps. They will then tell you how the fight
progresses, but you soon learn to discount their story, for the field
is big and their view of it small. It is not till the following day
that the reliable news leaks out.

During the days of stress you may see a thousand or more
cases in twenty-four hours. It means hard, constant toil, with an
hour or two snatched for sleep. But there is a satisfaction and
inspiration about it that keep fatigue at a distance, for it cannot
last long, and in a few days the lull comes, when you can indulge
your tired eyes and mind and back. This feeling pervades all
ranks. We have to make arrangements, of course, for regular
reliefs, but I have learned afterwards that some of our bearers
have toiled almost incessantly for forty-eight hours. They would
not be stopped by their sergeants. They all worked well, and
we had great difficulty in picking out any for special mention.
But we decided on one man who had worked nearly without
stop at carrying patients during almost constant shell- and rifle-
fire for forty-eight hours when he himself, a great part of the time,

310 James Young

was carrying a wound through the leg. It was, of course, super-
ficial, but the deed showed at once the nobility and the staying-
power of the man. He was recommended for the D.C.M., and he
got it. I am glad to say, also, that it was a very popular honour
amongst us.

After the patient leaves our station of the nullah he is carried
down the track under shelter of the bank for a quarter mile or
so, where another squad takes him over. Just close to the place
of exchange the bank drops down flush with the track. Here
there is nothing to shelter you from the bullets that ping past in
their hundreds on a busy day and that you hear any night. It
is a veritable death-trap, and you are wise to hurry past as quickly
as you can. This place is called Backhouse Post. A few yards
farther on the track is continued into a deep trench, and this you
only have to leave once, where a road crosses, before you arrive
at the next station, about a half a mile farther on.

Just now this station is a haven of peace, where you can rest
for a moment on your way up the nullah. When there is a rush
of work it is the site of busy treatment. When the cases gather
more quickly at the nullah station than the staff can cope with
the overflow are brought right on here. It is a simple little place
nestling at the foot of a small hill. We call it Skew Bridge
station, because of the bridge of planks crossing the stream that
trickles down the nullah, and that flows to the sea near by. The
shelter is primitive, and consists of a roof of sand bags supported
on wood and set up against a wall of earth that stands 10 or
12 ft. high. Near by there are dug-outs cut out of the earth that
do for sleeping and for sheltering any patients who are waiting
to be sent off down the line. Behind, they have recently made
a bigger dug-out, with a profusion of sand bags, that does for the
medical officer.

It is an attractive place to work at. It has less shelter than
the upper station, and when you stand at the entrance you look
beyond some hundreds of yards of sandy, scrub-grown ground
occupied by the French, straight across Morto Bay, where the
blue waters of the Dardanelles dip deep into the Peninsula.
Beyond the Dardanelles you see the coast of Asia, fiat in front
and rising in steep cliffs to the left. It looks quite near, and yet
it is some miles distant. Beyond it the mountains of Asia show
purple in the distance. The exposure on this side means that
there is nothing to protect the station from the Asiatic guns.
The other day, when we were sitting having tea, a piece of armour-

A Field Ambulance in Gallipoli 311

piercing shell, 1 ft. long and 2 ins. thick, came whizzing into the
station.

The station lies at the foot of the nullah. On the left you
see the high land that forms the continuation of the hill along
the southern side of the nullah falling abruptly into the sea at
Morto Bay. At its extremity, where it juts into the sea, there
is the battered remnants of a fort. On the near or seaward side
the French have taken advantage of the admirable shelter for the
construction of the largest, the most artistic, and, at the same
time, probably the most efficient dug-outs on the Peninsula. To
the right of the flat, sandy stretch that runs in front of the
station right into Morto Bay, the ground rises again in a ridge
that extends close to and parallel to the shore for half a mile or
so, where it falls fairly steeply, just beyond Sedd-el-Bahr, into
V Beach, the sice of the historic landing from the River Clyde.
This ridge is perhaps 200 ft. high. It is dotted over with trees,
and it affords excellent shelter for heavy guns.

The Skew Bridge dressing station lies on low ground, and,
while it is out of sight of the hill and the front line trenches, it
is by no means immune from the shells and bullets that come
from that direction. The proximity of a large number of artillery
batteries, that hug the admirable shelter the region affords, brings
about our ears shrapnel and high explosive when the Turks'
stores can spare them.

In the evenings, also, and especially when there is any serious
action on in front, when the danger may be as great during the
day as at night, it is a favourite site for falling bullets. Many a
man has been hit about here on his way back to his rest camp
when he had thought that he had left rifle-fire at a safe distance
behind. One morning a patient with a bullet in the abdomen
had just been carried from the dug-out, where he had been under
observation for twenty-four hours, down to the ambulance waggon
for removal to the shore, when a bullet came into the waggon and
went right through his arm, as he lay on the stretcher. It must
have passed between the two bearers who were still bending over
him. The poor fellow had to be carried back again to have his
arm attended to. Truly the fates dog some men with most
relentless step ! The same morning an Australian officer was stand-
ing in front of our dressing-room examining an old water-bottle,
when a bullet struck the bottle and fell inside. As a matter of
fact, many of the bullets that fall here are spent, or nearly so,
though not so far spent that they cannot pierce flesh and bone.

312 James Young

This station of Skew Bridge is the farthest point to which
ambulance waggons can be taken, and, as a matter of fact, it was
formed as the rendezvous to which the patients could be brought
to meet the waggons. It is little else than that just now, though
on a big day its functions are much more serious and strenuous.
I have seen a large crowd of men sitting or lying about outside
waiting their turn, although the waggons were being loaded to
the full as they arrived in quick succession. I have seen such a
crush of work during the night that the whole of the available
ground in front has been littered with the wounded, and you had
to face the task of sorting out the slight from the serious cases
and the dying with the dim light of a lantern. A weird and
memorable sight it is, this ministration of the night.

Under the roof of sand bags there is the medical officer and
his orderly assistants busy snipping and bathing and tying, or
injecting the God-given serum that holds off the spectre of tetanus.
Outside, the orderlies pass hither and thither amongst the patients,
with their lamps, discovering the red tallies, for they must have
first attention and first place in the ambulance. At another
place you can dimly see the padre bending over a stretcher and
lifting the man's head whilst he sips his cup of water, or he is
speaking some words of comfort to the man whose last account
with this world is nearly closed.

Nowadays that is all past, and one motor ambulance waggon
does all the work. It is kept here, and it takes down the patients
as they arrive to the field ambulance a mile or so farther on. It
is a Napier car, with a fine, sturdy body, and it requires it, for I
doubt if you will find a worse road for a motor car anywhere. It
is nothing but a track of ruts and holes, on which, in previous
times, probably nothing but the lightest vehicles were ever risked
for the journey up the nullah. In these days, of course, its
defects of nature have been greatly amplified by the large number
of shells that have torn it up at odd times. The car has come
through it all with nothing worse than a broken spring. Taking
it over the road in the dark, with lights showing neither on. road
nor car, is a feat of driving, but it is a feat that has been performed
many times without mishap. The drivers, a fresh, healthy, clean-
limbed pair, with a strong Lancashire accent, obviously find great
happiness in their work. ■

The road twists about for a bit over very broken ground, and
then turns round on the north side of the ridge that spans the
south shore. It then runs straight into the open ground that

A Field Ambulance in Gallipoli 313

forms the tip of the Peninsula. This open space, about 2 miles
across in each direction, is scooped out like a shallow spoon, so
that, if you start from the centre, you have to climb in any
direction you decide to go. On the north and west sides you
mount by fairly gentle slopes to the cliffs that overhang the shore.
These slopes were the scene of fierce fighting during the days of
late April and early May, when the battered division, which had
mowed its way through almost unheard-of slaughter and obstacles
to the shore, at last began to get a foothold on the higher land.

On the south you scale the ridge dotted with olive and fig,
and, just on the other side, standing about 100 ft. or so above the
shore, you see the long village of Sedd-el-Bahr, once a place of
beauty and happiness, now a mass of broken walls and loose
stones. Underneath there is the long thin sheet of purest blue
of the Dardanelles, and, beyond, the outstretched Continent of
Asia Minor, whose ever-changing colours and long deep valleys
of shadow and romance beckon with an appeal that is not for
these times.

The basin along which the broken road passes is dusty and
barren, and trenched beyond any recognition of its former self.
A few months back, when our men first arrived, it was a smiling
land of blossom and vine. There is scarcely a trace of building
anywhere, for the husbandman prefers to have his house in the
society of the village. Should his toil keep him in the fields, there
is always the shade of the orchard during the day's heat, and at
night what could be better than the warm earth for bed, with
the starlight dome above ? It is all gone. The hand of war has
laid its ravaging touch everywhere. The countryman has been
driven from the ground that he nursed in simple contentment,
and that he loved better than anything else on earth. He has
been forced into a fight that he never chose, and that he probably
only dimly understands. His orchards have fallen into waste,
and where before there was plenty, there is now nothing but
parapet and trench in endless succession. The gods of ancient
Greece in all their wrath never ravaged the land so ruthlessly
as this modern god of war with his western myrmidons.

Our main dressing station, to which the cases are carried,
stands in the open, just where the farther side of the basin begins
to rise in a gentle slope to the cliffs. It is three-quarters of a
mile or thereby from the shore.

This station has gradually grown, till now it provides accom-
modation for quite a large number of patients. It is all dug

314 James Young

beneath the ground level, a series of spreading trenches, with
■offshoots for the various departments of a hospital.

From this station the cases are transferred by motor car to
the casualty clearing station on W Beach, where they are trans-
ferred by trawler or barge to the hospital ship that rides at anchor
a mile from the shore. The beach is a sinister place, for it is
raked night and day by the guns on Achi Baba and the Asiatic
shore opposite, and the patients do not like to linger long within
the casualty clearing station, for there is no shelter there save
canvas tents. There are many tragic stories of men who were
gathered there waiting their removal to the Bed Cross ship, and
for whom vistas of the comfort of a base hospital or even home
had already opened before their eyes.

(To oe continued.)

Clinical Record 315

CLINICAL RECORD.

TWO CASES OF ARTERIOVENOUS ANEURYSM OF
THE POPLITEAL VESSELS.

By FREDERICK C. PYBUS, Major, R.A.M.C.(T.), Newcastle-on-Tyne.

Both these patients were shot through the calf, the bullet making
a clean entry and exit. In both cases the popliteal artery and
vein were damaged, leading to an arteriovenous aneurysm.
Swelling and pulsation of the calf was present in each.

Exploration revealed damage to both main vessels of such a
character that repair was impossible, and in such a position that
simultaneous ligature of the popliteal, anterior, and posterior tibial
arteries and their corresponding veins was necessary to control
bleeding. In both cases recovery ensued without any loss of
vitality of the distant portions of the limb and with full
functional use.

Cask I. — W. R., aged 40, was wounded on 20th November 1917,
near Cambrai, by a machine-gun bullet, which traversed the calf of
the left leg. When admitted to the First Northern General Hospital
the wounds of the leg were almost healed. About three weeks after
admission he complained of pain down the leg, and examination led
to the detection of a swelling in the calf. The swelling occupied the
upper part of the calf and extended to the popliteal space ; it was
pulsating, and a systolic bruit could be heard over it.

An operation was performed on 20th December 1917, one month
after the receipt of the wound. The circulation was controlled by a
tourniquet on the thigh. An incision was made behind and parallel
to the inner border of the tibia. A large aneurysmal sac was found
occupying the inner head of the gastrocnemius and the popliteal space
beneath it. The sac was emptied, and a large rent found in the
popliteal vein which led directly into the sac. The opening in the
vein communicated directly with a similar tear in the popliteal artery.
The sac was separated from the vessels, and the popliteal artery and
vein ligatured above the damaged area. The tear at its distal end
was found to be close to the posterior tibial artery which, with its
corresponding vein, were ligatured. On attempting to remove this
damaged segment of the vessels the anterior tibial artery and vein

316 Clinical Record

were found to lead from the damaged area and both had to be liga-
tured as well. On releasing the tourniquet the wound remained dry-
after ligature of some muscular branches.

The wound healed normally, and a month later the patient was
discharged to an auxiliary hospital with the foot and leg normal.

Case II. — A. E. C, aged 19, was wounded on 27th March 1918.

The bullet entered the leg just behind the head of the fibula,
traversed the calf, and emerged on its inner aspect. He was admitted
to the First Northern General Hospital on 5th June from a Command
Depot on account of aching in the leg and pain on walking.

On examination the left calf was found enlarged and pulsating.
A systolic bruit could be heard over the swelling.

Operation — 8th June 1918. — The circulation was controlled by a
tourniquet. An incision was made behind and parallel to the inner
border to the tibia. The gastrocnemius was drawn aside and the
soleus detached from the tibia. A small sac about the size of a walnut
was found partly above and partly in the substance of the muscle.
The sac opened into the popliteal vein by an aperture which would
admit the tip of the finger. The sac was separated from the vessel.
On isolating the vein for a short distance the lesion was found to be
seated close to its formation.

An examination of the interior of the vein led to the discovery of
a similar perforation on the opposite wall leading into the popliteal
artery. A portion of the artery was isolated above and below its
junction with the vein. The edges of the openings were in direct
contact, there being no intervascular sac.

The popliteal artery and vein were ligatured above the communica-
tion, as were also the posterior tibial vessels below. The anterior
tibial artery and vein were then isolated and ligatured. On relaxing
the tourniquet free bleeding ensued. Several bleeding points were
found amongst the muscles and were ligatured. On again relaxing
the tourniquet bleeding occurred from the depths of the wound. The
circulation was again stopped, and a second small sac found at the
lower part of the popliteus muscle communicating with the anterior
tibial vessels. The sac was cleared out and a ligature of the tibials
distal to the sac controlled all bleeding. The foot was cold at the
conclusion of the operation, but was quite warm and comfortable
next day.

Except for some shortening of the calf muscles, which has been
corrected, convalescence was normal and the function is fully retained.

The popliteal vessels were readily reached after detaching the
soleus from the oblique line of the tibia.

Had the wound in the vessels not been so near the bifurcation, in
the second case suture might have been practicable.

Clinical Record

317

In both cases the main vessels were in direct communication,
the aneurysm paravascular, and projecting from the vein. It
would seem that little danger attaches to a simultaneous ligature
of these main vessels in patients with a healthy vascular system.

I am indebted to Brevet-Colonel T. Gowans, K.A.M.C.(T.),
for permission to publish these cases.

318 Recent Advances in Medical Science

RECENT ADVANCES IN MEDICAL SCIENCE.

MEDICINE.

UNDER THE CHARGE OF

JOHN EASON, M.D., and A. GOODALL, M.D.
Prognosis in Cardiac Disease.

P. D. White (Arner. Journ. Med. Sci., January 1919) deals with the
subject of prognosis in heart disease in relation to auricular fibrillation
and alternation of the pulse. Three series of cardiac cases were
collected. The first was composed of cases with auricular fibrillation,
the second of cases with alternation of the pulse, and the third of
cases with normal cardiac rhythm without alternation. Heart-block,
auricular flutter, and paroxysmal tachycardia were not included per se.

For study as to prognosis, the groups of auricular fibrillation and
pulsus alternans were subdivided, each into three classes. The
patients with auricular fibrillation were subdivided into (a) those who
showed aberrant ventricular complexes, the so-called " bundle branch
block"; (b) those who showed ectopic ventricular contractions; and
(c) those who had uncomplicated auricular fibrillation. The patients
with alternation of the pulse were also subdivided into (a) those who
had constant pulsus alternans ; (b) those having marked alternation
after premature contractions only ; and (c) those showing only slight
alternation after premature contractions. Patients with pulsus alternans
had radial pulse-tracings taken. The 1000 patients with normal rhythm
were not subdivided. Three years after beginning to collect these
series of cases, and two years after finding the most recent case,
White determined their condition. The results of this investigation
are shown in the accompanying table. About one-third of the patients
were lost sight of.

These figures show that pulsus alternans taken in toto gives a much
poorer prognosis than auricular fibrillation, but that auricular fibrilla-
tion as such adds little, if anything, to the gravity of prognosis in a
case of heart disease. The higher grades of pulsus alternans are
almost twice as grave as the slight degrees, i.e. slight alternation
following premature contractions, while between the two severe
grades — constant alternation and marked alternation after premature
contractions — there is little to choose, the mortality in such grades
together being 94 per cent, within a period of three years. Even
the cases with slight alternation after premature beats have a
mortality of over 50 per cent, within the three years, and definitely

Medicine

319

Cases
followed

c

f

d

Per cent.

Condition.

Type.

i

5

until

present

time.

■
pa

a
&
O

3
fc>

0

2
o
*

0

«

■
Q

dead of
cases
traced.

' Constant

26

22

2

20

91-0

Marked after pre-

Alterna-

mature beats

16

12

0

0

0

12

100-0

tion of -

Slight after pre-

the pulse

mature beats .
Total of alterna-

58

42

4

13

1

24

57-0

tion .

Cases electro-car-
diographed

(1) Aberrant ven-
tricular com-

100
69

76

6

13

1

56

74-0

plexes

5

4

0

0

0

4

100-0

Auricular
fibrillation

(2) With ectopic

beats

11

7

1

1

0

5

71-0

(3) Uncomplicated

53

35

2

18

4

11

310

Cases not electro-

cardiographed .

31

16

2

3

1

10

62-5

Total of auricular

fibrillation
No alternation,

100

62

5

22

5

30

48-0

Normal
rhythm

fibrillation, par-
oxysmal tachy-
cardia, flutter or

1

heart-block

100

49

8

15

3

23

47-0

higher than either the auricular fibrillation or the normal rhythm
averages.

In the case of auricular fibrillation White endeavoured to pick
out the more serious cases from the electro-cardiograms. He noted
that patients who show auricular fibrillation complicated by aberrant
ventricular complexes or by ectopic ventricular contractions have a
much graver prognosis than the uncomplicated auricular fibrillation —
much more than twice as grave, especially in the case of the aberrant
ventricular complexes, where in his small group of five cases the
mortality was 100 per cent, within three years. This finding might be
expected, because the electro-cardiograms indicate serious myocardial
damage or irritability in the ventricles. Such diseased or hyper-
irritable ventricular muscle does not stand up under the strain of
auricular fibrillation as relatively healthy ventricular muscle does.
These two conditions, according to White, probably have the same
prognostic significance as pulsus alternans in the case of a non-
fibrillating heart. One of the patients tabulated above as having
aberrant ventricular complexes and auricular fibrillation combined
had been seen by him before the heart became arrhythmic. A radial
pulse-tracing at that time showed pulsus alternans. The two main
conclusions drawn by White are that the higher grades of alternation

320 Recent Advances in Medical Science

of the pulse carry with them an especially high mortality — nearly
100 per cent, in three years — and that cases with auricular fibrillation
complicated by aberrant ventricular complexes seem to be very fatal
(100 per cent, in his series). Those cases with ectopic ventricular
contractions complicating the fibrillation have a mortality almost as
high as the total of alternation, while uncomplicated auricular
fibrillation has a surprisingly low mortality percentage.

Lumbar Puncture.

There is considerable conflict of opinion among authors upon many
of the details of this operation. The route for puncture and the
direction of the needle are among the points over which there is
controversy. J. C. Regan (Amer. Journ. Med. Sci., January 1919)
states the conclusions at which he has arrived from his clinical
experience, confirmed by experimental work on cadavers of adults
and children in the dissecting-room and at autopsy.

The median route is greatly superior to the lateral route for the
puncture of children by reason of its simplicity. The lumbar spinous
processes of children are rudimentary, rather short, horizontally
directed, and partly cartilaginous processes, which have a fairly even
superior and inferior border, somewhat rounded at the summit of the
process, but without any tendency to overlap. When the spine is
well flexed there exists between them an interval (the interspinous
space) which is usually quite wide and which permits the introduction
of the needle in the median line without any liability of touching the
spines. The distance to be traversed is very small, especially in
young children ; in fact, after the needle has pierced the skin and the
supraspinous ligaments it. quickly glides through the interspinous
ligaments and is immediately felt to penetrate the dural sac. In the
case of young children and infants a slight resistance is offered by the
rather tough supraspinous ligaments, but this is easily overcome, and
is the only difficulty encountered in the median line.

Many authors base their objection to median puncture in the adult
on the thickness and resistance which they claim the interspinous
ligaments offer, especially in muscular individuals. To determine the
basis for this argument Regan studied these ligaments on several adult
cadavers. This study gave the following findings : — The supraspinous
ligaments are rather tough, fibrous, cord-like ligaments extending
between the summits of the adjacent spinous processes. The inter-
spinous ligaments are rather thick, quadrilateral-shaped, pearl-coloured
ligaments attached along the whole length of the inferior border of
each spinous process from its root to the summit and extending down-
ward to the same parts of the superior border of the spinous process
below. The ligament is in reality composed of two folds and layers
of lateral fibres, with a clearly defined line of cleavage between. For

Medicine 321

this reason, when a needle is introduced in the median line after
penetrating the supraspinous ligament it enters the interspinous
ligament and passes along between its two layers, and is thus guided
forward with precision to the interarcual space. Marked resistance is
not encountered even in muscular individuals except in rare instances.
Therefore, instead of the interspinous ligaments being a contra-
indication to the use of the median route they are, in most cases, a
great aid in holding the needle safely to the median line and directing
it thus to the interarcual space.

Among the advantages of the median line for puncture of adults
are the following : — It is a clearly defined procedure and is quickly
and easily learned by the inexperienced ; no calculation is necessary as
to the direction inward and upward to be imparted to the needle in
order to reach the interarcual space as in lateral puncture. The
liability of striking bone and bending or breaking the needle or
wounding the periosteum is less. The possibility of passing beyond
the limits of the interarcual space is reduced to a minimum, while it is
ever present with the lateral route. The injury of nerve filaments or
spinal blood-vessels is less likely to occur. No difficulty is experienced
in penetrating the dural sac exactly in the median line, as in the
lateral route — a point of importance for spinal anaesthesia and serum
injection. The chances of the needle being plugged by the tissues
traversed and of blood-vessels being encountered is less with the
median than with the lateral route. Dry taps are less common in
median puncture. In other words, chance plays a much greater part
in lateral puncture.

In adults the anatomical structure of the spine differs from that of
a child, and this fact influences markedly the manner of insertion of
the needle. The lumbar spinous processes are not as horizontal as at
an early age, but have a distinct downward inclination, which is con-
siderably increased by a projection of the tubercles on the inferior
border. Flexion of the spine widens the interspinous intervals but
does not appreciably alter the direction of the spines themselves.
With the spines well flexed, however, the interval between the
adjacent processes is widened sufficiently to allow the introduction of
a needle in the majority of instances in a perpendicular direction (90°)
to reach the subarachnoid space without encountering bone. In some
cases (a decidedly minor percentage) it is impossible to introduce the
needle in a perpendicular direction without having it impinge on the
bony obstruction of the superior border of the spinous processes of
the vertebrae below. In such instances the needle's course should then
be changed by withdrawing it slightly and directing it obliquely
upward at an angle of 60° to 45°, and this will, except in rare cases,
be followed by the disappearance of the bony obstruction and the
entrance of the needle into the subarachnoid space.

23

322 Recent Advances in Medical Science

It is possible to obtain fluid by the median route in adults, even in
cases of marked opisthotonos, if a sufficiently marked inclination
upward is given to the needle.

Flexion of the spine is attained only with difficulty in elderly
individuals, hence the needle should be introduced slightly upward
from 70° to 45°.

The anatomical configuration of the spine helps to explain why
some cases of failure to obtain fluid by the median route, with a
perpendicular insertion (90°), may be due to a deviation of the
instrument from the median line, and its impinging on the superior
border of the lamina, while a more upward inclination would have
been entirely successful even though a similar deviation of the needle
occurred. J. E.

SURGERY.

UNDER THE CHARGE OP

D. P. D. WILKIE, F.R.C.S., and JAMES M. GRAHAM, F.R.C.S.
Displacement of the Mandibular Meniscus.

This somewhat rare but very distressing condition is described by
Hogarth Pringle (Brit. Jowrn. of Surg., vol. vi., No. 23, p. 386), who,
besides having personally experienced the condition, has met with four
cases. A study of the anatomy of the meniscus shows that the text-
book descriptions are inaccurate and must be modified. The disc
presents a central thickening in the coronal plane over the summit of
the condyle of the jaw. In front of the ridge is a distinct depression
in the disc which fits the tuberculum articulare of the temporal bone,
while below and anterior to this is a second thickening, which forms
the anterior border of the disc and has the external pterygoid muscle
attached to its lowest part. The posterior portion of the disc tails off
from the thick coronal ridge, and, lying in close contact with the posterior
surface of the condyle, becomes lost in the fibrous tissue of the capsule
of the joint.

Pringle believes that displacement of the meniscus is usually due
to over-action or irregular action of the external pterygoid muscle, the
disc becoming dragged askew. It goes forwards and inwards, so that
its thick central ridge becomes placed obliquely instead of lying in the
coronal plane. After displacement the disc acts as a foreign body,
being either caught between the condyle and the tuberculum articulare
or moving with the condyle and preventing the latter from clearing
the articular eminence.

Displacement usually occurs during yawning or sneezing, or in
forcible opening of the mouth by a gag as in dental extractions. The

Surgery 323

patient finds that he cannot close the mouth completely, and efforts to
do so cause intense pain in the region of the joint, and the sensation
that some foreign body is interfering with the movement. The disc
may remain in its abnormal situation for days at a time until reduced,
or it may slip in readily and be subject to repeated displacements.
Reduction can usually be effected by keeping up hard pressure behind
the condyle with the mouth open, and then slowly closing the jaw.

In recurring cases the tissues, ligaments, muscles, etc., around the
joint become so relaxed that it is impossible to maintain the disc in
position, and operation is called for. In two such cases Annandale
sutured the loose disc to the periosteum, and Pringle records one case
in which he excised the disc with a satisfactory result.

Euptured Internal Lateral Ligament of the Knee.

The importance of recognising and the difficulties in treating this
condition are pointed out by M'Murray (Brit. Journ. of Surg., vol. vi.,
No. 23, p. 377). The ligament, which is put in a state of tension
when the knee-joint is extended, usually tears between its attachment
to the femur and that to the internal semilunar cartilage. Force
applied to the outer side of the knee with the joint extended will
result usually in a rupture of the ligament, whereas force applied to
the outer side of the flexed knee usually detaches or splits the internal
semilunar cartilage. It is particularly important to distinguish a tear
of the ligament above the cartilage from injury to the latter itself, as
removal of the cartilage will only aggravate the disability resulting
from the torn ligament. The fact that in many cases, owing to the
laxity of the ligament, a fold of capsule may become invaginated
between the ends of the bones must be borne in mind, as the symptoms
in such cases will mimic those of torn cartilage very closely.

The operation of shortening the ligament by pleating has been
found by M'Murray to give only very short-lived improvement. As
a rule, a few months after such an operation the laxity of the joint has
returned.

The following operation, devised by the writer and carried out in
ten cases, has given satisfactory results, some of the patients so treated
having stable and useful joints when examined over two years after
operation : —

The operation essentially consists in the utilisation of the tendon
of the sartorius to reinforce the internal lateral ligament. With the
knee partially flexed the ligament is exposed, its femoral attach-
ment split vertically, and a small vertical wedge of bone removed from
the femur. The tendon of the sartorius is now freed by dividing the
fascia along it. The tendon is pulled forwards and laid in the groove
in the femur in such a manner that the portion of tendon between the

324 Recent Advances in Medical Science

femur and tibia is quite tight. It is then sewn firmly into the groove
by stitches passing through the periosteum and the ligamentous inser-
tion. The outer surface of the internal lateral ligament is then scarified,
and the ligament is tightened up by suturing adjacent portions of the
scarified surface together. The success of the operation depends on
keeping the knee in the flexed position during the whole course of
the procedure and the subsequent retention of this position during
a mjnimum period of three months.

Operation for the Cure of Incontinence of Urine.

Young (Surg., Gynec, and ObsteL, vol. xxviii., No. I., p. 84) records
two very successful results following the operation which he devised
for the cure of incontinence of urine due either to injury or weakness
of both vesical sphincters. As will readily be understood, a very
careful preliminary examination of the case will be necessary in order
to determine exactly that some defect in the sphincters is the cause
of the incontinence before any such operation is undertaken.

In both the cases recorded by Young the sphincters had been
damaged by previous operations : in one by a perineal urethrotomy,
in the other by a perineal prostatectomy.

The essential features of the operation consist in, firstly, restoring
the vesical sphincter by the suprapubic route, and, secondly, by repairing
the external sphincter by the perineal route.

With the patient in the Trendelenburg position a free exposure of
the interior of the bladder is obtained through a generous suprapubic
incision. The dilated internal prostatic orifice is exposed, and with
curved scissors the mucous membrane from its lateral and posterior
aspects is removed, leaving wide muscular surfaces exposed for
approximation. Using a special "boomerang" needle-holder and
chromic catgut, the operator now sutures the muscular coats from side
to side in such a manner as to narrow the internal meatus and to form
an artificial prostatic bar, finally suturing the mucosa over all. Before
the suturing is completed a small catheter is introduced to obviate
undue narrowing of the orifice, and the catheter is left in situ for ten
days after operation. Suprapubic drainage is, in addition, kept up for
one month. For the second part of the operation the patient is placed
in the exaggerated lithotomy position, the urethra exposed through a
long perineal incision, and the dissection carried down to the triangular
ligament and the external sphincter. It is usually desirable to open
the urethra and to excise a small portion posteriorly, as it is usually
dilated. Any cicatricial tissue should be excised so as to obtain good
muscle tissue for approximation. The urethra is first closed with
chromic catgut, then the muscle is stitched over it, and a third line of

Surgery 325

catgut sutures is inserted for reinforcement and further approximation.
The skin may be sutured or the wound left gaping for drainage.

Following the operation, it may be necessary to pass an instrument
occasionally to obviate stricture formation, though in one of Young's
cases this was unnecessary.

The results obtained by Young in his two cases were very gratify-
ing, one being in perfect health and having practically normal
micturition ten years after operation.

The writer is confident that this operation offers a very reasonable
hope of cure in a carefully selected number of these very distressing
cases.

Hypertrophic Pyloric Stenosis in Infants.

Whilst a certain number of cases presenting the typical clinical
picture of this condition may be cured by medical treatment, many
cases will succumb unless surgical measures are adopted. Green and
Sidbury (Surg., Gynec, and ObsteL, February 1919, p. 159) report five
successful cases in which the Eammstedt operation was performed.
This operation, which was described in 1913, consists in dividing the
pyloric muscle fibres down to the mucous membrane, and partially
separating the muscle ring from the mucosa, allowing the latter to
bulge up into the wound.

The advantages of the operation are the speed with which it can
be accomplished and the absence of shock. The one danger in the
operation is wounding of the mucosa, especially that of the first part
of the duodenum. This is best avoided by taking care that the
stomach is emptied of air — so often sucked into the stomach by young
infants during anaesthesia — by passing a stomach tube before cutting
the pyloric muscle. When the muscle is cut, the mucosa should be
separated from the stomach side towards the duodenum. If any
visible puncture of the mucosa is made, it should be immediately
closed with a purse-string suture of tine silk. To ensure that no
puncture has been missed, it is well to inflate the stomach gently
through the stomach tube so that any aperture may be revealed.

The whole operation can be done in from ten to fifteen minutes
with less exposure, handling, and trauma than either gastro- enterostomy
or any stretching operation. Careful post-operative medical treatment
is essential. Feeding with breast milk may be begun two hours after
operation, and continued every three hours thereafter.

D. P. D. W.

326 Recent Advances in Medical Science
OBSTETKICS AND GYNECOLOGY.

UNDER THE CHARGE OF

A. H. F. BARBOUR, M.D., and J. W. BALLANTYNE, M.D.

Puerperal Infection.

Dr. Potocki (Ann. de gynic. et d'obstdt., 1918, xiii. 129, 217) has
published the results of au interesting series of observations on the
bacteriology of the blood in puerperal infection. In all, the blood from 196
puerperal patients suffering from fever was examined, the object being
to establish prognosis on a more reliable basis than can at present be
done. In order to avoid contamination of the blood with the bacteria
of the skin it was taken direct from the vein, and in all details the most
careful technical skill was employed to exclude errors. In some cases
more than one observation was made; indeed the blood cultures
numbered more than 300. In 105 out of the 196 patients the blood
cultures gave negative results ; in the remaining ninety-one cases
bacteria were found, although in some of these the results were positive
at one time and negative on another occasion. In a group of ninety-
three blood cultures a single microbe developed : in forty-four it was
the streptococcus, in eleven the staphylococcus, in eighteen a diplo-
coccus, in seven the gonococcus, in four the micrococcus tetragenus, in
three the colon bacillus, and in two it was a bacillus resembling
Eberth's. In single observations the pneumococcus, the enterococcus,
the meningococcus, and diplobacilli were discovered. In a second
group of nine cultures, two microbes were found associated : strepto-
cocci and staphylococci twice, streptococci and diplococci twice, diplo-
cocci and a diplobacillus twice, staphylococci and gonococci once,
staphylococci and a diplococcus once, and the colon bacillus and a
diplococcus once. In a third group of seventeen blood cultures a very
small and extremely mobile microbe was found, which possessed a
strange power of penetrating the red cells of the blood. The exact
significance of these tiny microbes was not cleared up.

Several conclusions seem to be justified from the study of Dr.
Potocki's observations. The most important is that whilst blood
cultures do not give absolutely certain prognostic indications they
strongly reinforce other guides, such as the pulse, the temperature, the
local signs, the bacteriology of the lochia, the histology of the blood,
and the general condition of the patient. It is clearly shown that the
micro-organisms in the blood are most commonly of one kind ; this was
so in 93 per cent, of the cases with positive results, and the fact goes
to prove that puerperal fever is generally due to infection with one
variety of microbe. As to the cases of puerperal fever with negative
cultures from the blood, it may perhaps be concluded that they are

Obstetrics and Gynecology 327

due to the absorption of bacterial toxines. The streptococcus stood
out as, without doubt, the most common microbe (38 per cent.), whilst
staphylococci and diplococci accounted for 10 and 14 per cent, respec-
tively. It is a curious fact that in a few cases one microbe took the
place of another ; thus in one patient the first culture from the blood gave
staphylococci and the second streptococci. In at least half of the cases
in which this substitution took place death occurred very shortly after-
wards. A leading result derived from Dr. Potocki's observations was
that death was four times more common amongst the patients whose
blood cultures gave positive results as to the presence of microbes ; the
proportion was as 33 per cent, is to 8*5 per cent. Further, the strepto-
coccus was a dangerous microbe ; where it was the only pathogenic
micro-organism the mortality was 55 per cent. When the staphylo-
coccus alone was present the mortality was 71 per cent., but the
number of observations was relatively small. It was noteworthy that
the seventeen patients, whose blood exhibited the tiny, mobile, faintly
staining microbe, all recovered. A careful scrutiny of the relation of
the appearance of microbes in the blood to the occurrence of rigors
seemed to show that the rigor could not be regarded as due to the
passage of microbes into the circulation. Yet, as a general rule, the
more numerous the rigors were the more likely were microbes to be
found in the blood. The more serious, also, were the results : thus,
when the septicaemia was accompanied by rigors the mortality reached
62 per cent, when the blood contained pathogenic microbes, and it was
only 10 per cent, when the blood remained sterile. Speaking generally >
the presence of microbes in the blood (apart from the presence or
absence of rigors) brought with it a mortality of 33 per cent., whilst
the sterility of the blood was accompanied by a mortality of only 8-5
per cent, of the infected cases. It is obvious that these results all
point to the use in treatment of serums and of vaccines adjusted to the
types of microbes found in the blood.

Dr. P. Balard of Bordeaux {Arch. mens. d'obsUt. et de gyn6c, 1918,
ann. vii. 135-156) admits that puerperal infection with the bacillus of
Lbfjler (b. diphtherice) is rare ; but he maintains that routine bacterio-
logical examination of the vaginal secretions would prove it to be less
rare than is thought. In support of this view he describes a small
epidemic of seven cases of vulvo- vaginal diphtheria which occurred in
1915 under his care ; all the patients were primiparas and they all
recovered. In all the cases the labour was spontaneous, but in three
instances there were stitches in the perineum. It was noted, however,
that in only one of the three cases with stitches did the diphtheritic
membrane affect the sutured part. In all the cases the cervix was
affected, and in most of them the vaginal walls to a great or small
extent were involved. The infection was traced to a mild case of
angina without glandular enlargement which had occurred among the

328 Recent Advances in Medical Sciettce

puerperal patients in the ward. The false membranes were rather late
in appearing : in only one case were they recognised on the seventh
day of the puerperium ; in all the others they were seen between the
tenth and fourteenth days. Ordinary antiseptic applications had no
effect upon them, but plugging the vagina with gauze soaked in anti-
diphtheritic serum caused their disappearance after two applications.
Dr. Balard allowed the infants to be suckled by their mothers, but he
did not permit them to come into contact at any other times. None
of them was affected with diphtheria, and it is claimed that the milk
of a mother suffering from diphtheria is inoffensive, and may even be
immunising for the child if the mother is having specific treatment.

Drs. Harold A. Miller and Sidney A. Chalfant (Amer. Journ. Obstet.,
1918, lxxviii. 395) have reported eleven cases in which arsenobenzol was
given as an intravenous injection in puerperal blood-stream infection.
After noting that in puerperal bacteremia bichloride of mercury,
collargol, formalin, colloidal gold, isotonic sugar solution, electrargol,
eusol, magnesium sulphate, and salvarsan have all been tried intra-
venously, but without permanent acceptance, these authors have
employed arsenobenzol with the hope of reducing the mortality in such
serious cases. At first they always waited for the result of the blood
culture before giving the arsenical preparation, but this was the cause
of delay, and so in their later cases they injected 6 milligrammes of
arsenobenzol at once into the vein on clinical evidence of blood infection.
The leucocytes showed a decided increase during the twenty-four hours
following the injection, and a blood culture taken at that time was
generally free from organisms. The patient's general condition usually
showed a decided improvement also. Five out of the eleven patients
had one injection, three had two, one had three, and two had four
injections. There were four deaths : one occurred forty-four days
after delivery, with multiple abscesses in the kidneys, one on the
thirteenth day from double pneumonia, and the other two on the four-
teenth and fifth daj^s, apparently from the severity of the infection,
although the blood cultures were negative. The other two fatal cases
gave streptococcal cultures from the blood, as did five which recovered ;
the remaining two (which also recovered) showed Gram-negative bacilli
in the blood. The general treatment consisted in giving water by the
bowel and stimulation as seemed indicated. In only two cases was
there local treatment (uterine irrigation with Dakin's solution every
two hours) ; one case died and the other recovered. Toxic effects from
the arsenobenzol were not severe : in two cases there was a rigor and
in all a mild and transient albuminuria. The authors do not regard
this treatment as applicable to cases of thrombo-phlebitis or to those
of localised abscess or pelvic cellulitis of long standing. Of course
repeated infection of the circulation will require a fresh injection, but
such a case does not benefit so much. The special field of usefulness

Obstetrics and Gynecology 329

of the arsenobenzol is found in the cases in which there is little or no
evidence of local disease, the cases in which the mortality is very high.
Dr. Samuel B. Schenk (Amer. J own. Obstet., 1918, lxxviii. 596) has
recorded a somewhat unusual case of puerperal infection in which the
causal microbe seems to have been solely the staphylococcus albus, a
micro-organism which has been regarded as almost non-pathogenic. The
patient was delivered by means of forceps and the lacerations which
were produced were not repaired. On the day following she had a
severe rigor, along with pain in the abdomen, fever, and other symptoms.
On the eighth day of the puerperium she was admitted to the Long
Island College Hospital. She had then a tense and tender abdomen,
a deep, suppurating perineal laceration, foul vaginal discharge, a pulse
of 120 and a temperature of 103°. A blood culture was sterile. On
the eleventh day of the puerperium a large extraperitoneal abscess
appeared in the right inguinal region and was incised. Bacteriological
examination showed a staphylococcus albus hsemolyticus in pure
culture. A similar abscess was afterwards opened in the left inguinal
region, and pus from it gave the same bacteriological result. A blood
transfusion of 500 c.c. was given on the nineteenth day of the
puerperium, when she was almost hopelessly ill (pulse 160, tempera-
ture 104°). For ten days she remained in a semi-comatose condition ;
thereafter she became wildly delirious and was practically maniacal.
She received another blood transfusion of 500 c.c, and had the abscess
cavity washed out with 1-4000 formalin solution. The case is of
interest, partly because of the high degree of psychosis developed and
partly because of the unusual nature of what must be regarded
apparently as the causal microbe.

J. W. B.

330 New Books

NEW BOOKS.

Pensions and the Principles of their Evaluation. By Ll. J. LLEWELLYN,
M.B., and A. Basset Jones, M.B. Pp. xviii. + 702. London :
William Heinemann. 1919. Price 30s. "net.

War pensions and the principles on which they are awarded are
subjects of such great importance to the community which has
to bear their cost as well as to the disabled who receive them
that a book dealing comprehensively with the question is assured
beforehand of a wide circle of readers. Drs. Llewellyn and Basset
Jones, already known as joint authors of a treatise on malingering,
have compiled the large volume under review primarily for the medical
profession, on whom, ultimately, falls the responsibility of securing
even-handed justice between the pensioner and the State. Though
their book cannot be described as an exhaustive discussion of the
pensioning of disabilities, it is certainly the largest and most ambitious
that has yet appeared in England. It deals very fully with the general
principles of pensions, and then applies these to certain classes of dis-
abilities— injuries of bones, joints, nerves, and muscles, amputations,
eye conditions, and ear conditions. It leaves untouched, or only
incidentally alluded to, the great bulk of medical disabilities — effort
syndrome, organic heart disease, nephritis, neurasthenia, psychoses,
for example — the consideration of which, along with other disabilities
due to disease or injury of the internal organs, is postponed to a later
volume.

To criticise the authors of a book for the plan that they have
deliberately adopted is, perhaps, outside the province of the reviewer,
but it may be pointed out that, notwithstanding the magnitude of the
subject, much more information might reasonably have been compressed
into a volume of this size had terseness been aimed at and prolixity
avoided. The necessary extent of an inquiry into disabilities from the
pensions' point of view invites question as to the practical utility of
dissertations on pensions in classic and Anglo-Saxon times, or on their
relation to the feudal system. These serve more to display the authors'
erudition, which no one doubts, or, to speak the truth, is interested in,
than to aid the reader to solve the knotty problems which so commonly
arise at pensions boards. And there are other redundancies in the
book to which we shall again advert.

One of the first points made, in regard to the principles of war
pensions, is the fundamental distinction which exists between these and
awards under the Workmen's Compensation Act. In the latter, com-
pensation is based on an economic standard ; in the former, the standard

New Books 331

is a physiological one. It is essential that this should be clearly grasped,
for although we may agree with the authors that, as a matter of abstract
justice, a physiologico-professional basis — i.e. one which took into account
the relation between the disability and the earning capacity — would
be preferable, it is evident, the more the subject is considered, that
the difficulty of correct appraisement in this way would be enormous.
For one thing, the occupations of war pensioners far surpass in variety
those of persons coming under the Workmen's Compensation Acts,
and, in addition, in war pensions the question of social disabilities —
deprival of or injury to the power of enjoying the amenities of life —
has to be considered. Probably, therefore, the physiological standard
which assesses an injury as such, but not its results on the individual
is, on the whole, the least likely by reason of its uniformity to lead
to discontent. Moreover, pension boards are only human, and, in spite
of all injunctions to the contrary, they will always, we suspect, give
due weight to the pensioner's occupation in assessing, where a rigid
adhesion to the letter of the law would inflict undue hardship.

Chapter X. is perhaps one of the most original and valuable in the
book. It discusses the question of functional adaptation — Nature's
way of curing disabilities. The importance of a due appreciation of
the possibilities of functional adaptation can scarcely be overrated ;
it has a vital bearing on the decision as to when a temporary pension
should be made permanent — when, in other words, the disability has
functionally reached a permanent stationary condition. It also bears
on the question of awarding gratuities, for it will not infrequently
happen that functional adaptation — the attainment of the best possible
use of a maimed organ or limb — may be delayed by the receipt of a
pension and stimulated by the award of a gratuity. The question of
State training to aid in recovery of function is also raised.

Much of the chapters on the principles of pensioning is concerned
with what may be called the "malingering" side of the case. Here
the dangers of premature assessment of permanent pensions, the need
for a time-limit being set to the period during which disabilities alleged
to be caused or aggravated by military service may become the subjects
of claim, and the importance of the Pensions' Ministry having the
courage to diminish pensions where treatment is refused, are among
the subjects considered. With the authors' views on these questions
there will be general agreement. Throughout the whole of these early
chapters the authors' grandiloquence is especially noticeable, and it
leads to a curious alternation between exuberant praise of and
sympathy for the heroes of the war, along with exhortations to the
State to do its duty by them, and, on the other hand, a great deal
of copy-book rhetoric about deceit, the greed of gain, and the inherent
wickedness of man, as exemplified by war pensioners past and present.
The discontinuity in style between the purple passages on one page, and

332 New Books

the prosaic phraseology of a Royal warrant or the bald description of a
surgical disability on the next, produces an inharmonious jangle, which
is, to say the least, unpleasing. It is surely one of the first canons of
good writing that a certain uniformity or level of style should be main-
tained throughout. Apart from being verbose, the writing in many
parts of the book is ornate without being elegant ; pretentious rather
than scholarly. It is overcharged with quotations which neither
illuminate nor emphasise. What does this sentence (the reference
is to hysterical mutism, blindness, or deafness) convey that might not
have been better said simply and without metaphor? — "How bridge
the ' unplumb'd salt estranging sea ' which ever, even in health,
sunders all human entities." Mr. Matthew Arnold would assuredly
have been the last to condone such a misuse of quotation. Sentences
which scan, such as "Corruption lurks in ever specious guise," or " As
the fog of war recedes, The insensate havoc wrought," or " Of bodies
"maimed and marred, of minds distraught, Of hopes foregone, of lives
forsworn," may be verse of a kind, but are certainly bad prose. Pseudo-
archaisms, such as " of a verity, a shrewd question " ; " we trow not " ;
locutions such as "men of this ilk"; words such as "crescive,"
" gradative " ; phrases such as " The world, mute with horror, hunger-
ing for expression, hides as yet the olympian bard who in some immortal
epic . . . ," "To unmask or render effete fraudulent or unjustifiable
demands," and similar flowers of speech embellish the text. In fact,
the book is " gravid " — a favourite expression — with such blossoms.

Everyone knows, none better than the reviewer, that to write
English well is difficult, that the pitfalls are many. Is it too much
to ask that in their next book on pensions Drs. Llewellyn and Basset
Jones will adopt a chastened, and more austere style 1

War Neuroses. By John T. MacCurdy, M.D. With a Preface by
W. H. R. Rivers, M.D. Pp. lx. + 132. Cambridge University
Press. 1918. Price 7s. 6d.

Dr. MacCurdy's book is probably the best that has appeared on the
subject. From a psychologist of his standing and experience some-
thing of the kind was to be expected.

Stress is laid on the importance of the mental make-up of these
patients, and the author shows that the majority of those who have
failed to adapt themselves to military life and warfare had had some
previous difficulty in civil life, though this may not have amounted
to a failure to carry on with their work. Dr. MacCurdy shows how
much more important the strain of war is in the etiology of a neurosis
than any physical injury or " shell shock." The greater part of the
book is therefore taken up with the discussion of the anxiety state.

New Books 333

It is pointed out that this form of neurosis is commoner among
officers who have a better education and a greater sense of responsi-
bility than the men, while the latter furnish the larger number of
cases of "conversion hysteria."

The great difficulty of distinguishing between hysteria and
malingering is indicated — a difficulty which is accentuated by the
fact that a malingerer is a psychopath. ,

If there is a fault to be found with the book, it is that its tone
seems too optimistic as to the utility of returning men, who have had
a serious breakdown, to the fighting line. More recent investigations
appear to show that the military value of such men has been very
small. The main object of treatment has been served if they have
been made capable citizens, able to do their share of the world's work.

The Statics of the Pelvic Female Viscera, in which the Evidence of
Pathology, Phytogeny, and Clinical Investigation, etc., is Surveyed.
By K. H. Paramore, M.D.(Lond.), and F.R.C.S.(Eng.).
Vol. I. With 26 Illustrations. London : H. K. Lewis.
Price 18s. net.

In this comprehensive volume the author surveys a complex subject
from the standpoint given above. The anatomical structure of the
pelvis is well given from the dissectional standpoint, but less satis-
factorily from the frozen sectional intact method of investigation.
The author considers the pelvic floor as what remains after the visceral
part of it has been cut away ; that is, when it is reduced to its
muscular elements. Frozen sectional anatomy, however, gives the
idea of a pelvic floor unbroken in its extent, a movable portion in
front, the anterior to the rectal wall, and a fixed portion surrounding
this. Both views must be combined, and undue prominence given to
neither. It is a pity that the imaginary section from another author
should have been reproduced (Fig. 1, facing p. 8), as it gives a com-
pletely erroneous representation, especially as to the relations of the
levatores ani to the obturatores interni. In the various chapters the
author gives, step by step, the details of his proof.

Practically, the question of the nature of prolapsus uteri is the
great problem, and nowhere does the author distinctly state its
hernial nature. It is really a hernia through the pelvic floor, just as
inguinal hernia is a hernia through the anterior abdominal wall.

The question of the action of the bladder during urination is
discussed. Matthews Duncan's view that the bladder does not
contract during urination was based by him on the clinical fact that
the catheter does not descend during catheterisation. It does not
follow, however, that the bladder does not contract because its fundus

334 New Books

<3oes not sink during urination. The uterus contracts during labour,
but its fundus remains high and at the same level during the whole
process.

The title is not satisfactory, as "statics" is a less correct word
than dynamics. The literature is given with fair fulness, but many
observers' works have not been consulted in their original monograph
but only from the summaries of text-books. The light literature of
some observers might well have been omitted. A favourite phrase is
that of the "anterior pelvic outlet," an erroneous corollary to the
author's limited view of the pelvic floor — "the pelvic floor is for us
but the musculature " (p. 332). The whole work is praiseworthy
but not comprehensive enough. It should be read by all interested
in the subject, and its second volume will be looked forward to
with interest and with the hope that the author may take a more
comprehensive view of the structure of the pelvic floor.

Typlwid Fever, considered as a Problem of Scientific Medicine. By
Frederick P. Gay, Professor of Pathology in the University
of California. Pp. xi. + 286. New York : The Macmillan Co.
1918.

This volume, as is pointed out by its author, is devoted to an attempt
to follow the life-history of the typhoid bacillus rather than the mani-
festations of the disease it produces. It is in no sense either a
clinical treatise or a laboratory text-book, but is concerned with the
dependence of practice upon theory and with the application to
practical uses of recent work in the laboratory. We welcome it as a
valuable contribution to the literature of an ever-increasing subject
and congratulate its author on the production of so lucid and so well-
balanced an account of the pathogenesis, sequels, and modes of preven-
tion of typhoid fever. The chapter on laboratory diagnosis is of great
practical interest, and an excellent summary is given of the results of
protective vaccination. The possible uses of the " typhoidin " test,
introduced originally by Professor Gay, are interesting reading, and
the author has hopes it may be employed for the detection of healthy
and recovered carriers, a point well worthy of further investigation.
The intravenous use of sensitised vaccines is recommended as a method
of treatment, although it is freely admitted that such a method does
not succeed because it is specific, but on account of the subsequent
leucocytosis which can be also secured by the injection of any foreign
protein and even by inorganic substances. The only blemish to a
well-written, well-arranged, and well-printed book is the total absence
of an index, a want we hope to see corrected in future editions.

New Books 335

Equilibrium and Vertigo. By Isaac H. Jones and Lewis Fisher.
Pp.444. With 130 Illustrations. Philadelphia and London:
J. B. Lippincott Co. 1918. Price 21s.

This volume appears at a most opportune time in view of the rapid
development of aviation. It has been adopted as the standard for the
Medical Division of the Aviation Section of the United States Army.
It has, of course, long been known that balance depends on the sense
of sight, the muscular sense, and on the vestibular apparatus of the
inner ear. As long as a man has the use of his eyes and of his muscular
sense, e.g. on the solid ground in daylight, the importance of his ear-
balancing mechanism may not seem very great. When, however, man
becomes a bird and flies by night, it is essential that he should have
healthy ears. It is thus important that we should understand the
anatomy, physiology, pathology, and methods of examination of the
semicircular canal apparatus. These are dealt with in Part I. Jones
points out that for many years physicians and surgeons have gone to
the eye specialist for an opinion which is often of great value to them
in the diagnosis of various conditions, but that hitherto the inner ear
has been regarded as merely the organ of hearing. The vestibular
apparatus, however, is connected with many nerve centres which affect
the entire body, and the new ear tests — rotation, caloric, galvanic —
stimulate not only the ear itself but also this widely distributed nerve
apparatus. By producing the expected phenomena we demonstrate
that all the nerve pathways are intact. The physician has not yet
learned to turn to the otologist for the analysis of the causes of vertigo.
The syphilologist does not yet recognise the use of the ear tests in
detecting early involvement of the central nervous system. Even the
neurologist may get assistance from a detailed report of the examina-
tion of the vestibular function. In many American clinics neurologists
are accustomed to seek the aid of otologists in the examination of their
eases, especially those of suspected cerebellar disease. Jones also
points out the great importance of the new tests in aviation. " Stunt "
flying is very largely a question of the condition of the vestibular
mechanism : indeed an apparatus called the orientator has now been
devised in America by which aviators can be instructed in "stunt"
flying without danger. The importance of the inner ear in the causa-
tion of sea-sickness is well brought out and some useful hints given for
its treatment.

In Part II. the author gives an extremely clear account of the
anatomy and physiology of the labyrinth and of its nerve centres and
tracts in the brain. Here, as elsewhere in the book, the illustrations
are excellent. A new feature is the reproduction of cinematograph films
showing the method of carrying out the rotation and pointing tests
and the results produced. The method of case-taking recommended

336 New Books

and the chart to be employed can hardly be improved upon. Chapter
XXII. gives a clear picture of the conditions present on examination of
the auditory and vestibular apparatus in various hypothetical lesions of
the labyrinth, eighth nerve, pons, cerebellum, etc. Finally, Lewis Fisher
gives a detailed analysis in Chapter XXIII. of thirty-one pathological
cases. This is probably the most interesting and important feature of the
book, as the writer does not hesitate to record his failures in diagnosis,
e.g. Case 10, page 336, as well as his numerous successes.

Altogether, the book is clearly and interestingly written, printed
on good paper, and excellently illustrated. It should appeal not only
to otologists but also to neurologists and physicians, and should not
be beneath the notice of general surgeons who have to deal with
intracranial tumours. The authors must be congratulated upon the
production of a most excellent piece of work.

New Editions 337

NEW EDITIONS.

A Treatise on Clinical Medicine. By William Hanna Tuomson,
M.D., LL.D. Second Edition. Pp. 678. Philadelphia and
London: W. B. Saunders Co. 1918. Price 24s. net.

With so many excellent systems of medicine available, the progress
of medical science and its rapid advances along many lines would be
the only justification for the appearance of this volume. In the second
edition of his book on Clinical Medicine Dr. Thomson has retained the
arrangement adopted in his earlier one, with the consequence that a
stereotyping of method has probably been the reason for the absence of
much reference to the more recent advances in medicine that one would
have expected to have found in a modern work. For example, it is
a matter of disappointment that in his account of the treatment of
diabetes mellitus no mention is made of the method of the treatment
of that disease introduced by his American colleague, Allen.

The introductory chapter on the elucidation of morbid symptoms
is good, and contains many very suggestive hints and ideas culled
from the author's wide experience.

The chapter on the various infective diseases is also good, but its
value would be enhanced in future editions by the introduction of
graphic temperature records. In this chapter, however, as in the sub-
sequent portion of his book, which is taken up with the systematic
description of diseases grouped according to the various systems
involved and clearly and succinctly described, the subject of treatment
might have been more fully extended.

This is a book which the practitioner would find useful to dip into,
in order to refresh his memory with symptoms of diseases with which
his experience has not yet made him too familiar.

Clinical Diagnosis. By James Campbell Todd, M.D. Fourth
Edition. Pp. 687. Philadelphia and London : W. B. Saunders
Co. 1918. Price 14s. net.

This manual is one of the best of its kind with which we are
acquainted. It is not unduly large, it is thoroughly up to date, and'
the methods advised are well and, so far as we have tested them,
accurately described and trustworthy. It covers the whole field of
ordinary clinical pathology (physical diagnosis, strictly so-called,
does not come within its scope, nor do the graphic methods of
recording circulatory phenomena), and will be found a most useful

24

338 New Editions

reference work for a ward sidcroom. The illustrations, which are
numerous, are good, and many of the coloured plates are excellent.
Although this is its fourth edition, the book is new to us, but the pre-
diction that it will be popular may be hazarded. Dr. Todd, the author,
is the Professor of Clinical Pathology in the University of Colorado.

i
Diseases of the Digestive Organs, with Special Reference to their Diagnom
and Treatment. By Charles D. Aarox, Sc.D., M.D. Second
Edition. Pp. 818. 213 Illustrations. Philadelphia and New
York : Lea & Febiger. 1918. Price $7.

This book has been carefully revised and has been considerably
enlarged. * A number of chapters have been rewritten. A new chapter
is devoted to the subject of examination of the duodenal contents and
the employment of the duodenal tube for duodenal lavage and for
removing the duodenal contents at will. Another new chapter deals
with chronic intestinal toxaemia and chronic intestinal stasis, and
their medical and surgical treatment. There is also an additional
chapter on flatulence, meteorism, and tympanites.

The plan of the work follows the physiological path of the digestive
tract. The author successfully avoids the tendency of the specialist
to isolate the consideration of his subject from the other branches of
internal medicine.

The physiology of digestion has been considered from the view-
point of the clinician, and attention has been given to the bearing of
the internal secretions on the physiology of digestion. Space has
been devoted to many • tests for the diagnosis of carcinoma. An
endeavour is made to give the test-diet stool findings in each one of
the diseases of the digestive organs.

The volume is encyclopaedic in the description of diagnostic and
therapeutic methods, and, if it were for no other reason, these suffice
to make it a valuable book of reference for special and general
practitioners. The articles on pathology are less satisfactory. The
section on diseases of the liver and gall-bladder is much too per-
functory, and in a less degree this criticism might be applied to the
section on diseases of the pancreas. The paper, type, and illustrations
are excellent.

The Elements of the Science of Nutrition. By Graham. Lusk, Ph.D.,
Sc.D., F.R.S.(Edin.). Third Edition. Pp. 641. With 2S
Figures. Philadelphia and London : W. B. Saunders Co.
1917. Price $4.50 net.

In the new edition of this well-known work on nutrition there are
many additions and alterations of importance. But it is significant of

New Editions 339

the present position with regard to the science of nutrition that the
first chapter, in which the scheme of treatment of the wholo subject
is set forth, remains practically unchanged since the first edition,
written ten years ago, the bulk of the changes occurring in the
succeeding chapters concerned with the experimental data and their
detailed consideration. Notwithstanding this, the author, in announcing
that he does not intend to issue any further revisions of the work, is
so optimistic as to express the hope that it may soon be possible to
place the treatment of the subject on a physico-chemical basis. Though
this is, no doubt, the tendency in all directions of biology, it must be
confessed that no such development seems to be in sight.

Failing this desirable advance, one can only be thankful to have
such a clear, interesting, and authoritative exposition of this all-
important subject, which has too often been left to the propagandist
zeal of what one may perhaps be allowed to term faddists. Whether
the food economies rendered necessary by the war will have a permanent
influence in calling scientific attention to the subject remains to be
seen. One of the most interesting sections of the book is the last
chapter, which deals with food economics of the war, though only in
a tentative and preliminary manner.

The scope of the work is so wide that it not only appeals to the
physiologist and the scientific physician, but should also be of great
use to agriculturalists and others concerned with animal nutrition.
The revision appears to be thorough and up to date in spite of the
obvious difficulties.

Both sides of the vexed question of normal diet are stated fairly
and with moderation, and the chapters on " deficiency diseases " and
on metabolism in anaemia, in gout, and especially in cases involving
acidosis, are worthy of special notice.

The data given in the various tables throughout the text and in
the appendix should be useful, and are readily accessible, thanks to the
careful and exhaustive index j and, as indeed was to be expected, the
general get-up of the work is all one could desire.

A Manual of Physiology. By G. N. Stewart, M.D., D.Sc. Eighth
Edition. Pp. xxiv. + 1245. London : Bailliere, Tindall & Cox.
1918. •Price21s.net. (University Series.)

The last edition of this admirable manual appeared in 1914, and
notwithstanding what Professor Stewart calls the " withering influence
of the war," the output of new work from physiological laboratories
has necessitated some changes and additions. Cushny's filtration-
reabsorption theory of the urine is critically discussed, and reference
is made to recent work on the function of the endocrine glands. This

340 New Editions

is so well known and popular a student's manual that it is unneces-
sary to do more than commend the new edition to the student of
physiology.

Materia Medica and Therapeutics. By R. Ghosh. Seventh Edition.
Edited by B. H. Deare, Lieutenant-Colonel, Indian Medical
Service, and Birendra Nath Ghosh, F.R.F.P.S.(Glasgow).
Pp. xii. + 698. Calcutta: Hilton & Co. 1918. Price
7s. 6d. net.

The popularity of this treatise is well deserved. The preceding
edition was already based on the new pharmacopoeia, but efforts have
been made to bring the present one more up to date. It is an excellent
handbook for students and young practitioners. The dispensing and
prescribing hints are good, but incompatibilities might be a little more
elaborately considered.

Local and Regional Anaesthesia, including Analgesia. By Carroll W
Allen, M.D., of Tulane University, New Orleans. Second
Edition. Pp. 674. With 260 Illustrations. Philadelphia and
London: W. B. Saunders Co. 1918. Cloth, 28s. net.

Thanks to the discovery of new analgesic drugs by the synthetic
chemist and the careful study of their use by the clinician, the field in
which local anaesthesia can be successfully used has been considerably
extended in the last two decades. More or less successful efforts have
been made to perfect the technique of its induction, so that major
as well as minor operations may be painlessly performed under its
influence, and the production of a book of 674 pages, dealing only
with the various methods of using local analgesic drugs, is good
evidence of the growing importance of the subject.

Dr. Allen's work is almost encyclopaedic in character. The history
of the introduction and gradual development of local anaesthesia is
fully narrated in the first chapter. Later, all the drugs that have
held the field as local anaesthetics are described and their relative
merits indicated. The physical conditions influencing the action of
local anaesthetic solutions are fully discussed, and thereafter comes the
description of the technique of inducing local anaesthesia as used at
the present day. Its application in general surgery and in the surgery
of the eye, ear, nose, and throat, and in dental surgery, is dealt with
in the fullest possible manner.

Illustrations have been introduced wherever they might be useful
in making descriptions of technique more graphic or to remind the
reader of the anatomical features of the parts under consideration.

New Editions 341

Throughout tho book Dr. Allen has quoted freely from the writings
of other well-known workers on local anaesthesia, notably from Braun's
standard text-book on the subject, and he acknowledges his indebted-
ness to Braun, and especially also to his early teacher, Rudolph Matas,
who contributes an interesting introduction to his pupil's book.

While it might be legitimate to join issue with Dr. Allen in regard
to his estimate of the relative value of local and general anaesthesia,
there is no doubt whatever that he has provided us with a most
complete account of local anaesthesia and its applications, and his book
may be cordially recommended to those seeking information on the
subject.

The Errors of Accommodation and Refraction of the Eye and their Treat-
ment. By Ernest Clarke, M.D., F.R.C.S. Fourth Edition.
Pp. viii. + 243. With 93 Illustrations. London : Bailliere,
Tindall & Cox. 1918. Price 6s. net.

The fourth edition of this well-known handbook will sustain and
enhance its reputation. Some new matter has been added without
unduly lengthening the book, and the text has been thoroughly revised
and partially rewritten. The subject is treated in a comprehensive
though at the same time a concise manner, and many points are
touched on which are often omitted in similar works. Clarity of
expression is conspicuous throughout, and the reader is never at a loss
to understand the author's meaning. A useful test-card for distant
and near vision is included.

Gynecology. By William P. Graves, A.B., M.D., F.A.C.S., Harvard
Medical School. Second Edition. Pp.883. With 490 Illus-
trations (100 in Colours). Philadelphia and London : W. B.
Saunders Co. 1918. Price $7.75 net.

Professor Graves' work on Gynecology, which has reached a second
edition, is constructed on a somewhat novel plan. At the very end of
the volume, immediately before the index, the methods of examining
the gynecological patients are described ; at the beginning of the book
176 pages are devoted to the study of the physiology of the pelvic
organs and to the relationship of gynecology to the general organism ;
and between these two parts lies the central part of the work, con-
sisting of a description of gynecological diseases and operations. The
book, therefore, in part appeals to the student, in part to the prac-
titioner, and in part to the specialist; but its chief claim, as we take
it, is upon the specialist. To him (the specialist) the first part of the
volume will prove of great interest, for in it he will find an admirable

342 New Editions

summary of the known facts relating to that fascinating but more
than usually difficult subject — the relation of the sexual life of the
woman to her organs with internal secretion and to all her other bodily
systems. The views of Freud are not forgotten. The portions con-
cerned with the gynecological diseases and operations show less novelty
than the introductory chapters, but are clear and readable. As a
whole, Professor Graves' contribution to the literature of gynecology
is mainly remarkable for its wide outlook and for the manner in which
the sexual life and the psychology of the woman are related to the
activities of her various systems (circulatory, glandular, renal, etc.).
The illustrations are beautifully clear.

Notes on Books 343

NOTES ON BOOKS.

It is only necessary for us to chronicle the appearance of the twentieth
edition of Gray's Anatomy, edited by Professor Robert Howden
(Longmans, Green & Co., price 37s. 6d.). Nothing can now be said
that will enhance the value of such a classical work.

Another anatomical work which needs no further commendation is
Dr. Gwilym G. Davis' Applied Anatomy, which now appears in its fifth
edition (J. B. Lippincott Co., price 30s.). Both as to text and illustra-
tions it stands in a class by itself, and that the highest.

A second edition of Dr. W. W. Keen's Treatment of War Wounds
(W. B. Saunders Co., price 8s. 6d.) has been issued. It has been
rewritten to incorporate as much as possible of the new work that has
appeared since the first issue. It is a useful compilation.

The 1917 Collected Papers of the Mayo Clinic, vol. ix. (W. B. Saunders
Co., price 28s.), is, like the preceding volumes of the series, a valuable
summary of American work in all branches of surgery and in allied
departments of medicine. Mrs. Mellish is again editor, and contributes
a suggestive paper on medical journalism, with much of which we find
ourselves in cordial agreement.

There is little need to do more than allude to the appearance of
the sixth edition of A Manual of Chemistry by Arthur P. Luff and Hugh
C. H. Candy (Cassell & Co., Ltd., 1918, price 12s. net), and to reiterate
the favourable opinion expressed when the last edition was reviewed
in this column in 1915. Many additions have been made, and the
book has been enlarged by about a hundred pages, and now includes
more organic chemistry than formerly. The sections relating to the
sugars, urea, uric acid, and amino acids have been much expanded. It
is an admirable students' guide.

344 Books Received

BOOKS RECEIVED.

Barrett, James W. The War Work of the Y.M.C.A. in Egypt (H. K. Uvnt & Co., TM.) 10*. fid.
Bknnett, Edith M. Babies in Peril . . . (John Bale, Sons & Danielsson, Ltd.) Cd.

Chance, E. J. Bodily Deformities. Vol.11. Edited by John Poland (John Murray) 18s.

Chandler, Asa C. Animal Parasites and Human Disease . (Chapman & Hall, Ud.) 21s.

Depaoe, Sous la Direction du Dr. A. Ambulance de "l'Ocean." Tome II., Fasc. L,

Juillet 1918 . . (H. K. Lewis & Co., Ltd.) Annual subscription, 25s. ; single copy 14s.
Docroquet, Dr. La Prothese Fonctionnelle des Blesses de Guerre (Masson et Cie) frs. 5+10%

Fischer, Martin H., and Marion O. Hooker. Fats and Fatty Degeneration

(Chapman dt Hall, Ltd.) 9a. 6d-
Lewis' Medical and Scientific Library, Catalogue of

(H. K. Leviis & Co. Ltd.) 12s. 6d. ; to subscribers fls.
Maloney, Michael F. Irish Ethno-Botany .... (M.'H. Gill dt Son, Ltd.) 4s. Cd.
Parker, G. H. The Elementary Nervous System ... (/. B. Lippinctit Co.) dols. 2.50
Rea, R. Lindsay. Chest Radiography at a Casualty Clearing Station

(//. K. Lewis & Co. , Ltd.) 15s.

Scottish Hospital at Rouen, Appeal and Case for Members of the Nursing Staff of the.

Edited by George Wilton Wilton \(H. & J. Pillans & Wilson) Is. 6d.

Turner, A. Logan. Sir William Turner .... (William Blackwood & Sons) 18s.

Tyler, Albert Franklin. Roentgenotherapy (Henry Kimpton) 13s.

White, J. Renfrew. Chronic Traumatic Osteomyelitis . (H. K. Lewis & Co. , Ltd.) 12s. 6d.

JUNE 1919.

EDINBURGH
MEDICAL JOURNAL.

ACUTE POLIOMYELITIS.*

By EDWIN BRAMWELL, M.B., F.R.C.P.

Mr. President and Gentlemen, — Permit me, in the first
instance, to express my appreciation of the compliment which
your Council has paid me in inviting me to address you this
evening. Erom among the several subjects which occurred to me,
I have selected as my topic acute poliomyelitis, or polio-encephalo-
myelitis, as it is perhaps better termed — a disease which in recent
times has aroused widespread interest both from the scientific and
practical standpoints.

Poliomyelitis has, in the past, been comparatively infrequent
in this country ; indeed it is not uncommon to meet with medical
men of wide experience who tell one that they have rarely met
with cases in their practice. In the future, however, it is not
improbable that this disease may be more prevalent than formerly,
while recent observations suggest the possibility that some means
of combating the acute process, prior to the onset of the paralysis,
may be discovered, in which case early diagnosis may come to be
a matter of vital moment.

Acute poliomyelitis is one of those diseases regarding which
our conception has of late undergone very material modification.
Until comparatively recent times we were in the habit of picturing
the malady as due to an inflammatory process of unknown origin,
which selected as its locus the anterior horn of the spinal cord,
and which, by damaging or destroying the motor cells there
situated, produced an atrophic paralysis, varying in extent accord-
ing to the distribution of the inflammation and in degree according
to its severity.

* An .address delivered at the annual meeting of the Perthshire branch of
the British Medical Association on 14th November 1913.

E. M. J. VOL. XXII. NO. VI. 25

346 Edwin Bramwell

Heine, more than seventy years ago (1840), when he first
differentiated the atrophic from the spastic form of infantile
paralysis, described the febrile onset of the former, the subsequent
palsy, and the development of wasting and deformities. He
recognised, almost as we do at the present day, the results of the
disease, and argued, though he had no opportunity of proving the
truth of his assertion, that the lesion must be situated in the spinal
cord. Isolated reports from the time of Heine onwards served to
show that the paralysis was sometimes completely recovered from ;
that adults very occasionally suffered from an affection indis-
tinguishable from infantile spinal palsy ; that more than one child
might be simultaneously attacked ; and that two children in the
same house might develop, the one a flaccid, the other a spastic,
palsy, the latter obviously of cerebral origin. The febrile onset,
the circumstance that in extremely rare cases two children had
been known to be taken ill at the same time, and the further
observation that poliomyelitis was shown to occur especially at
certain times of the year — the late summer and autumn months
— were alluded to, even in the days of Charcot, as suggesting the
infective character of the disease.

Interesting as were these speculations as to the nature of the
process, it was not until the closing years of the last century that
unexpected data began to accumulate, which served to confirm
these views. In the early eighties the natural history of the
disease began to change, and first one author and then another
recorded groups of cases occurring in the same district and at the
same time, which differed in their features from the sporadic type.
For some reason as yet unknown it was in the Scandinavian
Peninsula, in the first instance, that the disease seems to have
taken on its new phase, and it was Medin, the Swedish physician,
who, at the meeting of the International Congress at Berlin in
1890, reported the first real outbreak, consisting of forty-four
cases, which had occurred at Stockholm three years previously.

To Medin is due the credit of pointing out the unusual mani-
festations which poliomyelitis presents when it occurs in an
epidemic, as opposed to a sporadic, form. His contribution, in
which he distinguished spinal, cerebral, polyneuritic, bulbar, and
ataxic types, aroused general attention, and the value of his
clinical observations is recognised bj the name Heine-Medin's
disease, a nomenclature often met with in literature, which com-
memorates the services of two observers who have done so much
to elucidate its clinical features.

Acute Poliomyelitis 347

Epidemics of poliomyelitis, it is almost unnecessary to remind
you, have occurred in many parts of Europe and America within
the past few years, so that instead of regarding the disease as
unimportant it has come to be dreaded in those localities in which
it has been rife. Holt and Bartlett in 1907 reviewed thirty-five
epidemics reported in the literature, and Batten, writing four
years later, found reports of twenty-seven epidemics which had
occurred in all parts of the world during the intervening period.
The great epidemics in Norway and Sweden (1903-5) and those in
New York City (1907), in Massachusetts, Westphalia, and Austria
(1909), have been, from the number of individuals affected, the
most severe yet experienced. The reason why these epidemics
should have occurred all the world over is as unanswerable at the
present moment as is the fact that Scandinavia has been the
region in which pandemic poliomyelitis has been so prevalent.

Fortunately, in Ivor Wickman of Stockholm, Sweden possessed
a physician who made full use of his opportunities of studying the
disease. This observer investigated very thoroughly the 1031
cases reported in the Swedish epidemic of 1905. Wickman's
observations on the morbid anatomy and the mode of spread of
poliomyelitis are of such importance that his name might be
worthily added to those of Heine and Medin in narrating the
history of the disease. He further directed attention to the com-
parative frequency of abortive cases in which recovery takes place
without paralytic manifestations, and to cases characterised by an
onset with pronounced meningeal symptoms. He pointed out
that an intimate association of the disease with the principal high-
ways of traffic was clearly demonstrable, and that the mode in
which it spread was essentially analogous to that established for
a number of other infectious diseases in which transmission takes
place from person to person. He was of opinion, from a study of
his material, that it was rarely probable that infection was carried
by food or by inanimate objects, and he laid great stress on schools
as foci of infection, figuring in his monograph convincing illustra-
tions in support of his contention. He further demonstrated that
the disease may be carried by a third person, and he arrived at
the conclusion that in man, if the onset be calculated from the
commencement of the fever, as it should be, the incubation period
would be found to be at least three or four days.

Let us now look for a moment at poliomyelitis as it has
occurred in this country during the past few years. Although in
1897 Dr. W. Pasteur described a remarkable instance in which

348

Edwin Bramwell

seven members of a family were simultaneously affected, it is only
within the last five years that any definite increase in these cases
and the occurrence of groups of cases have been noted. In 1903
a group of eight cases was reported by Treves at Upminster in
Essex. In the following year Dr. George Parker collected a series
of thirty-seven cases which occurred in Bristol; while in 1910
thirteen cases were reported from Mary port, thirty- four from
Carlisle, eighty-three from Melton Mowbray, and sixteen from
Cerne Abbas in Dorsetshire. Since then similar reports have
been received from other parts of the country.

From inquiries made in 1910 I was able to show that cases
of poliomyelitis had been distinctly more numerous in Scotland
during the autumn of that year than during the previous four
years. Figures obtained from the Out-Patient Departments of the
Edinburgh and Glasgow Koyal Hospitals for Sick Children, for
example, showed that fifty-two cases had been seen in 1910, as
compared with twenty-six cases in 1909, twenty-one cases in 1908,
twenty-three cases in 1907,. and thirty cases in 1906. Further,
one met with or heard of several instances in which two or more
children were simultaneously attacked, of abortive cases, of cases
presenting the features of the cerebral and meningeal types, and
of adults who had suffered. Previous experience had shown these
instances to be so rare that one feels justified in affirming that
there was not only a relative increase in the frequency of the
disease in Scotland, but that there was an approximation in the
clinical manifestations of the cases met with to the epidemic type.

Personal experience leads me to believe that in the autumns
of 1911 and 1912 poliomyelitis was also more frequent than
formerly, and that the proportion of adults attacked was unusually
high. Thus, of twenty- two cases which I have seen in private
practice, during the past three and a half years, seven of these
within ten days of the onset of the fever, I find that in four the
onset was in 1910, in six in 1911, in seven in 1912, and in one in
1913. All these eighteen cases occurred during the latter half of
the year, viz. : —

In July

1 case

August .

8 cases

September

• 6 „

October

■ 2 „

November

1 case

It is interesting to note in this connection that in the Swedish
and New York epidemics the maximum number of cases was

Acute Poliomyelitis 349

met with in August and September respectively. With the
exception of five of my cases, in which the patient was living
in Edinburgh (two), London (one), or abroad (two) at the time of
onset, all the other cases occurred either in the country (seven),
or in a country town (six), while in no instance was there clear
evidence of contagion either direct or indirect. The age at onset
in these eighteen cases was as follows, viz. : —

Before 5 years

From 5 to 10 years
„ 10 to 15 „
„ 15 to 20 „

Over 20 years

5 cases
4 „
3 .,

a „

3 „

Small though these figures are, the large proportion of cases in
older children and in adults in this series is striking, when one
realises their rarity prior to 1910. Although I have not included
the cases seen in hospital practice, I can recollect three at least
seen during this period, in which the onset occurred from the
age of 18 upwards. It is of interest to note that all of the
nine patients, including the three hospital cases to which I
have referred, in whom poliomyelitis developed after the age of
15, were of the male sex. This is, however, probably a mere
coincidence, since the general statistics show that the sexes are
about equally liable.

A comparison of these figures with earlier statistics serves
to emphasise the point referred to in connection with the age
incidence. Thus, Dr. Byrom Bramwell in 1908, on analysing the
cases of poliomyelitis which he had seen both in private and
hospital practice prior to that time, found that, of seventy-three
cases, in only five was the age at onset over 15 years.

The age incidence in different epidemics .has varied greatly.
Wickman, for instance, found that of 1025 Swedish cases, 220
of the patients were over 15 years of age when attacked, while,
of 729 cases met with in the New York epidemic, in only 8 was
the patient over this age.

I shall now refer briefly to a group of cases seen with Dr.
Currie at Tillicoultry in October 1910, and not included in the
series already referred to, which exemplifies in a striking manner
several of the features of epidemic poliomyelitis. The cases,
five in number, occurred in a homestead of four houses, some
2 miles from Tillicoultry, one house being occupied by the farm
steward, the others by farm employes. In the first house lived
the farm steward, whom we may designate A., with his wife and

350 Edwin Bramwell

two children, aged 5 and 1\ years respectively ; in a second house
on the opposite side of the road, not 20 yards away, lived a
farm employe* whom we may call B., his wife and four children,
aged 7£, 5£, 4 years, and 7 months. With the children living in
these two houses we are alone concerned. A.'s two children slept
in the same room; the three older B.'s slept in the same bed,
while the B. baby occupied a cradle in the kitchen, where his
father and mother also slept.

The clinical features presented by this group of cases may be
summarised as follows : —

On 12th September B. B., aged 5|, complained of headache ;
on the 14th he was feverish, complained of pain in the back of
the neck, and was drowsy and heavy. The fever continued for
three days. He said that his legs felt tired, and he seemed to
have difficulty in holding up his head. On 26th September he
returned to school. On 16th September, that is to say, four days
after B. B. was taken ill, A. B., aged 7|, developed similar
symptoms, with pain in the legs, especially the right; on the
third or fourth day weakness of the legs was observed, which
rapidly progressed to complete paralysis of the right leg and
marked weakness of the left, the features of the palsy being
typical of the common type of poliomyelitis. On 18th September
D. B., aged 7 months, was feverish and fretful ; the fever lasted
for three days; two days later he developed a convergent
strabismus; he appeared to be perfectly well when examined
on 31st October, except for the squint. It is of interest to note
in passing that on and after 14th September B. B. also slept in
the kitchen, and that it was four days later that D. B. was taken
ill. On 20^ September B. A., aged 2\, complained of headache,
and was feverish and drowsy ; three or four days thereafter the
right side of the face was seen to be paralysed ; when examined
on 6th October, although there was still a slight paresis of the
right side of the face, the child in other respects was quite well.
On 2Uh September A. A., aged 5, sister of the last patient, who,
as we have said, slept in the same room, was taken ill with
headache, fever, and a tired feeling in the legs; she subse-
quently developed a typical paralysis of both legs, with weakness
of one arm.

These cases illustrate quite a number of features characteristic
of epidemic poliomyelitis.

Firstly, we find five of twelve children living in an isolated
homestead affected ; whatever the source of the infection in

Acute Poliomyelitis 351

the initial case, it seems reasonable to believe that in the
subsequent cases the mode of infection was probably by direct
contagion.

Secondly, we have here instances of three separate types of
the disease, viz. two examples of the ordinary spinal type,
two examples of the cerebral type, and one example of the
abortive type.

Thirdly, the circumstance that all the patients were in good
health serves to emphasise a point which has repeatedly been
noted, that robust children are at least as liable to suffer as
weaklings.

Fourthly, the several instances in which a four days' interval
occurred between the onset of the individual eases suggests that
four days or less was very probably the incubation period.

Fifthly, there are grounds for believing that Mrs. A. may
have been a healthy carrier, conveying the infection from the
house of the B.'s to her own, and thus infecting her own children,
for on 16th September, and again on 18th and 19th September,
she visited the B.'s house, on the two days last mentioned
remaining on each occasion in the house for several hours,
assisting to nurse the baby (D. B.).

Three additional cases occurred in Tillicoultry at the time,
the dates of onset being 15th and 20th September, and 7th
October, but we were unable to trace any connection between
these cases and those above described; nor had the A. or B.
children, so far as we could ascertain, encountered any healthy
person who had recently been in contact with a case of acute
poliomyelitis.

As we have seen, Wickman has proved transmission by direct
contagion, has indicated the spread by school infection, and has
pointed out that the abortive cases are special sources of danger>
and that healthy individuals may act as " carriers." Contagion
is not evident in all cases, and it is necessary to look for some
other source of infection. Rosenau's experiments in this con-
nection suggest, and his observations are supported by those of
Anderson and Frost, that a common fly (Stomoxys calcitrans),
which bears a close resemblance to the house-fly, is capable of
transmitting poliomyelitis from one monkey to another.

So much for the symptomatology of the malady : let me now
refer in a few words to the experimental pathology, to the nature
of the virus, and to the possible channels of infection.

Strumpell, writing of acute poliomyelitis in 1884, after

352 ' Edwin Bramwell

summarising the symptoms, says : " These are all signs of
infection by a pathogenic organism." Nevertheless, for thirty
years the actual organism has escaped detection. The first real
advance derived from an experimental source was Landsteiner's
observation, published in 1909, that poliomyelitis could be trans-
mitted to monkeys by injecting an emulsion of the spinal cord
of a fatal case into the peritoneum of the animal. In November
of the same year several independent workers reported that they
had succeeded in transmitting the disease from one monkey to
another. A description of the symptoms and anatomical appear-
ances met with in experimental poliomyelitis in monkeys is
unnecessary here; suffice it to say that they bear a very close
resemblance to those observed in the human subject.

The observation independently arrived at by Flexner and
Lewis, and by Landsteiner and Levaditi, that the virus, whatever
its nature, would pass through a Berkfeld filter, disposed of the
claims of the micrococcus which Giersvold had described in the
cerebro-spinal fluid in 1905, and discouraged further bacterio-
logical research. Flexner and Noguchi have, however, succeeded
during the present year in cultivating a micro-organism in
poliomyelitis by adapting the method so successfully utilised by
the last-named observer for growing spirochete. The special
medium which they used was human ascitic fluid. Not only
were cultures obtained from the nervous tissue of fatal cases
in man, and of monkeys in which poliomyelitis had been experi-
mentally produced, but also from filtrates which had passed
through the bacteriological filter. Eegarding the organism
they say: —

" Fluid cultures, viewed under the dark-field microscope, exhibit
among the innumerable dancing protein and other granules
present, minute bodies, globular in form, hanging together in
short chains, pairs, and small masses, devoid of independent
motility and distinguishable with difficulty as a special class
among the indefinite granules present. Stain preparations, on
the other hand, bring out unmistakable organisms grouped in
the three ways stated, and of very minute size." The two
methods of staining with which they have so far obtained the
most satisfactory results are those of Giemsa and Gram. The
same observers have further proved that inoculation of the
cultures is followed by the appearance of the clinical symptoms
and pathological effects characteristic of experimental polio-
myelitis in the monkey ; while by employing a special technique,

Acute Poliomyelitis 353

discovered by Noguchi, they have succeeded in demonstrating
the presence of the organisms in film preparations and sections
prepared both from the central nervous organs of human beings,
and of monkeys which had succumbed to the experimentally
produced disease.

Pathological considerations naturally lead to speculation as
to the channels by which the causal organism enters the body.-
Flexner and his associates have demonstrated that experimental
poliomyelitis may be produced by injection of the virus at a
variety of different situations. The observation that the disease
may be experimentally produced if the virus is brought in contact
with an abrasion in the nasal mucous membrane is suggestive.
The circumstance that an intestinal or bronchial catarrh not
infrequently accompanies the initial symptoms suggests the
possible entrance by way of the respiratory or alimentary tracts.
As Romer has shown, however, diarrhoea may occur after experi-
mental injections into the cerebrum, and must, therefore, be
regarded as a direct consequence of the action of the virus.
Wickman advances as an argument in favour of infection by way
of the alimentary canal that the legs are almost always first
affected. Again, acute inflammation of the mesenteric glands has
been repeatedly met with; it is, however, to be remembered, as
more than one writer has pointed out, that such changes afford
no necessary proof as to the site of invasion, for they may
represent irritation resulting during the process of excretion of
the virus. The discovery of the organism may possibly help to
expedite our knowledge as to its mode of ingress.

The chief difficulties in diagnosis arise in the pre-paralytic
stage, though they are by no means confined to this period.
When cases of poliomyelitis have been occurring in a district, the
practitioner is anticipating the disease, and will regard any febrile
attack with suspicion. If, however, there have been no previous
cases in the locality, it is most unlikely that the possibility will
occur to him. Two diseases for which poliomyelitis is especially
apt to be mistaken during the febrile stage, and I could mention
several instances in point, are meningitis and articular rheumatism.
The former difficulty may be a very real one, for an onset with
headache, vomiting, drowsiness, neck rigidity, and general hyper-
esthesia is common. The latter mistake can be readily understood
when one recalls the extreme tenderness and pain on passive
movement which some of these patients exhibit, which symptoms
may for a time obscure the underlying paralysis. Among striking

354 Edwin Bramwell

early symptoms of poliomyelitis, Eduard Muller, who has given
special attention to this question, mentions heavy perspiration,
hyperesthesia, and the presence of a leucopenia, while several
observers have shown that both the cell and globulin content of
the cerebro-spinal fluid are increased in the great majority of
cases examined during the first week. Nevertheless, it must be
admitted that, although acute poliomyelitis may be suspected in
the pre-paralytic stage, we possess as yet no certain method of
diagnosis at this period.

Our views as to prognosis have also been materially modified
since the appearance of the epidemic type of case. Formerly it
was held that the disease was very seldom fatal, and that there
was almost invariably some degree of permanent paralysis. That
this statement does not now hold good is shown by recent
statistical inquiry. Thus Wickman, in one localised epidemic in
Sweden, found a mortality of 42*3 per cent., while in another it
was only 10 per cent. In the German and Austrian epidemics
the mortality varied from 10 per cent, to 20 per cent., while in
New York it was estimated at 5 per cent. There can be no
question that the prognosis as regards life is better in infants
and young children than it is in older children and adults.
Thus Wickman's Swedish figures show a mortality of 11 '9 per
cent, in patients up to 11 years of age, and of 26*6 per cent, in
those from 12 to 32.

The frequency of abortive cases is very difficult to estimate.
Leegaard, however, found 258 abortive cases in a total of 794
(32-5 per cent.). Conclusions as to the frequency of these cases
in infants and young children, as compared with older children
and adults, are conflicting.

Statistics as to recovery from paralysis vary. Thus, of 530
Swedish cases reported as paralysed soon after the acute stage
of the illness, inquiries made by Wickman, from one to one and
a half years later, showed that 44 per cent, had recovered, while
of the New York cases only 5*3 per cent, made a complete, and
1*8 per cent, a partial, recovery. My own limited experience is
in accord with that of Leegaard and Wickman that the prognosis
as regards a recovery in adults is not so good as in children,
although I have seen one case with extensive and pronounced
paralysis in a patient of 19 in whom recovery was practically
complete. The electrical examination, when the patient is
examined a few weeks after the onset of the paralysis, certainly
affords some indication as to the probable improvements which

Acute Poliomyelitis 355

will take place in individual groups of muscles. Personally, I
am inclined to think that the statements as to prognosis based
on the electrical examination, which are laid down in the majority
of text-books, tend to picture the outlook as unnecessarily gloomy.

Although no specific therapy that will prevent the disease or
influence its progress is, as yet, available, the work which has
been appearing from the Rockefeller Institute and elsewhere
permits us hopefully to anticipate the future. Clinical deduc-
tions as to the effect of remedies in an acute disease, such as polio-
myelitis, are admittedly difficult to formulate, and we must look
to the experimental pathologist for the solution of the problem.
Several observers have succeeded in establishing a resistance to
the virus, but the practical value of these experiments has not
yet been determined. The observations of Cushing and Crowe
that urotropin is excreted into the spinal fluid led Flexner to
test its efficacy in poliomyelitis, with the result that he found
that this drug delays, if it does not actually inhibit, the experi-
mental infection in animals. Urotropin should, therefore, be
employed during the acute stage, when it may be given in doses
of 3 to 10 grs. four-hourly.

The question of prophylaxis is one of practical importance.
In this connection I would again emphasise the fact that abortive
cases and healthy carriers may transmit the infection. All
observers are agreed that it is wise, in order to minimise the
chances of infection, to cleanse the oral and nasal cavities of both
patients and contacts with some antiseptic solution, such as 0*2
per cent, solution of permanganate of potash. The patient should
be isolated as in any infective fever, while in the present state
of our knowledge it is probably well to disinfect the stools. The
period of time after the onset of the disease during which the
patient is infectious is uncertain, but it is probably well to
insist that isolation shall be maintained for at least three weeks
(Batten).

I have made no attempt this evening to describe poliomyelitis
in detail. My purpose has rather been to draw attention to the
leading clinical features of the epidemic disease; to point out
recent advances in our knowledge regarding the pathology,
symptomatology, epidemiology, diagnosis, and prognosis; to
indicate that in Scotland, although there has been no great
increase in the frequency of poliomyelitis, there has been a
tendency on the part of those cases met with to approximate
to the epidemic type; and to emphasise the advisability of

356 Edwin Bramwell

adopting prophylactic measures in the treatment of these cases.
Time does not permit me to refer, much as I should have liked
to do so, to several practical points in the treatment of the
residual paralysis, notably to the scope of electricity, to Robert
Jones' observations on the beneficial effects obtained by maintain-
ing paralysed muscles in a state of relaxation, and to the use of
the celluloid splint, as suggested by Batten, in aiding recovery
and preventing deformities.

Possibly it may seem to you that I have exaggerated the
importance of my topic. Personally, I do not think so, for polio-
myelitis is a very terrible disease, not so much perhaps when we
regard the mortality, as when we realise the way in which it
handicaps the majority of its victims in after-life.

A Case of Diaphragmatic Hernia 357

A CASE OF DIAPHRAGMATIC HERNIA FOLLOWING A
GUNSHOT WOUND. ATTEMPT TO BRING ABOUT
RADICAL CURE BY EXTENSIVE THORACO-
PLASTY.

By DAVID M. GREIG, CM., F.R.C.S.(Edin.),
Senior Surgeon, Dundee Royal Infirmary.

On 29th May 1916 Robert Cowans,* aged 26 (late Z. 1490, Clyde
Royal Naval Division), was referred to me by Dr. Rorie on account
of vomiting which had recurred since the New Year. This he
associated with a wound he had received in the left chest on
5th June 1915.

His family history indicated no particular weakness. He was
the third of four children, two older than himself, well, and one
younger, who had died at the age of 3. His mother was well,
aged 52, and his father had died, aged 47, of blood-poisoning
following a sore toe. The patient had had no illness since
" measles and inflammation when at school." He is married and
has four healthy children. Cowans joined the Royal Naval Divi-
sion on 23rd October 1914, and when at the Dardanelles was shot
in the left chest by a Turkish bullet .The bullet entered through
the conjoined costal cartilages in the left parasternal line, about
an inch above their free margins at the epigastric notch. It must
have passed obliquely to the left, for it lodged at the level of the
diaphragm under the lateral thoracic wall. He had no haemo-
ptysis. He was taken on board ship and a fortnight later arrived
at a Greek hospital in Alexandria, having developed dysentery, he
says, the day before he was put ashore. Some six or seven weeks
later, after being radiographed, he had an operation under local or
spinal anaesthesia. The lower part of the left chest was opened
behind and he " heard something falling into the bucket," and on
asking what it was he was told by the Sister that it was " about
two pounds of hard matter." The doctor told him later that it

* In the medical literature of war it is a matter for regret that the identity
of patients should be purposely obscured. In civil practice this can easily be
understood and indeed must be generally advisable. In military practice,
however, the honourable nature of the wounds, the benefit which may accrue
to the patient, the advantage to previous observers in being able again to
particularise the case, make it desirable that, if not the name, at least the unit
and the identity number of the patient be openly recorded.1 John Bell,2
Guthrie,3 Williamson,4 Ballingall,6 and the older writers set a good example
which has, unfortunately, been departed from.

358 David M. Greig

had been caused by the dirt on the bullet being carried into the
chest. After two weeks he had a second operation, an incision
being made lower down in the back over the sacrospinatus muscle,
parallel with the lumbar spine, for the evacuation of an abscess
which had formed there. He got on well after that, and, when able,
was transferred to Haslar Hospital and from thence to Queen
Mary's Hospital. He was then sent home on a month's leave and
then to a camp at Blandford (Dorset). While there, on 3rd
January 1916, he took ill with pain in the shoulder and vomiting
and he was sent into hospital at Portland, where on 8th January
he had " a pint and a half of matter taken out by opening up
the first incision." He was discharged from the service on 7th
February 1916, the wound being entirely healed. He then returned
home, and a week or two later attempted to resume his ordinary
work in a calender. The work was fairly heavy, necessitating
a good deal of stooping and of weight-lifting, and it was not long
before he discovered that the pain of stooping and lifting, which he
noticed at once, did not improve as he persevered with his work,
and was associated on occasions with vomiting. On that account
he had to cease work after three weeks. He did not attempt work
again, and during the five months which elapsed before I saw him
he had had attacks of vomiting, on occasions accompanied by pain
in front of the left hypochrondrium and down the left arm as far
as the wrist. He thought that exertion sometimes brought on the
pain, but at other times there was no apparent reason. He could
always bring on pain by stooping, and repeated pain was apt to
culminate in vomiting, the vomited matter being simply the food
he had previously ingested. He was a thin and not very robust-
looking man, intelligent, and able to give a good account of him-
self. The wound of entrance was evidenced by a small circular
cicatrix. At the posterior part of the left chest there was a scar
of a considerable operation, and palpation indicated that some of
the lower ribs, probably the seventh and eighth, had been partially
removed. A vertical scar in the left loin indicated the secondary
abscess which he had had in Alexandria.

It was not until 27th July that he was admitted to the ward.
Eadiographic examination by Dr. Pirie showed that about the level
of the diaphragm there was a collection of fluid, and that above
that fluid was some air. A curious phenomenon which neither I
nor my colleagues had seen before was that when the man was
pushed sharply from side to side the fluid splashed up and down
the sides of the cavity in waves, like water in a bowl. Dr. Mackie

A Case of Diaphragmatic Hernia 359

Whyte, who examined the lungs for me, reported: "Lungs seem
clear (resonance, vesicular breathing, etc.)."

The explanation of the symptoms gave rise to some discussion.
Dr. Pirie thought that the fluid and air lay above the diaphragm
and that the man had a hydro- (or pyo-) pneumothorax, but I felt
that the absence of any recent history of inflammatory trouble in
the pleura and the absence of lung symptoms — dyspnoea, short-
ness of breath, cough, or expectoration — made the production of a
pneumothorax, via the lung, improbable ; nor did I think it possible
that an empyema could have satisfactorily healed up, leaving a
quantity of fluid and air in the pleural cavity, and give rise to no
discomfort, increase of temperature, or constitutional disturbance.
The left side of the diaphragm did not move freely, and it appeared
to me more likely that the left cupola had been drawn upwards
during the healing of the empyema, and that the air and fluid
were contained in the stomach and that the stomach had become
adherent to the diaphragm in the course of his illness or as a
result of his injury. In all radiograms the rifle bullet was seen
to be lying apparently in relation to the thoracic surface of the
diaphragm. It was observed that the left diaphragm scarcely
moved at all, and that the bullet did not move with respiration.
The left diaphragm, indeed, was fixed, and its cupola much higher
than the right, and where a barium meal had been given it was
noted on one occasion that the fluid was thrown into waves by the
heart's motion. The barium meal sank through the fluid to the
level of the umbilicus and collected there. No peristalsis was
visible. With the patient supine, the stomach was noted to be
entirely on the left side, the lower two-thirds of the left lung were
dim, and Dr. Pirie concluded that the stomach was " fairly normal."

It is curious in the light of later knowledge that the existence
of a diaphragmatic hernia was not accepted by any of us at that
time. It appeared certain, from the man's own description of his
first operation and from the scar and the removal of ribs, that he
had been operated on in Alexandria for a left empyema, and that
reaccumulated fluid had been aspirated at Portland some months
later. The assumption that he had had an empyema seemed to
negative the possibility of a hernia ; it seemed incredible that a
collection of pus could take place within the chest while an open-
ing existed in the diaphragm, and I am afraid that due allowance
was not made for the rapidity with which adhesions might form
in a traumatic rupture, and for the rapidity and ease with which
the opening would be closed by the herniated viscus.

360 David M. Greig

A few days after his admission to the ward, when he had been
up and about, and apparently very well, he complained of a feeling
of fulness, and vomited a large quantity of undigested food. This
was typical of what had recurred at intervals, and occurred always
on exertion.

Evidently the stomach and not the lung was at fault, and the
question arose whether one should reopen the thorax and examine
the condition there, or open the abdomen to examine the left
cupola of the diaphragm. The certainty of finding adhesions in
connection with the previous operations in the chest decided me
to take the abdominal route. On 9th August the abdomen was
opened through the left rectus sheath, the muscle being pulled
outwards. There was no evidence of peritonitis. The stomach
appeared considerably dilated and disappeared upwards through a
large circular hole in the diaphragm. This opening, which was
smooth -edged, was fully 2 ins. in diameter, and situated in the
muscular part of the left diaphragm. It admitted four fingers
easily, but did not admit the whole hand. The herniated stomach
was attached high up in the left chest, and could not be entirely
drawn into the abdomen. The abdominal wound was closed in
the usual way, the layers of the rectus sheath being brought
together separately by continuous catgut, and the skin by silk-
worm gut sutures. During the first day or two he suffered a
good deal from accumulation of mucus in the respiratory passages,
and, though his discomfort was relieved by the continuance of
Fowler's position, the difficulty of coughing interfered with the
expectoration. On the seventh day after the operation he had a
recurrence of the gastric strangulation. He complained of fulness
and tightness across the upper part of the abdomen and lower
part of the chest, followed by pain in the left chest, and then
much retching and copious vomiting. During one of these attacks
he stated that he felt the stitches give way, and when I saw him
some hours later I found that the wound had opened, and a coil
of about 3 ft. of small intestine was lying under the dressing,
The bowel was replaced under an anaesthetic and the wound
resutured. For the next two days he had a good deal of restless-
ness, with some pain and vomiting, but by the third day he had
returned to his normal condition of convalescence, and thereafter
made an uninterrupted recovery. He was temporarily discharged
from hospital on the 12th of September, and readmitted for
further operation on the 30th.

Operation for the Radical Cure of Diaphragmatic Hernia. —

A Case of Diaphragmatic Hernia 361

A vertical incision was made midway between the axillary
folds on the left side, well clear of the previous thoracotomy
cicatrices, and portions of the third and the succeeding six ribs
were removed. The parietal pleura was incised and free access
gained to the thoracic cavity. The lung was not adherent to the
parietal pleura. The stomach was found to be fixed to the visceral
pleura by a small attachment. It was freed from its adhesions,
drawn down in the thoracic cavity, and passed through the opening
of the diaphragm into the abdomen. Three silkworm gut sutures
were then passed as mattress sutures through the adjacent edges
of the opening in the diaphragm, but instead of being tied were
then brought through the most convenient costal interspace and
tied on the surface of the skin. In this way the diaphragmatic
opening now closed into a linear slit, and the portion of the
diaphragm below was braced firmly against the chest wall. The
intention was to promote obliteration of the lower part of the
pleural cavity, and bring about the permanent adhesion of the
injured part of the diaphragm to the thoracic wall. The operation
was a long and severe one. It was followed by the intravenous
administration of three pints of saline that evening, and this was
repeated five hours later. When dressed two days later, it was
found that one of the silkworm gut sutures controlling the
diaphragm had given way. As after his previous operation, he
was considerably troubled with accumulation of mucus in the
bronchi and inability to expectorate efficiently, but he did not
have the fulness and vomiting which had troubled him before.
As the condition of the stomach was now known, and as it was
presumably in its normal position, stimulants by the mouth and
fluids as desired were not withheld, and he soon passed into a
satisfactory condition of convalescence, and the progress continued
as in an ordinary empyema. The sutures which controlled the
diaphragm were removed at the end of a fortnight, and the
thoracic wound was entirely healed by 27th November. He was
then radiographed, and with a bismuth meal the stomach was
found to be normal in position, the bullet lying lateral to the
stomach at a higher level. The normal shape of the cupola of
the diaphragm was altered, the lateral half being apparently
adherent to the thoracic wall, the medial half passing across in
the usual way, but presenting no movement on respiration. The
thoracic wall where the ribs had been removed had fallen in to
some extent, but the lung itself must have expanded very con-
siderably, and materially assisted the obliteration of the pleural

26

362 David M. Greig

cavity. Normal breath sounds could be heard down to the
diaphragm, though the percussion note was naturally a little
impaired in comparison with the other side.

It now looked as if the operation was to be an unqualified
success. He had no complaints, was taking ordinary diet, and
was putting on flesh very quickly. He had no cough, and neither
gastric nor intestinal disturbance. He alleged that a fortnight
after leaving hospital he contracted a bronchial catarrh and a
troublesome cough. With this he had a pain, but not very severe,
in the left side of his chest over the lower part of the costal arch.
On the last day of December 1916, after having had discomfort
and sickness for two days, accompanied by giddiness and a
tendency to faintness, he vomited about an hour after dinner,
and the vomiting was repeated about an hour after supper. The
vomiting then continued daily, and sometimes several times a
day, until he was readmitted to my ward on 5th January 1917.
He stated that after a big drink of water he could feel " the same
splashing sensation he had had previous to his operation." He
had vomited nearly every day, and sometimes had long bouts of
vomiting, lasting for many hours at a time. I decided to re-
examine the thorax to see if anything more could be done, and
on 3rd February, through the mid-axillary line, reopened the left
pleura and removed anteriorly further portions of those ribs
which had been excised at the previous operation. A good many
adhesions were found, and the diaphragmatic rupture was repre-
sented by two considerable openings, which I again sutured with
silkworm gut and again attached to the flaccid chest wall. I was
less hopeful this time of success, as the diaphragm appeared very
attenuated and the muscular element not well developed. The
skin wound" was left open, as in the usual treatment of empyema,
for the purpose of promoting obliteration as much as possible of
the pleural cavity. The following forenoon, while coughing, he
stated he felt something give way in the left side.

This operation was not followed by the complete relief of
gastric symptoms which had characterised the previous one, for
the vomiting, though not so severe, recurred occasionally, and he
had to be careful as to quality and quantity of his food. He was
discharged from hospital on 17th April. Three months later he
reported that he vomited " about every day," but he was not loosing
weight, and he looked well and was of good colour. He was again
in my ward under observation from 8th August till 12th September
1917, and the frequency of the vomiting was confirmed.

A Case of Diaphragmatic Hernia 363

Thereafter he continued much the same. The incidence of
vomiting varied, but he seldom went for longer than a fortnight
without discomfort or sickness. He believed his diet had little
or no effect, but actual vomiting occurred more after a meal, while
" dry " retching occurred frequently when the stomach was empty.
Though thin, he retained his good colour and did not lose flesh.
On 20th January 1919 he again presented himself for examination.
The lower angle of the cicatrix had for some weeks been inflamed
and had been discharging, and now the Turkish bullet is projecting
from the sinus base first. It was easily removed by the fingers.
Since then there has been immunity from attacks of sickness
or vomiting.

Remarks. — Wounds of the diaphragm are notoriously more
prevalent in military surgery than in the surgery of civil life.
Indeed, except from a few Italian and Spanish monographs, contri-
butions from countries in which the use of the knife, in the settle-
ment of quarrels, is more common than among other European
nations, it is difficult to obtain references to this injury. It is to
military surgeons, therefore, that one looks for information as
regards wounds of the diaphragm, and assuredly that information
is meagre enough. Guthrie,6 in giving his experience on this
subject, heads his page, " A wound of the diaphragm never heals ; "
and he writes : " These cases confirm the fact I was the first to
point out — that wounds of the diaphragm, whether in the
muscular or the tendinous part, never unite, but remain with
their edges separated, ready for the transmission between them
of any of the loose viscera of the abdomen, which may receive
an impulse in that direction." He admits that on the right side
a wound may become blocked by the solid viscus (the liver)
becoming adherent to it, and indeed this is only what would be
expected from the experience gained by opening an abscess of
the liver through the diaphragm. In this relation Dr. F. M.
Milne of the Dundee Eoyal Infirmary tells me that recently
he conducted the post-mortem examination of a soldier who
had been wounded four weeks previously. A piece of shrapnel,
\ by f of an inch, had entered the right chest in the 7th inter-
space, had passed through the diaphragm and lodged in the right
lobe of the liver, where an abscess had formed. The wound was
not obvious in the diaphragm. The liver was adherent to the
muscle, and the lung, consolidated, adhered to the diaphragmatic
pleura.

In one other point Guthrie's dictum requires modification.

364 David M. Greig

I have recorded 7 the case of a lad who, falling on an upturned
pitchfork, was pierced through the epigastrium and the central
tendon of the diaphragm into the heart wall. The hsemoperi-
cardium I relieved by incising from below the central tendon of
the diaphragm and then suturing the wound with catgut. The
sequel, however, to that case has not been previously published.
The patient remained well during seven years, when, at the age
of 19, he was readmitted to the Dundee Royal Infirmary suffering
from endocarditis, from which he died three days later. On post-
mortem examination there were found a considerable vegetation
on one of the mitral cusps, a pericardial sac obliterated by
adhesions, and a wound in the tendon of the diaphragm, soundly
healed hut recognised as a linear cicatrix when that part of the
muscle was held up to the light. This case alone refutes the
statement that wounds of the diaphragmatic tendon never heal.

It is not surprising that wounds of the tendon should heal,
but wounds of the diaphragmatic muscular tissue stand in a
different category altogether. In the tendon we have a more or
less passive structure, moving a little, it is true, but with no
comparison to the movement of the muscular element.

Verification of the condition by ultimate post-mortem examina-
tion is necessary in any case of injury to the diaphragm. Relief
of symptoms is no guarantee that closure of the diaphragmatic
opening has been maintained. Most of the cases of diaphragmatic
hernia published have been those of congenital defect, and it is
well known that improvement may follow surgical interference
though it can be proved that the hernia still exists.8 On the
other hand, many cases of diaphragmatic hernia, whether con-
genital or acquired, have escaped recognition until strangulation
or other accident9 had brought about the final catastrophe or
the patient had died from some intercurrent illness. During the
hundred years which have elapsed since Guthrie gathered his
experience, no case, so far as I know, has been published which
has shown by post-mortem examination that a known wound of
the muscle-constituent of the diaphragm has ever closed spontane-
ously or remained closed after operation.

The surgery of the chest has gained achievements Guthrie
may have dreamed of but could not have foreseen. Yet
apparently his experience is still undenied in regard to wounds
of the diaphragm. The statement " I put in four stitches in the
wound in the diaphragm " occurring in the course of a surgical
report may be evidence of a surgeon's manual dexterity, but it

A Case of Diaphragmatic Hernia 365

is no proof that subsequent diaphragmatic hernia was prevented.
Neither is it evidence of success that on post-mortem examination
a few days after operation the sutures in the diaphragm appeared
to be holding well. What is wanted is a description of the
diaphragm months or years after a known operation. Cases of
wound of the diaphragm are cases beyond all others that ought
to be followed up, that should be passed from the military surgeon
to his civilian confrere, and that is rendered immeasurably more
difficult unless in each report each man's identity is established.
For operation, access may be gained to the diaphragm through the
thoracic parietes or through the abdominal parietes, and recently
Be'rard and Dunet have recorded a case in which they combined
the thoracic with the abdominal route.10 The patient was
wounded in the left chest, and a diaphragmatic laceration was
followed by a hernia of part of the stomach and transverse colon.
Symptoms of strangulation set in four months later, and two
months after that the diaphragm was sutured. The manipulations
were carried out through a large rectangular thoracico-abdominal
flap, so that the herniated viscera could be drawn down into the
abdomen and resection of the 6th rib allowed 'manipulations on
the diaphragm to be carried out, working between the two cavities.
The soldier did not survive the operation many hours, and after
death the wound of the diaphragm was found accurately sutured.
This method must have greatly facilitated suture of the diaphragm,
but it differs from my method in that I tried to utilise the ribless
portion of the chest wall to reinforce the diaphragm. I do not
advocate it as a routine method, but bracing the diaphragm
against the chest wall may have its indications and be applicable
in certain cases.

References. — l Greig, D. M., "Sequel to a Gunshot Wound of the
Chest," Journ. of B.A.M.C, May 1904. 2 Bell, J., The Principles of Surgery,
Edinburgh, 1801. 3 Guthrie, G. J., Commentaries on the Surgery of the War,
London, 1853 (5th ed.). 4 Williamson, G., Military Surgery, London, 1863.
6 Ballingall, G., Outlines of Military Surgery, Edinburgh, 1852 (4th ed.).
6 Guthrie, G. J., op. cit., p. 481. 7 Greig, D. M., "A Case of Stab- wound of
the Heart," Internat. Clinics, Philadelphia, 1912, iv. 183. 8 Greig, D. M.,
"Clinical Consideration of a Case of Congenital Diaphragmatic Hernia," Clin.
Journ., London, 1914. 9 Lennox, G., " Perforation of a Gastric Ulcer Occurring
in the Sac of a Large Congenital Diaphragmatic Hernia," Brit. Med. Journ.,
19th August 1916. 10 Berard, L., and Dunet, Gh., " Lahernie diaphragmatique
etranglee consecutive aux plaies de guerre," Lyon Chirurg. No. 5, xv. 39.

366 James Young

A FIELD AMBULANCE IN GALLIPOLI, EGYPT,
PALESTINE, AND FRANCE.

By JAMES YOUNG, D.S.O., M.D., F.R.C.S.(Edin.),
Lieutenant-Colonel, R.A.M.C.

V. Memories of Cape Helles.

For some time after the eventful days in the middle of July
things remained quiet, though desultory fighting and increasing
sickness kept us busy in the ambulance. But in the early days
of August rumour, that so often precedes big things, began to be
whispered about from lip to lip. We soon learnt that we were
going to make another bid for victory, and our spirits revived
with new hope.

On the 6th August we heard officially of the intended landing
further up the coast, which it was hoped would bring us to our
goal. There was a stir in our midst, and already in spirit we
found ourselves marching up the slopes of Achi Baba hot-foot
after a routed enemy, across the " few miles of scrub " that stood
between us and victory. Within a short time the Straits would
be open, and the British Navy would be hammering at the gates
of Constantinople. But it was not to be. Our bounding spirits
outleapt our sober judgment.

Looking back on it, this seems to us the greatest disappoint-
ment we have ever had. It was not till some time after, however,
towards the winter months, that the full force of our unenviable
plight gradually dawned upon us. And then, I remember, we
used to wonder and guess what fate had in store. The pessimist
was ever abroad selling his dismal wares, but to our credit be
it said that as a whole the attitude that prevailed was one of
determined if not cheerful optimism. There were factors, other
than the purely military, which tinged our feelings. The chief of
these was sickness.

Coincidently with the landing at Suvla, a strong demonstra-
tion was made from our side of Achi Baba. We can remember,
on the afternoon of 6th August, the vigorous bombardment of the
Turkish trenches in front of the village of Krithia, in which guns
from the sea largely participated. And then in memory we can
still see the long lines of our boys with the tin plates on their
backs glistening in the sun as they clambered up the slopes of
Achi Baba towards Krithia. The Turk counter-attacked that

A Field Ambulance in Gallipoli 367

night, and again on the following night — the 7th August. On
this latter occasion flares went up along the whole line, and the
noise of bursting shrapnel and the crackle of rifles and machine
guns was so great that for a time it seemed as if the Turk had
gathered up all his force and was bearing down in an irresistible
wave on our position, and that before long we could scarcely escape
being driven into the sea. But within a short time the whole
line was quiet again.

On the 9th August we at last received news regarding the
doings on the other side of Achi Baba. It was good. Sari Bah
ridge was taken, and the new landing troops were in touch with
the Anzacs. But this was the last satisfactory news we ever
received, and it soon became evident to us that our dreams of
victory were not yet to be realised.

From this time to the end there was no fighting on a big
scale, though there were repeated smaller attacks in which for the
time being we found ourselves busily employed in the ambulance.
The campaign settled down definitely into fighting between two
entrenched armies, with all that that means.

To many of us the memory of our life in these days is haunted
by the spectre of sickness which seized hold of the Army early,
and maintained its grip throughout the whole campaign. Few
there were who escaped altogether. The young athlete was
marked down just as surely as those of less robust vigour.
Disease, when once it enters an army, is prone to spread through
all ranks without discrimination.

So it was with us. To many the time spent on Gallipoli
stands for a six months' constant battle against fever and malaise.
Many succumbed early. Many were stricken late. Some braved
it out, and of these not a few will carry the effects on their frame
to the end.

Our chief enemy was dysentery in its varied forms. It
gripped us early, and during the summer and autumn months it
took a heavy toll. None of us can ever forget the horror of the
scourge as it held us in its claws during these hot, broiling
months. Least of all, I imagine, can we ever forget it who,
suffering often ourselves, had to hide our pains in our effort to
minister to others more needy.

A great deal has been spoken and written about the dysentery
of Gallipoli. Scientists are still arguing amongst themselves
about the germ that caused it. And it is right, in the interests
of our armies and of practical medicine, that the thing should be

368 James Young

settled. "We, who knew the reality, may be pardoned for looking
on these discussions as a trifle academic. I doubt if any, except
those who saw with their own eyes, can ever picture the tragedy
of hundreds and thousands of brave, strong men battling in vain
against a loathsome thing, whilst the flesh left their bodies and
their strength ebbed away, till at last they were stretched out
helpless as babes.

It is still too early to attempt to explain the various factors
responsible for this condition of affairs. As guardians of the
Army's health, the experience pressed heavily on us at the time,
and has left us thinking deeply since. The ultimate explanation
was, of course, easy — imperfect sanitation. We all learnt a lesson
during these days of trial that we can never forget. The fire has
burnt deeply into our hearts. "We know that the lessons, learnt
on that battlefield in front of Achi Baba, have served us con-
stantly in our efforts since then. "We know also that regulations,
no matter how perfect in their scope, will fail to establish any-
thing approaching perfection until the sanitary conscience of an
army is thoroughly awakened. At that time we were young
soldiers embarked on a campaign under - eastern skies, and
surrounded by circumstances that were as unfavourable as it is
possible to imagine. Youth, inexperience, and environment were
all against us.

Few of us escaped. At times dysentery and fever played a
sorry havoc in the ranks of the ambulance. At one time we were
working the whole ambulance, including dressing stations, with
only two medical officers instead of nine, and one of these was
just able to drag himself from bed when a patient was announced.

"With the advent of the cooler weather and the rains in
October things improved greatly, though it was about this time
that a mysterious epidemic of jaundice claimed a large number
of victims. The disease itself was not a severe one, and few died.
Slight fever and pains, and then the yellow tinge, which, first
starting in the whites of the eyes, rapidly overspread the whole
body. The morning sick parades in these days were rarely without
their little jaundiced procession.

Though it is true that the ardent spirits with which we had
embarked for overseas service soon tamed down considerably
under the trial and stress of war, there were nevertheless many
things and incidents which added greatly to the pleasures of our
life at that time.

As I have said, we were warned before we arrived that life

A Field Ambulance in Gallipoli 369

was going to be a nightmare. And there is a popular idea per-
sisting to the present day that the life we spent there was one
long procession of gloom and misery. But it was not so; for,
throughout, there was the opportunity of pleasing intercourse
with your fellows. This constitutes one of the saving pleasures
of Army life at all times. We had small dinner parties, in which
the two other field ambulances of the division joined, and then
there were the opportunities for friendship with the French
troops, which we availed ourselves of.

On the 28th September the news of the French successes on
the Western Front with the capture of twenty thousand prisoners
reached us. This caused great jubilation, and at 7 o'clock that
night one battery in each artillery group fired twenty-one
rounds at a special object, amid cheers raised from all throats
for our gallant French allies. It was a tremendous occasion
for us. The sudden artillery outburst and the great volume
of cheering that shook the silence of the night must have
startled the Turk badly. He must have taken it for a general
attack, for he loosed off the most vigorous fusillade of rifle and
machine gun that we heard during the whole time we were on
Helles.

On the 14th October we heard of the German advance on
Serbia and of the fall of Belgrade. The imminence of our danger
specially directed our thoughts to this piece of news.

It was just about this time that we evacuated three of our
officers from sickness, including our commanding officer, Colonel
Koss, all suffering from epidemic fevers. Some time after we
heard with feelings of keen sorrow of the death of our beloved
commanding officer.

There was little natural beauty about Helles itself, for the
country, that must have looked well in its clothing of grass and
flower in the early days of the campaign, by the time we arrived
was barren to a degree.

But if you climbed the high land overhanging the northern
shore towards X Beach, especially about sunfall, you would see the
islands of Imbros and Lemnos and Tenedos, with the shadows
playing on their hills. Beyond Imbros you would catch a sight
of the peaks of Samothrace, and further to the west you might
get a glimpse of Mount Athos. Then, in the opposite direction,
from your point of vantage you would get Achi Baba standing out
lull in his curious symmetry of central head and lateral shoulders

370 James Young

sloping down on each side to the sea. Across the southern
shoulder the cliff's of Chanak could be seen. Further to the
right, across the Hellespont, could be seen the evening shadows
gathering about the mountains and valleys of Asia Minor and the
Plain of Troy.

The beauty of the evenings at Helles was sometimes very
great, especially when the purple hues gathered on Achi Baba
and crept across to the south. The air was then very clear, and
distant objects on the sides of Achi Baba would stand out with
surprising distinctness. We often then at one place could pick
out with the naked eye the red crescent flag flying at a Turkish
dressing station. During the time of twilight a quiet would fall,
witli nothing to disturb except the constant tiresome chirp of the
cicada, the pathetic, half human and wholly diverting neigh or
bray of the mules, with the big guns roaring on occasions to
remind you of battle. Twilight and dawn were the quietest times
of the day. It often seemed then as if by common consent a hush
had fallen on the field of battle.

During the last months our advanced dressing stations moved
about as our division moved from one flank to the other, but our
main station remained in the same place throughout the whole
campaign.

The later weeks consisted largely of a battle with the elements.
Especially was this the case towards the middle of November,
when we had a severe storm of wind and rain that washed us out,
followed immediately by an intense frost that hit the men in the
trenches severely, though we did not experience the same tragic
results that befell the troops at Suvla at that time.

VI. The Evacuation of Cape Helles.

It is difficult to say when the preparations for the evacuation
of Helles really began. Suvla and Anzac had been evacuated.
We knew that, and we wondered if our turn would follow. But
on the 20th December an order circulated to all ranks for the time
set all doubt aside. Helles was not to be abandoned. " To the
Eighth Army Corps was entrusted the duty of maintaining the
honour of the British Empire against the Turk." We were
exhorted to " make our positions impregnable, and while driving
back every attack we must ever seek to make steady progress
forward and maintain, both in spirit and action, that offensive
which, as every soldier knew, alone leads to success in war."

A Field Ambulance in Gallipoli 371

Reinforcements of artillery and increased supplies of ammuni-
tion had already arrived, and further troops would be available
shortly.

We read those words with the spirit that animates all true
soldiers — calm submission and determination to endure to the end.

Big guns arrived and were planted near Hunter Weston Hill.
Reinforcements could be seen in the morning against the skyline
as they climbed the hill from the beach where they had landed
over-night. We could see them and the Turk could see them,
and he every now and then turned his guns in their direction.

But we soon saw that, whilst troops were certainly landing on
the Peninsula, troops were at the same time leaving it, and before
long it was evident to those who knew that men were leaving
more rapidly than new troops arrived. It was soon apparent that
something secret was afoot. Orders reached us that no case was
to be kept in the ambulance unless he was calculated to get better
in a day or two. No letters arrived, and there were many who
waited in vain that Christmas for the home parcels which were to
swell their meagre celebrations to some semblance of the days of
peace.

Within a few days the extent of the preparations was so great
that, whilst the Turk on the far hillsides of Achi Baba was kept
in complete ignorance of the plans, no one in the neighbourhood
of the beaches could any longer be deceived.

Eventually we received definite orders to prepare to evacuate.
The Peninsula was to be emptied gradually, but every effort was
to be made to maintain the ordinary routine appearance of things.
Our camps were to be undisturbed and the evacuation of wounded
and sick two or three times a day from advanced dressing to main
dressing station was to continue whether there were patients or
not. The patients naturally grew less as the troops dwindled in
numbers, but dummies were to be used and the performance of
loading and unloading the waggons was to go on as before.

A great deal of natural 'amusement was extracted from this
theatrical show. The spirits of the men rose higher and higher
each day as the hour of their deliverance drew nigh. They threw
themselves with zest into the construction of dummy water-carts
and motor cars to replace those which were sent to the beach to
be shipped. At that time we had one motor ambulance car. The
chassis was sent off, whilst the hood was mounted on four wheels
in the usual place by the hospital entrance.

It almost seemed as if the Turk had grown suspicious, for the

372 James Young

roads round our camp were shelled more heavily than usual at
night and the camp itself did not escape.

A few days before the end of the year we received orders to
send off any officers or men who were in any way unfit. It was
with great difficulty that any men could be induced to admit they
had not felt better in all their lives. But a party was mustered
and sent off under our old quartermaster. On New Year's Eve,
whilst we were sitting at the evening meal, a hurried message came
to send off one N.C.O. and twenty-five men within the hour.
With a scramble the order was carried out. That same night the
preliminary operation orders for the final day were received. On
our ambulance, reinforced by the other two ambulances, was to be
placed the task of attending to the medical arrangements of the
division during the evacuation.

The general scheme was that, on the fateful day, bearers and
nursing orderlies were to be provided with stretchers and dressings
and placed along the route from the front lines, so that during the
evacuation every party of fifty soldiers would be accompanied the
whole way from trenches to boats by a squad of four E.A.M.C.
men. To provide for any casualties in excess of the numbers
which could thus be dealt with, additional stretchers were placed
at known spots along the route so that the infantrymen would be
able to lift their wounded mates along with them. The medical
officers were stationed at definite intervals to attend to the wounded
as they arose.

The route was arranged in every detail. From the front line
it came down Leith Walk and Central Street, the Mule Trench,
thence via Backhouse Post past Skew Bridge to the Rendezvous,
a spot opposite our main camp about three-quarters of a mile from
the shore. Thence it went by the shortest route to an improvised
pier near V Beach which was selected for our evacuation. The
route was to be policed throughout so that even the most stupid
could not wander.

The evacuation was to be carried out gradually. Each line
was to be thinned out in stages. There were to be eight control
posts, No. 1 being in front, No. 8 at Skew Bridge about three miles
behind. The troops were to be counted and checked as they passed
these points, and here the E.A.M.C. personnel were to be stationed,
The evacuation was to be conducted in three trips during the night,
separated by a two to three hours' interval.

Days of tense hard work now set in for us. On New Year's
Day we received orders to send all the equipment and dressings

A Field Ambulance in Gallipoli 373

which would not be required to a depot near the beach. It was
difficult to decide what our requirements would be, as we had had
no previous experience of evacuations ! But we worked with a
will, loading our boxes and our panniers that New Year's night
and carted them off to the depot. A loading party under an officer
stood by from the ambulance beside the equipment, but it was not
loaded on board a trawler for two days. It was not till many
days after that we again saw this loading party. Tossed about
on the trawler " G. 8," backwards and forwards between Mudros,
Gallipoli, and Tenedos, they had adventures which make the stories
of our boyhood's heroes shrink and pale.

The preparations for the final day were pushed ahead. Men
and horses and guns and stores of all descriptions were shipped
away under cover of night, whilst during the day troops arrived in
constant succession accompanied by guns and ammunition and all
the things of war. To the Turk watching from Achi Baba and
the coast of Asia it must have seemed that a host was gathering
for a final vigorous assault.

Every detail required attention. Nothing was to be left to
chance. Each man was to know his duty and his post. He learnt
where he would join his " trip " and whether he was first, second,
or third trip. Every officer and man wanted to be in the last trip,
but this could not be. After consideration it was decided that the
oldest hands would be given the post of honour, whilst the younger
soldiers would leave the Peninsula first.

Then we recall the difficulty there was in arranging the packs
and kit of the men so that they could move in perfect silence.
The mess-tins and water-bottles were muffled and the feet were
swathed in sandbags. The greatcoat was rolled and fixed so that
each man would be free to carry a loaded stretcher.

An order that hurt us sorely we remember was received during
these days. All rum in possession was to be destroyed ! The
nights were cold and cheerless, and there had been no opportunity
for the usual celebrations of the season. The order hurt, but it
was obeyed to the letter.

At last the " day before " arrived. The morning of the 7th
January broke clear and cold with frost, and our luck seemed to
be holding. Our preparations were nearing completion. "We
remember that morning at daylight receiving an order to despatch
four mules and one man forthwith to the Beach. To us it had
now become apparent that the naval people organising the evacua-
tion at the Beach loaded up with the items to their hand, and if

374 James Young

there was a spare corner on the ship to fill up before they started
they sent a hurried message for a fragment of the ambulance !

During this day the Turk launched a big attack on the front
to our left. There were still enough men in our trenches to oppoae
him with resistance, and any suspicion he may have had must
have been allayed. It may have been as the result of this attack
that he remained so quiet during the whole of the next day and
night.

The eighth, the day of our fate, broke cold, with a stormy breeze
blowing. We wondered if luck, which had smiled on us so far,
was at last going to play us false, for a rough sea would damn
our every chance. But we worked away at our final rehearsai
The bearers were sent to their control posts, close touch was main-
tained with the fragment of the Divisional Headquarters that was
now left, so that our plans would be modified in accordance with
any altered dispositions of the troops, the officers had a conference
to discuss the final details, we synchronised our watches and the
last trip of officers and men set off to their posts.

The last day will always stand out in memory as one of the
greatest days of our life. As usually happens on such an occasion,
every detail, however trilling, is fixed in imperishable relief against
the background of momentous experience.

We remember that after we had thought that all details were
finally settled, orders and wires still poured in from headquarters.
Still they came, and if the Day of Judgment arrives before the war
is ended the orderly room will assuredly be late in responding to
the last trump. A series of orders were sent to us regarding the
disposal of the horses that were still left on the Peninsula. It
was evident that at headquarters there were two opposing influences
at work, the one a love of horses and the desire to save them, the
other a determination that come what might they must not be left
to the Turk. The first order came early. All horses were to be
shot at dark. An hour after this was cancelled. Horses were to
be watered and fed before dark, and those not required for the
ambulance waggons were to be liberated. A chit came hot on
the top of this to say that an officer would call round during the
day to shoot all horses not required for the evacuation. The
contest between the two camps was now becoming exciting to us
who looked on, and when a later order arrived instructing that
horses would not be liberated or shot, but would be left in their
lines with plenty of water and feed, it was received with loud
cheers. But from this jubilation we were soon plunged into

A Field Ambulance in Gallipoli 375

despondency by the next order, the last of the series, to the effect
that all horses not needed would be shot immediately after dusk.
At dusk an officer was given a revolver and sent over to the horse
lines to carry out the dire deed of execution. Now, R.A.M.C.
revolvers are not always kept in the best of condition, and when
he was asked some days later how his task had fared, he said, " Oh,
I had to let them go. The confounded revolver would not work."

During the last two hours of the afternoon the First Trip and
the Rendezvous parties were engaged in an orgy of wanton destruc-
tion. Dozens of tins of bully beef were punctured by a blow from
a pick. Stoves, camp-kettles, galvanised iron roofing, tents, rubber
thigh trench boots and anything which we could not take were all
destroyed beyond use.

The First Trip party moved out to join the infantry who were
to move off from the back areas at 6.30 p.m. The Rendezvous party
alone was now left, and after lighting up the camp with candles
which were due to burn out at 10 p.m. and which were placed in
tents and dug-outs as if nothing were amiss, they set off to their
posts leaving a camp forsaken but with all the semblance of life.
All round the camp-fires burned as if there was nothing to disturb
the ordinary routine of the night.

The Rendezvous was in telephonic connection with the eight
posts all along the line and with the Beach, so that we knew at
any moment how things were progressing both in front and behind.
As we gazed into the dark, waiting for the First Trip, we watched
four large French guns pass towards the Beach, each drawn by
twelve pairs of fine horses. There was no fuss. Tney moved past
us in a silence that was impressive. It was a noble sight.

The First Trip arrived to time. They were due at the
Rendezvous at 7 p.m. #nd to embark at 8.30. The men were
keen and anxious as they trooped past us. There was to be no
smoking and no talk above a whisper, for the night was clear
and lights would be visible for miles and the smallest noise
travels far on such a night.

Just as we heard that the First Trip had been embarked safely
the Second Trip arrived. In silence they were halted and
marshalled into fours and counted. When the complete party
was collected they set off on the final stage of their journey.

Whilst the hearts of all beat anxiously during these hours
that seemed to be prolonged to the length of days to those who
waited in silence, the usual amount of night firing could be heard
on the hillsides of Achi Baba. Occasional flares would rise

376 James Young

lighting up the slopes far up in front, or a sudden burst of
machine-gun fire would startle us into thinking that the Turk
had spotted the game. But always the comforting report kept
coming down the wires from the control posts: "Everything
going well, no casualties reported." Once or twice we heard
shells whizz overhead to the Beach, and we had momentary spells
of tense anxiety, but the suspense lifted with the reassuring
reports.

At one time, however, our anxiety reached an acute stage.
The sea was running high and rising, and the embarking of the
Second Trip was being carried out under grave difficulties. The
prospects for a bit became extremely gloomy, and it almost
looked as if dire disaster was pressing in to overwhelm us, and
our plight was an unenviable one. We had destroyed all the
rations except what we carried. The big guns had gone, all except
a few old veteran pieces the last function of which was to burst
into occasional fire that night. We should have been a sorry
crowd if morning and the Turk still found us stranded on the
Peninsula amid the desolation of our deserted camps and the
havoc which we had wreaked on them with our own hands.
Visions of Constantinople rose before our eyes. For a time Fate
looked to have turned black against us at the last moment.

But just when our horizon seemed to have darkened to
irretrievable disaster the welcome news was flashed back along
the line that the Second Trip had been embarked at the Beach.
We took a deep breath of renewed hope and peered anxiously
out towards Achi Baba for the arrival of the last party.

At last No. 1 Control Post at the front line rang up to say he
was cleared and was removing his instrument. A few minutes
later No. 2 Post did the same, then No. 3. The excitement was
now extreme. The stage of final crisis was on us. The next few
minutes would decide our fate. In succession the remaining posts
rang up to announce the passage of the last trip. No. 4, then
No. 5, then No. 6, then No. 7, and finally No. 8 reported that all
was well and that they were lifting their instruments.

Would our luck hold ? There was now in front of us, between
us and the large Turkish Army on the slopes of Achi Baba,
nothing but miles and miles of empty trenches with the parcel of
men who had forsaken them pressing eagerly towards us. It
would be half an hour before the first of this last batch would
reach us.

Still the rifles crackled on the hillside and still our flares

A Field Ambulance in Gallipoli 377

climbed into the skies at the far-off trenches as if everything were
as usual. For the engineers had rigged up ingenious devices by
which rifles and flare-pistols automatically discharged themselves
long after their owners had left. By an accumulation of clever
mimicry and dumb play the Turk was lulled that night into the
belief that our lines were still firmly held against him. At the
very moment when they were being completely emptied, for all
we knew he may have been preparing to meet a gathering attack.

At last, just as the moon began to peer over the distant hills
of Asia away beyond the Hellespont, our straining eyes picked
out the first few men of the last batch. Their dour Scotch faces
were set in a look of mingled determination and suspense as they
approached. They had come miles through trench and over the
open without a moment's pause, for this was not a night for
dallying by the way. The sweat poured down their faces
although the night was cold. As they gathered in front of us to
be marshalled for the final count the excitement that animated
them spread to us.

In a short time the "all correct" was announced, the Staff
closed their office at the Bendezvous, and the procession turned
its back on Achi Baba and made off for the Beach, the ambulance,
or what was left of it, taking its usual position in the rear.

Everything had so far gone better than in our wildest hopes
we could have wished for. The only casualty of the night was a
man who carried a machine-gun and who in the unwonted bustle
and exertion had developed a pain in the side and a palpitation
that left him breathless. He was the only occupant of our
ambulance waggons.

As we had a large reserve of stretchers, at the last moment,
prompted by a laudable desire to help the British taxpayer, each
man picked up two stretchers before he joined the procession.

The way to the Beach, which we had often marched and
thought nothing of, seemed a very long trek that night. But we
pushed on as quickly as the length of our procession and the
darkness of the night would allow. The rifle bursts still broke
the silence of the far-off slopes of Achi Baba, and the lights of
the flares still rose into the heavens. The Turk was still unsus-
pecting, though every now and then a gun from the Asiatic side
of the Hellespont would hurl a shell over to the Beach near us.

Gradually our pace became slower as the head of the pro-
cession reached the narrow track that runs between the sea and
the cliffs. In places it is only a yard or two wide and the column

27

378 James Young

was by now a long one. At one time " Asiatic Annie " served us
the last thrills which she was fated to do. "We could by this
time see the far coast of the Dardanelles showing distinctly in
the moonlight. Every now and then we caught the flash of the
large gun and then, eleven seconds afterwards, the shell burst
with a shriek and a crash. It fell near us in the sea, but it was
still thirty yards away. Our luck was still holding.

We marched past the River Clyde. With one last look at the
famous old tattered liner we passed on. We continued our course
past V Beach to the rocking, ramshackle wooden pier, and thence
along the breakwater to where we could just make out in the
darkness a torpedo boat destroyer tossing on the sea.

Here the delay seemed to be interminable, and "Asiatic
Annie" was rousing herself into renewed activity. But we
steeled our hearts to patience although it at one time looked as
if daylight would still find us on the shores of Gallipoli. One
by one the men scrambled on to the slippery rocking deck of
the T.B.D. across the gangway steadied by stalwart bluejackets.
Our gallant boys still clung heroically to their salved stretchers,
but this was more than the sailors could stand. It was going to
be a tight fit to get the men on board, and there was no room for
odds and ends on the narrow deck, apart from the fact that every
second of time was precious and it required the use of his every
limb to enable a man to clamber aboard. A stentorian voice

rang out " Chuck these things away ! " and it rained

stretchers in the vicinity of that gangway till all the R.A.M.C.
men were safely on board.

We slipped our moorings and were off. The moon was hidden
behind storm clouds and we could see little of the shore as we
bade good-bye to the land which had held us captive for these
many months past. We were cold and sodden, for the seas broke
over us as we huddled together on the deck. But we were happy
as we breathed the breath of liberty once more after months of
bondage. As we watched the searchlights in the Narrows grow
more and more distant behind us, even the greatest discomforts of
body and the buffeting of the elements could not rob us of the
relief we felt at the ending of our long chapter of trial. The
sailors, with the proverbial cheery kindness of the sea, did their
utmost to lighten the troubles of the passage. Within a few
minutes every man who had not fallen into a sleep of exhaus-
tion where he lay was served with a pannikin of steaming
cocoa.

A Field Ambulance in Egypt 379

In the morning we reached Mudros and here we stayed for a
day or two picking up the fragments which had left the ambulance
bit by bit during these last days of Helles. After a few days we
were hustled on board a troopship and set sail for Alexandria,
where we landed for the second time two days afterwards.

Thus ended the first chapter of our service overseas.

VII. Back to Egypt.

After the evacuation we were sent back to Egypt, and for
some time we were camped in the desert on the outskirts of
Cairo.

Those were great days ! Breathing freely again under the
sense of relief from a heavy strain, it is not surprising that the
spirit of holiday was abroad amongst us. Though the division
had spent some days in Egypt the previous year, leave had not
been open, and none of the officers or men had had a chance to
explore the sights. The opportunity now opened up and was
thoroughly taken advantage of. The hundred and one sights of
Cairo and the neighbourhood were visited. The numberless
mosques that vie with one another in splendour of architecture
and colouring, the bazaars with their most cosmopolitan gathering
of races that can be seen in the whole world, the Pyramids of
Gizeh and Sakkhara and the Sphinx, and the other things too
numerous to mention were all visited by eager throngs.

But there was plenty of work to be done as well. The
ambulance had to be refurnished almost completely with new
equipment to replace that lost at Helles. This kept the quarter-
master's department busily engaged. Then there were the drills,
which always loom large in the day's work in a more or less
standing camp, and we required drilling badly to endow us with
a renewed sense of self-esteem and to rub off the careless attitude
towards many things, which is quickly bred by trench life.
Those of us who had grown beards had to remove these hirsute
ornaments, which did not fit into the new scheme of polished
discipline.

We were very soon new men in appearance, health, and
outlook. And in a few weeks we were moved from Cairo to take
our place in the army guarding the Suez Canal.

This marked the second phase in our military career. We
were plunged into a wholly new life. Our ways of living had to
alter to suit our new environment. And amongst all the changed

380 James Young

circumstances that we had to adapt ourselves to, there were none
so great as these relating to the conduct of war itself.

It was some time before we settled into the new methods.
We had to find our feet not only metaphorically but literally also.
Those who have lived for any time on the desert will know that
it is only gradually that the feet and legs accustom themselves to
the soft sand. New muscles and new sinews are called into play,
or rather it seems to be that the old muscles drop out of use,
for after you have lived on the sand for any period of time and
get back again to terra Jirma your shin muscles ache sorely fpr
the first day or two. After months of disuse they become strained
by being called on to give the spring in walking that one again
acquires on the harder ground.

The methods of war were different. This was specially true
of transport and equipment. The early days were spent in
gathering up the animals and waggons remaining from the
transport, which we had left at Alexandria the previous June,
when we sailed for Gallipoli. The most of it had been taken
away. Some had gone to units in Egypt. A great part of it had
gone to furnish field ambulances for Salonika. What remained
over was brought down to the new camp on the Suez Canal.

Then we had to collect camels. From this time the camel
became incorporated as an intimate part of our economy, and
eventually we had as many as 300. At the beginning his
unconciliatory, supercilious ways, and his attitude of dignified
disdain, not to mention his occasional outbursts of actual vice,
rather chilled our dealings with him. But we little knew
then how greatly our lives and comfort, and how greatly
our failure or success, were going to hang on this at first
despised animal of burden. It was not till long after that we
came to realise the full worth of our new friend. And then our
hearts were often filled with gratitude when we thought of the
whole existence of an army that had depended on the four
hundred pounds or thereby of food or ammunition carried on each
back of that long, silent, and stately procession that followed in
the wake of the moving troops. Many a time, also, have we
had occasion to thank our camel convoy for the days and nights
of constant work entailed in clearing the wounded from the
battlefield.

It was the end of February 1916 when we took up our quarters
at Kantara, at that time a small station on the Port Said-Ismailia
railway line and situated on the west bank of the Suez Canal.

A Field Ambulance in Egypt 381

We opened our little hospital beside the Custom House, and
during the heat of summer we lived a comparatively leisurely
existence in which bathing and fishing helped for recreation.

We felt a certain thrill of pride in the thought that we were
there to safeguard one of the world's greatest highways of
commerce, and our British hearts beat high as we watched the
great ships in constant procession sweep slowly past, and realised
that in spite of war the vital links of empire were intact. At
night, especially, after dinner we would sit and watch the liners
glide past with their decks and saloons a blaze of light, silent
symbols of our imperial power.

One day (10th April) our eyes were staggered by the sight of
two large transports crowded with Kussian troops. Someone soon
came with the news that they had come from Vladivostock.
Their appearance caused great surprise in our midst, and all sorts
of surmises were soon abroad. Were they going to Salonika, or
to France, or where ?

From the time of our arrival our troops had been pushed
forward some miles into the desert on the east to occupy strong
posts, and we had an advanced dressing station in these early
days at Hill 40, about 4 miles from the Canal. From there we
brought our patients back to Kantara by motor cars.

Kantara is situated on the bridge of land that crosses the
salt lakes and unites the western with the eastern or Sinai desert.
El Kantara in Arabic means " the bridge." It is here that the
great highway that links together Asia and Africa passes — the
most ancient and in some ways the most famous road in the
world. It was down this road that Abraham and later Joseph
came from Syria into Egypt. At a later time Mary and Joseph
with the child Jesus passed along the same track, and an old tree
at Kantara is still shown as that under which the Holy Family
rested.

Then along that road in ancient times the armies of Egypt
passed to the conquest of Asia. With the decadence of the
Egyptian Empire the hosts of Persia swept in to add Egypt to
their conquests. At a later day Alexander the Great passed this
way to subjugate Egypt and to found his new city of Alexandria.
Then under Napoleon the tide of invasion swept the other way.
It was through Kantara that Napoleon's army, and later the
great conqueror himself, passed to subdue the Arabs of Sinai and
Palestine.

In the pre-war days this road was largely used by camel

382 James Young

convoys, which crossed the Suez Canal at Kantara by means of a
ferry. It then struck eastwards across the Sinai Desert, through
Katia, El Abd, and Mazar to El Arish. From El Arish it passed
northwards close to the shore past Sheikh Zoweid, Rafa, and
Khan Yunus to Gaza.

Its course was determined by the wells, for in the desert the
most compelling consideration is water, as we were so constantly
to experience during the next two years.

In the early months of 1916 the beginnings of the broad gauge
railway across Sinai were being laid at Kantara. We were
present at its birth and we watched its growth step by step as it
was thrust further and further forwards across the broad stretch
of sand, until at last it found solid bottom on the soil of Palestine.

It was in the narrowest sense of the term a military railway,
for in the desert, at least, the advance of the army was possible
and was consolidated only in proportion as the line was laid. We
paused when the railway paused and we leapt forward as the
railway leapt forward. At no time in the desert could we be far
in advance of the rail-head.

But, although its origins were purely military, there were
many of us who could foresee a time, after the clouds of war had
been swept away, when it would constitute a great commercial
and political link between Africa and Asia. Long after the traffic
of war is forgotten the busy trade of peace will be seen speeding
across the yellow sands of Sinai and — who can tell? — the inhabitant
of Cairo will be seen travelling north to spend his summer months
among the hills of Jerusalem instead of taking his accustomed
trip home. Since the days when we first knew Kantara the
railway has spanned the Suez Canal by means of a pontoon bridge
and the linking-up is now complete.

Colonel Young, who had been sent to hospital sick some
months before, rejoined the unit at Kantara. In his absence
Major Greer was in command.

{To be continued.)

Clinical Records 383

CLINICAL RECORDS.

By CHARLES F. M. SAINT, M.S., F.R.C.S., Assistant Surgeon, Hospital
for Sick Children, and Surgical Registrar, Royal Victoria Infirmary,
Newcastle-on-Tyne, late Major, R.A.M.C.(T.).

An Unusual Obstructing Band.

The patient was under the care of my late colleague, Captain
Denis Cotterill, whose untimely decease has led to my publication
of it, as he would certainly have published it himself, on account
of its unusual and important nature.

The patient was admitted to hospital with a gunshot wound of
the buttock, which had undoubtedly penetrated the abdomen. The
abdomen was opened in the mid-line below the umbilicus, several
holes in the small gut were sutured, and the shell fragment removed.
Extravasation was limited to the pelvic region, and there was no
injury to colon or rectum, so that a good prognosis was entertained.
However, in spite of all available measures, he did not do well.
There was some distension of the abdomen, and he continued to vomit
from time to time. He never had complete intestinal obstruction,
flatus being passed on giving an enema. It was not considered
advisable to do a second operation, and he died about five days after
operation.

Post mortem there was peritonitis and some fluid in the lower
abdomen and some distension of the small gut, though the suture
lines were quite sound. The interesting feature, however, was the
presence of a strong band, which was encircling almost the whole of
the small intestine. It was of the thickness of a small quill. Its
anterior portion was attached above in the region of the duodeno-
jejunal junction, and from there it passed down in front of the
mesentery, turning round the ileum a few inches from the ileo-csecal
valve. From this point it passed upwards behind the mesentery, and
was also attached in the neighbourhood of the duodeno-jejunal
junction about \\ to 2 ins. from the anterior end. The whole of
the small intestine, with the exception of a few inches, was thus
herniated through the loop, and there was some obstruction, though
by no means complete. On turning the small intestine over to the
right side of the abdomen and examining the duodeno-jejunal region,
a large paraduodenal fossa was discovered, which would easily admit
the closed fist. Its free anterior wall was very thin and translucent.
It was noticed that the free edge of the anterior wall, which normally
contains the inferior mesenteric vein, was also quite thin and trans-

384 Clinical Records

parent, and it was therefore suggested that the sequence of events
had been : (1) hernia of the small gut into the paraduodenal fossa,
with great distension of the sac ; (2) rupture of the anterior wall of
the sac and the passage of the gut through the rupture into the
general peritoneal cavity ; and (3) the free edge of the anterior wall
left to form the band round the gut. It was considered a rather
extravagant hypothesis, but the proof of it was easy, since, if it were
true, the band would contain the inferior mesenteric vein. The band
was therefore cut across, and, as had been anticipated, the inferior
mesenteric vein was found to be present in it.

An operation for intestinal obstruction in this patient, with
division of the encircling band and relief of the constriction, would
not have been so happy in its results as is customarily anticipated.
Fortunately it is an uncommon condition.

multiloculak mesentekic cyst with intestinal
Obstruction.

The patient, a married woman, 32 years of age, was the mother
of three children.

She came complaining of a lump in her abdomen, to which her
attention had been drawn very shortly after her last confinement,
four months previously. Up to that time she had had no abdominal
trouble, but two or three days after delivery she had an attack of
abdominal pain, which was rather severe, and caused her to vomit.
The abdomen was tender, and, on pressing it, she first noticed the
lump. Since that time she had had recurrent attacks of pain and
vomiting, and the lump had remained as before. Her menstrual
periods had not returned.

On examination her general condition was fairly good, though she
was somewhat slightly built. Temperature and pulse normal. The
abdomen was not generally distended, and a lump could be seen
situated just below and to the left of the umbilicus.

On palpation there was no rigidity of the abdominal wall, and
the tumour could be readily examined. It was the size of a cocoa-
nut, was firm in consistency, its surface more or less rounded, though
not quite smooth, and it was well defined. It was movable, though
not freely so, and it could not be pushed down into the pelvis. On
bi-manual examination no definite connection could be made out
between the tumour and the uterus.

Percussion demonstrated no free fluid, and only a limited impaired
resonance over the tumour itself.

From the occurrence of the first attack following on her accouche-
ment, the nature of the attack, the recurrences, and the characters
of the tumour, a diagnosis of ovarian cyst (probably dermoid) with

Clinical Records 385

twfsted pedicle was made. The limitation of movement was attributed
to resultant adhesions.

Operation. — The abdomen was opened in the middle line and an
exploration made. The tumour was found to be situated in the
mesentery of the lower jejunum, was multilocular and cystic in
nature, and the corresponding part of the small gut was stretched and
flattened out as it passed over it. The intestine above was markedly
hypertrophied and somewhat distended. The bowel below the tumour
was collapsed. It was impossible to shell out the cyst, and, in order
to remove it, it was necessary to excise 2 ft. 6 ins. of gut. The divided
ends of the bowel were then closed and invaginated, and a lateral
anastomosis performed. No other pathological condition was found,
and the abdomen was closed in layers in the usual way. The patient
made an uninterrupted recovery. She was last seen twelve months
after the operation.

The cyst was multilocular, and the cysts contained a clear pale
liquid.

Ovarian Fibroid with Ascites.

The patient, a married woman, 56 years of age, and weighing about
14 stones, had noticed increasing swelling of her abdomen for some
months. Latterly she had become very short of breath and suffered
from considerable swelling of the feet and legs, being finally bed- ridden
and considered beyond the scope of surgery. She complained of more
or less continuous discomfort and pain of a gnawing character, which
had no relation to food ingestion, bowels, or urinary function. In
spite of her great size she was certain that she had lost a great deal
of weight since the onset of symptoms.

A consultation was asked, not so much with a view to any operative
measure as to a concurrence in the hopeless nature of the case.

On examination her general condition was not good, her lips were
bluish, and she had obvious difficulty with her respiration. The urine
was normal. The pulse was soft but regular, and she had no rise of
temperature.

The abdomen was greatly distended, with bulging of the loins in
addition to an anterior prominence, and the lower abdominal wall was
cedematous. On palpation a hard tumour could be felt by pressing
deeply, but the abdomen was too tense to obtain any detail. A fluid
thrill was readily obtained and ballottement elicited with ease.

Percussion confirmed the presence of free fluid by shifting the
flank dulness, and epigastric resonance with convexity downwards
Per vasdnam nothing abnormal was felt. A diagnosis of malignant
ovarian cyst with ascites was made, and operation was decided on, in
the hope of giving at least temporary relief.

Operation. — A long mid-line incision was made, and the abdomen

386 Clinical Records

opened. A great quantity of serous fluid was evacuated and a large
smooth solid tumour exposed.

Some adhesions of the sigmoid were easily separated, but others
of the omentum, to a part of the tumour which was obviously under-
going some degenerative change, were so dense that the corresponding
part of the omentum was ligatured off. After this the tumour was
fairly easily delivered from the abdomen, and was found to be asso-
ciated with the right ovary. After ligature of the pedicle it was
removed. The left ovary showed nothing abnormal, and was not
interfered with. There was no evidence of secondary deposits in the
abdomen. The abdominal wall was sutured in layers without drainage.

The patient made an uninterrupted recovery from the operation,
and left hospital at the end of three weeks.

The tumour weighed 11 lbs. On section it was solid, and at the
part most distal from the point of entry of its blood-vessels of supply
was undergoing degeneration. It was here where the omentum was
adherent. The microscopic report was that it was a fibroma, very
cellular, and apparently rapidly growing.

Two years later she came to the hospital to show herself. She
was feeling very well, had put on a good deal of weight, and had not
had a day's illness since the operation. Her abdomen showed no sign
of recurrence of disease, but there was general bulging of the abdominal
scar, for which a belt was advised.

Pyosalpinx Eesembling Broad-Ligament Cyst.

The patient, a girl 17 years of age, was admitted to hospital with
the diagnosis of appendicitis.

The story she told was that she had been ill for some weeks with
pain and tenderness in the lower abdomen, which was more or less
continuously present, but which varied much in severity. When it
was severe she vomited occasionally, and she also complained of pain
on micturition at times. Her menses were regular, though excessive.
Her temperature was raised, but varied considerably from day to day.
Her general health was not good, and she had lost flesh.

On examination her abdomen presented a somewhat scaphoid
appearance and respiratory movements were free.

She had no rigidity of the abdominal wall, and nothing was felt
in the right iliac fossa. On deep palpation over the pelvis a firm mass
was felt, which was tender on pressure and fixed. As her virginity
was not called in question, a provisional diagnosis of tuberculosis of
the Fallopian tubes was made.

Before commencing to operate, a vaginal examination was made
under anaesthesia, when it was found that two fingers could be intro-
duced with ease. The cervix uteri was displaced well over to the
left, and the right fornix was bulged downwards by a swelling which was

Clinical Records 387

continuous with the mass felt on abdominal examination. There was
nothing to be felt in the left fornix. The diagnosis now suggested
was either a pyosalpinx or an infected broad-ligament cyst.

A mid-line abdominal incision was made and the pelvis investigated
with the patient in the Trendelenburg position. The right broad
ligament was occupied by a swelling the size of a large duck's egg.
The uterus was pushed over to the left side, and at this spot there
was sufficient space to introduce a finger into the pelvis, but in the
region of the swelling it was not possible to do so. Furthermore, the
summit of the distended broad ligament was flush with the brim of
the pelvis. Apart from a few flimsy adhesions, there was no obvious
lesion in the left tube and ovary.

It was decided to incise the broad ligament along its upper border,
and so to shell out the cystic swelling which occupied it. This was
accordingly done, it proving easier than had been anticipated. The
last portion to be separated was the attachment to the right horn of
the uterus, and when this was done there was an escape of extremely
foul-smelling pus from the sac into its bed. Nothing further was
done, and a tube drain was placed down to the bottom of the cavity
in the broad ligament and brought out of the lower end of the
abdominal incision. The incision was sutured in layers in the
usual way.

Subsequently there was profuse discharge of foul-smelling pus from
the tube, and a persistent sinus remained for a long time. Her general
health improved greatly.

On examination of the specimen it was found to be a thick-walled
unilocular abscess containing very foul pus, the only indication of its
being a Fallopian tube being the leak which occurred on its final
separation from the uterine horn. No microscopic examination of the
tissue of the wall was possible.

Pyosalpinx Containing a Eound Worm.

The patient was a virgin, 16 years of age, who was admitted to
hospital with abdominal pain, vomiting, and a rise of temperature.

She had'been ill for some days. Her pain was situated in the
lower part of the abdomen and was more or less continuous. She had
vomited several times. There was some pain with micturition, pro-
ducing delay in commencing the act, and being rather worse towards
the end of it. Menstruation was regular, somewhat excessive, and
there was accompanying pain.

On examination her general condition was good, with temperature
of 100° F. and pulse of 84. With the exception of hypogastric tender-
ness and some rigidity, more especially marked in the right lower
rectus, there was nothing to be made out on abdominal examination.
It transpired that her French medical attendant had made a vaginal

388 Clinical Records

examination, with some difficulty, with one finger. The condition
was identical with that found in the last case, the cervix uteri being
displaced over to the left side, and the right fornix bulging markedly
downwards and very tense. It was very tender on pressure. There
was no discharge from the urethra or vagina.

The similarity to the previous case was mentioned, the possibility
of its being an infected broad-ligament cyst being entertained in
preference to a pyosalpinx.

Operation. — The abdomen was opened by a mid-line incision, with
the patient in the Trendelenburg position. Apart from the presence
of some omental adhesions and evidence of recent acute peritonitis
in the pelvis, the picture presented was the exact counterpart of the
previous case. The right broad ligament was greatly distended by
an egg-shaped swelling almost closing up the true pelvis flush with
the brim, the uterus being pushed well over to the left side, and at
this spot alone could a finger be introduced into the pelvis. The left
tube and ovary appeared to be normal.

The same procedure was carried out as in the last case, the right
broad ligament being incised along its upper border, and the cystic
structure shelled out of its bed. As the separation was being completed
the cyst burst, and there was an escape of the same kind of pus as in
the previous case, with foul smell. In addition, however, there floated
out a round worm, 3| ins. long, dead.

After removal of the abscess wall complete, a tube drain was
introduced into its bed, but this time it was brought out into the
vagina. The broad ligament was sutured completely up and the
abdomen closed in layers without drainage. During the operation
the appendix was seen quite free from all adhesions, and apparently
normal.

Subsequently there was a discharge of foul-smelling pus per
vaginam for some days, but this rapidly cleared up, and the patient
made an uninterrupted recovery.

Examination of the specimen showed it to be similar in all respects
to the previous one, but, as in the other case, it was impossible to have
it examined microscopically.

The interesting point in this case was the presence of the round
worm, and, in the absence of any sign of gut or appendix adhesion,
one is constrained to believe that it had effected an entrance into the
Fallopian tube through the vagina and os uteri, which would appear
no easy task.

Two Unusual Cases of Inguinal Hernia.

Case I. — The patient was a female child, 3 years of age, and was
admitted to hospital with a right inguinal hernia, which was increasing
in size, and could not be controlled by palliative measures.

Clinical Records 389

A small incision was made over the hernia, and the sac exposed and
opened after division of the external oblique.

After reduction of the gut into the abdomen, the uterus and both
ovaries were found to be present in the upper part of the sac. They
could be returned to the abdomen, but came out again at once. On
closer examination the right round ligament was found to have no
intra-abdominal course, so that the right horn of the uterus was really
attached to the neck of the hernial sac, and, while there was a very
long broad ligament on the left side, the right one was very short and
almost absent. To allow of permanent reduction of the uterus and
appendages, the right round ligament was divided, and then a radical
cure of the hernia was done by separating and removing the sac after
ligature of its neck, the internal ring and the external oblique being
sutured with catgut, and the skin with silkworm gut.

Obviously, the condition had been produced by over-action of the
right round ligament of the uterus, the homologue of the gubernaculum
testis.

Case II. — The patient was, in this case, a male child between 2
and 3 years of age, who was admitted to hospital with a double
inguinal hernia, which was only partially reducible on either side, and
reached to the upper part of the scrotum, the testis being felt free at
the bottom of the scrotal sac on either side.

A small oblique incision was made over each hernia, and the
external oblique divided for a short distance from the external ring.

On the right side a fairly large funicular sac was found contain-
ing coils of gut, and below this, between it and the testis, were two
hydroceles of the cord, not tense, and containing about 1£ drms. of
fluid. The apex of the hernial sac projected into the first hydrocele
sac, and this in its turn projected somewhat into the second. The
testis with its tunica vaginalis was quite separate.

On the left side there was a similar, though less, funicular hernial
sac with gut content, and below it a single hydrocele of the cord,
of similar size to those found on the right side. The hernial sac
projected into the hydrocele sac in a manner similar to that seen on
the other side. The testis, with its tunica vaginalis, was here also
quite free.

On both sides the hydrocele and hernial sacs were removed, the
necks of the latter being ligatured, and the external oblique sutured
with catgut and the skin with silkworm gut.

The presence of two hernial sacs and three hydroceles of the cord,
apart from the complete separation of the tunica vaginalis on each
side, is an unusual example of imperfect obliteration of the processus
vaginalis.

390 Recent Advances in Medical Science

RECENT ADVANCES IN MEDICAL SCIENCE.

MEDICINE.

UNDER THE CHARGE OF

JOHN EASON, M.D., and A. GOODALL, M.D.

The Cutaneous Aspects of Tuberculosis.

The cutaneous reactions which occur as a clinical feature in some forms
of tuberculosis are equally interesting to the dermatologist and the
general physician. On the one hand, an inconspicuous skin lesion may
throw light on a case by suggesting a search for a tuberculous focus
somewhere in the body ; on the other hand, the recognition that some
forms of skin disease may be due to tuberculosis may assist the
dermatologist in advising treatment. The conditions in question are
grouped generally as tuberculides, and they form the subject of an
interesting series of papers from the Mayo clinic, by Stokes (Amer.
Journ. Med. Sci., February, March, and April 1919). Recent advances
in the study of dermatoses tend to show that many supposed clinical
entities, so styled on morphological grounds, have a multiple etiology.
One of the conditions to which this applies is the erythema group,
including erythema nodosum and erythema multiforme. E. nodosum
is of particular interest in this respect, because on its border lie ery-
thema induratum and the group which Darier designated "tuberculides,"
the relation of which to tuberculosis is generally accepted. Stokes
had his attention drawn to the connection of this group of skin lesions
with tubercle by a fatal case of miliary tuberculosis, the onset of which
was associated with an outbreak of rheumatic purpura and erythema
multiforme. The material analysed in Stokes' paper comprises a series
of about forty cases of these diseases — papulo-necrotic tuberculides and
erythema induratum — studied at the Mayo clinic during two years.

Erythema Nodosum Group. — The association of this disease with
tuberculosis has especially been urged by French observers. Landouzy
is said to have inoculated guinea-pigs successfully with tuberculosis by
means of material from the lesions of this condition, and at least one other
observer has confirmed the observation. On the other hand, a Gram-
negative diphtheroid, apparently arising from an oral infection, has been
demonstrated in some cases. The suggestion is that the etiology of
erythema nodosum need not be a single one, but that embolic infarct
or thrombosis due to tubercle or other bacilli may produce the lesion
on a hypersensitive individual. Ten cases of the disease are reported
by Stokes : — Case I. A girl, aged 24, typical E. nodosum following
pharyngitis. Was ill for four weeks with pharyngitis, during the first

Medicine 391

fortnight of which she was feverish. Lost 21 lbs. during illness.
No proof of tuberculosis, but on account of some indeterminate signs
in lungs was placed on antituberculosis treatment. Case II. Male,
38 years. In 1911 purpura and "rheumatic" pains; at this time
tuberculous cervical glands and evidences of apical disease were present.
The disease became quiescent. In 1918 E. nodosum, not quite typical,
inasmuch as the lesions were sluggish and did not show ecchymoses ;
calcified axillary tuberculous glands present. Case III. A patient,
aged 31, suffering from sacro-iliac disease with a sinus, gave a history
of purpura following on influenza two and a half years previously.
The scars following the so-called " purpura " were typically those of a
tuberculide. Case IV. A woman, aged 33, gave a history of anaemia
and a lump in the neck two years previously. She was admitted to
the clinic on account of erythema nodosum. The gland in the neck
was shown to be tuberculous, and there was healed disease of both
apices. The erythematous nodules were pale, and approached the
E. multiforme type. Notwithstanding treatment, they continued to
appear, and after about a year assumed the characters of erythema
induratum. Case V. is that of a girl previously operated on for cervical
adenitis, in whom the disease was spreading, and who became affected
by E. nodosum, approaching the indurative type. Case VI. is that of
a man, aged 44, with enlarged cervical glands, inconclusive lung signs,
fever, and erythema multiforme of wrists, erythema nodosum over
tibiae, and a few pustular lesions suggesting acute generalised miliary
tuberculosis of the skin. Case VII. was one of erythema multiforme,
followed by papulo-necrotic tuberculides, in a girl with a very bad
tuberculous family history, and suspicious signs at one apex. Case VIII.
was an obese woman of 30, with papulo-necrotic lesions and purpura.
No visceral or glandular focus could be detected. Case IX. was a
typical one of E. nodosum, with joint pains and a pleural effusion ; she
had septic tonsils and teeth. All signs cleared up under salicylates.
Case X. was a woman with marked arthritic E. nodosum, phlyctenular
conjunctivitis, and enlarged glands at the right hilus.

This forms a very interesting series of clinical observation, revealing
a relationship between purpura, erythema multiforme, nodosum, and
induratum, and papulo-necrotic tuberculides in persons who were
either proved to be, or suspected of being, tuberculous. Stokes
suggests the following provisional clinical distinctions between
(1) tuberculous erythema nodosum, and (2) "streptococcal" erythema
nodosum. In (1) nodes smaller, more circumscribed, and with
less tendency to ecchymosis. Tend to be localised on the posterior
aspect of the legs. Paler, colour changes less, more chronic, and less
tender. In (2) nodules larger, brawny, haemorrhagic, more superficial.
Distribution, anterior parts of limbs, especially shins. Colour changes,
those of a bruise. Symptoms and course more acute.

392 Recent Advances in Medical Science

To throw further light on this problem the following points require
study: — (1) Search for evidence of previous tuberculosis in patients
suffering from E. multiforme, etc. (2) Inquiry as to previous dermatoses
of this group in tuberculous patients. (3) Investigation of throat and
accessory sinuses, and radiographic examination of teeth for pyogenic
foci. (4) Systematic examination of temperature, and leucocyte
counts, in such cases.

Tuberculides. — This term was applied by Darier to describe a group
of lesions associated with tuberculosis of the viscera, which did not
necessarily show the characteristic pathological anatomy of tuberculosis
of other structures. Lupus vulgaris is a true tuberculosis of the skin,
whereas the papulo-necrotic tuberculide is a non-specific type of
inflammatory reaction, consisting of a papule with a central necrotic
plug which heals, leaving a punctate atrophic scar. Among tuberculides,
there are recognised as such: — (1) Lichen scrofulosorum ; (2) the
papulo-necrotic tuberculide as above, with its subtype, acnitis, appear-
ing on the face ; and (3) erythema induratum or Bazin's disease. In
addition to these, other skin diseases are also held by some to be
tuberculides — pityriasis rubra pilaris, acne necrotica, lupus pernio. The
explanation of the unvarying relation of certain lesions, the architec-
ture of which is not tuberculous, with tuberculosis is not clear. The view
which has most supporters is that, while most or all are due to hsemo-
genous infection with bacilli, the variation in the lesions is due to
varied reactivity of the individual. The papulo-necrotic tuberculide is
supposed to be due to a bacillary embolus, which causes local anaphy-
laxis, with destruction of the tissues and bacilli in the centre where
the reaction is most intense. The morphological analogy between
the papule of the von Pirquet reaction, the papulo-necrotic tuberculide,
and the lesion of erythema induratum is pointed out. Stokes dis-
cusses very fully the differential diagnosis of the various tuberculides
from other skin lesions, but this part of his paper does not lend itself
to summary, and should be consulted in the original. (In this con-
nection, also, a series of papers in the Journal of Cutaneous Diseases
for February 1919, where the whole subject is discussed from the
dermatological point of view, may be referred to.) One general feature
of interest is that these lesions tend to occur where the peripheral
circulation is feeble, as shown by cyanosis and vasomotor anomalies —
blue, clammy, mottled hands, or oedematous cyanosed legs. There is
also noticeable a periodicity in the development of the lesions, which
are most frequent in the spring, and next so in the autumn. In
Stokes' series of cases the collateral infections elicited by anamnesis
are of interest — tonsilitis, 39 per cent. ; " rheumatism," 46 per cent. ;
pneumonia, 29 per cent. ; influenza, 54 per cent. ; pleurisy, 18 per cent.
The " rheumatic " symptoms belonged almost entirely to the indefinite
group of neuritides, arthralgias, and myalgias, and the point made is

Medicine 393

that these, so far from being looked on as evidence of a true rheumatic
infection, should raise the suspicion of tuberculosis. The findings in
the tonsils of these patients confirmed the anamnesis, inasmuch as no
case had quite healthy tonsils. It was not found, however, that the
worst, most septic, tonsils were associated with the bad cases of skin
lesion — rather the reverse. On the whole, it does not appear that
tonsillar infection can be looked on as more than a possible pre-
disposing factor.

Treatment. — Twenty patients underwent treatment ; all were of the
type which is resistant to the tuberculous infection, inasmuch as such
active symptoms as cough, haemoptysis, and night-sweats were absent.
Most showed some pallor, asthenia, mild grades of fever, and loss of
weight. The cutaneous tuberculide was chronic, with little tendency
to remission. The group, therefore, was a good one on which to test
a new remedy (arsphenamine), since the presumption was against
spontaneous improvement. In the first place, it may be stated that
the surgical removal of a tuberculous foci does not cure or improve the
skin lesions. The results of tuberculin on papulo-necrotic tuberculides
is indifferent or bad. Vaccines (in cases with septic foci), X-rays,
arsenic, mercury, and local, even surgical, measures had been tried
in this series of cases, without marked benefit. Stokes employed
(1) arsphenamine (salvarsan — "606") combined with (2) X-raying of
accessible foci of glandular tuberculosis, (3) antituberculous outdoor
regime, (4) forced feeding, (5) removal of secondary pyogenic foci,
and (6) the correction of vascular stasis in the extremities. The
average course is six injections, at weekly intervals, the average dose
being 0*4 to 0*5 grm. On account of tendency to seasonal recurrence
the course was repeated in spring and autumn. Improvement is judged
of (a) in the skin lesion, (b) in the constitutional condition, (c) in
tuberculous foci. In most cases the results in the skin lesion were
prompt and usually complete ; in all some improvement occurred.
The constitutional condition underwent a marked change for the
better, and the foci also benefited. Stokes writes about the results of
treatment cautiously, and does not make undue claims for a method
which (from the cases recorded) seems to have been fairly successful.

Conclusions. — This review may be concluded by a synopsis of some
of his conclusions : — (1) There is a relationship between tuberculosis
and the erythematous group of lesions mentioned. (2) These lesions
may be conceived as cutaneous reactions to hsematogenously distributed
bacilli deposited in a hypersensitive skin. (3) Since the " tuberculous "
erythemata cannot be diagnosed clinically from the non-tuberculous
types, all cases demand a careful search for a tuberculous focus,
and ought to be subjected to re-examination at subsequent intervals
from this point of view. (4) Erythema induratum may be looked on
as a chronic ulcerative phase of tuberculous erythema nodosum.

28

394 Recent Advances in Medical Science

(5) Papulo-necrotic tuberculides are of great assistance in the
diagnosis of obscure tuberculosis. In this series one-fourth of the
patients had a family history, 57 per cent, definite signs, and 70 per
cent, presumptive signs, of the disease. (6) The type and locality of
the tuberculous focus do not influence the tuberculide, beyond the
marked association of glandular enlargement. (7) The influence of
vascular abnormalities and chronic venous congestion is very apparent.
(8) Slight fever, loss of weight, amenorrhcea, leucopenia, and vernal
periodicity are significant. (9) Rheumatic symptoms are common and
often misinterpreted. (10) Active tubercle is rather rare. (11) The
appearance or persistence of a tuberculide after reasonably complete
surgery is an indication for the discontinuance of surgical treatment,
and the adoption of medical measures for fortifying the patient against
progress or recurrence of his infection. (12) Tentatively, salvarsan,
along with other measures enumerated above, seem to offer fair
prospects.

THERAPEUTICS.

UNDER THE CHARGE OF

JOHN ORR, M.D.

Treatment of Amcebic Dysentery by Rectal Injections
of Neosalvarsan.

Dr. Paul Calame has a short paper {Rev. med. de la Suisse roni.,
February 1918) on this subject, and gives a short risumi of the
parasitology of amoebic dysentery. Among other points he shows
that the parasites are sometimes obtainable by scraping from the
rectal ulcers by the aid of a sigmoidoscope when they are not found
in the dejecta. Cases occur where the affection is chronic and the
amoebae are embedded in hard indurated infiltrations in the bowel, and
he finds that such cases are not reached by ipecacuanha or by emetine
excreted from the blood into the intestine. He accounts for the failure
of cases to respond to emetine by the fact that the amoebae are kept
from contact with the drug by the infiltrations around them. He has
found, however, that such cases can be well treated by rectal injections
of neosalvarsan, and gives clinical results of his use of this. Cessation
of diarrhoea, occurrence of regular formed motions, disappearance of
amoebae, gain in weight, and feeling of well-being are the events which
have followed the use of this treatment after the failure of ipecacuanha
and its derivatives.

Emetine Diarrhoza.

It has been known for some time that if massive doses of emetine
are injected into animals, diarrhoea occurs when the large amount of

Therapeutics 395

the drug is excreted into the intestine, and that this may be accom-
panied by blood and mucus. Kilgore and Liu {Arch, of Inter. Med.,
August 1917) cite three cases in children treated for amoebic dysentery
by emetine where severe diarrhoea occurred, and ceased when the drug
was stopped. It is pointed out that this occurred in spite of the belief
that children are more tolerant of emetine than adults in proportion
to their body weight. These cases seem to indicate that this idea of a
special tolerance in children must be subjected to reconsideration.

Amcebic Dysentery in England.

Warrington Yorke {Brit. Med. Journ., 12th April 1919) contributes a
valuable review of the question as to whether persons who are dysentery
carriers have really acquired the disease abroad or have had the disease
before leaving this country. He has found that quite a large number
of recruits were carriers when they joined the Army, and is of opinion
that there is a special tendency in young men to have this disease in
a latent form. He refers to the prevalence of the disease in asylum
inmates, and thinks that there is evidence that miners are perhaps
liable to it in a special degree. But most of these carriers do not
develop acute dysentery, and the author believes that there must be
some special consideration, the nature of which is at present unknown,
which determines this occurrence. He is of opinion that the best treat-
ment for most cases is the use of a saline purge, emetine hydrochlor.,
1 gr., subcutaneously, and bismuth subnit., 20 grs., three or four times
daily for twelve days.

Emetine-Bismuth-Iodide in Amcebic Dysentery Carriers.

Lillie and Shepheard {Journ. E.A.M.C, December 1917) show that
the percentage of carriers cured by this substance is higher when the
patients have had no previous injections of emetine. No good reasons
are adduced to account for the difference. It is generally admitted
that some cases fail to respond to emetine in any form, and the explana-
tion offered by Dr. Calame may be correct, viz. that the degree and
effects of chronicity determine this. The amount of emetine-bismuth-
iodide required varies a good deal, and the author uses 30 to 200 grs.
As other authors have found, so does this paper record that the sickness
produced by the drug does not militate apparently against its bene-
ficial action. But keratin or salol coating — especially the latter — has
been found distinctly useful in ameliorating the intestinal and gastric
disturbance.

Intestinal Disinfection by Benzonaphthol irt Goitre.

Dr. Messerli {Rev. mid. de la Suisse rom., April 1918) reverts to this
subject, on which he has written before. He has found that soft

396 Recent Advances in Medical Science

parenchymatous goitres are prone to undergo gradual diminution when
the patient is submitted to a course of intestinal antiseptics, and more
particularly to benzonaphthol. Cases are cited by the author in which
the soft goitrous swelling undergoes diminution, the measurements
round the neck decreasing, and the pressure symptoms abating and
ultimately becoming absent. He claims that the method of treatment
is all the more valuable in the case of persons who have an idiosyncrasy
against iodine. — -

The Medical Treatment of Graves' Disease.

Gordinier contributes a long article (Therap. Gaz., June 1918) on
this subject. Much of the ground covered by the article is familiar.
But the author makes a special plea for the recognition of focal or
general infections as important causal agencies, and pleads for their
precise determination and removal. He quotes illustrative cases,
including an acute case which occurred during the course of scarlatina.
Rest is insisted upon, and the period must vary with the results
obtained. Not till the circulation is quiet and stable will the author
permit the period of rest to come to an end. Diet is generous, including
milk, butter, eggs, cereals, fats, vegetables and fruit, and, except in
toxic cases, fish, chicken, and lamb, with beef strictly limited, and
stimulants, such as tea, coffee, alcohol, spices, and acids, excluded. The
drug most favoured is neutral quinine hydrobromide, in doses of
3 to 5 grs. three or four times daily, continuing for a long time, even
months, with occasional interruptions only. He also believes in the
value of phosphorus pills, y^ to ■£$ gr., and quotes six cases of cure
from this remedy. In this relation he quotes the belief of Kocher
that sod. phosphate acts as a direct antidote to the iodine-containing
substance of the thyroid. Of the value of X-rays the author admits
he has no experience, but quotes the work of Schwartz, Stoney, Fisher,
and Malcolm Seymour, and records their favourable opinion as to its
value. Gordinier's views are corroborated by Means and Aub in a
paper (Journ. Amer. Med. Assoc, July 1917) in which they conclude
that rest is the only reliable means of combating the disease, and that
X-rays may assist ; and if these means fail to arrest the disease, recourse
should then be had to surgery.

Vaccine Treatment of Whooping-Cough.

A number of papers have appeared which advocate the use of vaccine
for prophylaxis and cure of this affection. The vaccine used has been
obtained from Bordet bacilli with or without the addition of pneumo-
cocci, and the dosage has been 250 to 1000 million for each dose. The
conclusions reached by the various authors are substantially the same,
and may be stated shortly to be that this vaccine therapy is free from

Therapeutics 397

harmful effects and from risk of anaphylaxis, that the paroxysmal
stage of the disease is shortened and its seventy ameliorated, that
vomiting is diminished, as would, of course, be expected from lessening
of the spasms, that complications are fewer, and that the safety is such
that vaccine may be administered to infants so young as six weeks.

Turpentine in Hemorrhage.

Allan contributes (Prescriber, February 1918) a short article on the
use of turpentine as a local haemostatic, and cites several illustrative
cases where it has been beneficial, such as haemorrhage from a sliced
finger, after nasal operations, and following tooth extraction. He
suggests that it be used on gauze which has been soaked in the drug
and squeezed. There can be no doubt that this article comes timeously
to remind us of a remedy which has been perhaps a little overlooked
as a haemostatic. The author might have referred to its usefulness as
a remote haemostatic, and alluded to its beneficial action in haemoptysis,
purpura, and such-like affections, in which it is quite reliable and easily
obtainable as a rule under conditions of emergency.

Quinine Bihydrochloride, Sodium Cacodylate in Chronic

Malaria.

Dr. John C. Clark (Therap. Gaz., July 1918) gives a full account of
the intravenous use of these drugs in malaria, embodying the result of
observations on fifty-seven cases. The former drug is selected because
of its great solubility, and the latter because of the slow detachment
of the arsenic from the molecule. The author has used 1 gr. quinine
bihydrochloride per 10 lbs. of body weight, and 1 gr. sodium cacodylate
per 50 lbs. body weight, these doses being given daily for five days,
then every fifth day for thirty-five days. The results obtained were
satisfactory as regards the immediate effects, the freedom from relapse
or recurrence, and the disappearance of parasites from the blood.

Eye Symptoms in Cinchonism.

Cases of affection of vision may occur from time to time while a
patient is under treatment for malaria, and Fernandez in a recent paper
raises the question as to whether quinine or malaria, or both in com-
bination, may be responsible. Schweinitz and Holden have worked
experimentally and clinically on this subject, and have shown that in
some animals quinine may produce contraction of the retinal vessels
and optic atrophy. It would appear that in the human subject
idiosyncrasy plays an important part, for the dose which has caused
eye affections of an alarming character has been comparatively small,
and has produced its evil effect at an early date after administration ;
and, as the symptoms may be serious as regards vision prognosis, the

398 Recent Advances in Medical Science

question arises as to the immediate disuse of quinine in cases where
evidence of ocular idiosyncrasy appears. This point seems to be
determined by the comparative seriousness of the affection for which
the quinine is being administered. Sinton (fotdian Med. Gaz., September
1918) cites five cases where idiosyncrasy played an all-important part
in the incidence of unpleasant symptoms of cinchonism, including
oedema of the eyelids, conjunctivitis, and urticaria one case in particular
developing a condition bordering on coma, and showing dilated pupils,
conjunctivitis, and urticaria.

Treatment of Sciatica.

It is almost a matter of reproach that an affection so common as
sciatica should be so little amenable to modern treatment, and yet it
would be difficult to find an affection wherein therapeutic measures
show up so badly. It is therefore necessary to bring forward any
remedy, old or new, which affords a chance of removing this stigma.
The Lancet of 14th July 1917 has an article containing reference to
the observations of Harrington Sainsbury and of Wingh'eld on the
good effect of local applications of strong hydrochloric acid to the skin
over the nerve, and indicating the benefit conferred by this remedy in
sciatica and other forms of painful neuritis. Gennetas and Bayliss
record twelve and sixteen cases respectively, in most of whom great
improvement occurred, and all the cases so treated had so far proved
unamenable to other treatment. Bather less satisfactory is a paper by
Allen and Parrish (Med. Gaz., June 1918), where three cases of sciatica
have been cured by spinal puncture and the removal of about 30 c.c.
fluid, that is to say, less satisfactory, in that the authors admit the
absence of any rationale in this mode of treatment, although, from the
point of view of success, in every way satisfactory. All the cases
were males, aged 20, 81, and 50 respectively, and the improvement
is recorded as having been immediate, and, so far as observed,
permanent.

Reports of Societies 399

REPORTS OF SOCIETIES.

EDINBURGH MEDICO-CHIRURGICAL SOCIETY.

A meeting was held on 14th May 1919, the President, Dr. John
Playfair, in the chair.

President's Address.

Fellow- members of the Edinburgh Medico-Chirurgical Society, — My
first duty as your President is to congratulate you on the resumption
of our meetings after the years of strain and horror from which the
nation has victoriously emerged, and I am sure I express the
feelings of every member of this Society when I say we are all truly
thankful to an overruling and merciful Providence that the nation,
stricken and tried though it has been, closed its ranks and stood the
strain as it has done, and is now, we hope, about to enter upon a time
of liberty and peace.

It is too much to hope that it is to be a time of permanent
unbroken peace, but we have good reason to think that in all time
coming no nation will be able to break the world's peace and begin
a war of aggrandisement and oppression as easily and wilfully as
Germany began the criminal and devastating war of 1914.

Those four and a half years of war have, no doubt, brought out
many good qualities in our nation, and have strengthened the ties
between the Mother Country and the Colonies in a way which
probably could not otherwise have been accomplished. The war has
also brought together peoples of different nationalities, and made them
understand each other better than they ever did before. All this, we
hope, will make for the peace and ultimate good of the world, but,
nevertheless, those four and a half years of war have been a time of
immense material and scientific loss to the world. No doubt there
never was a time of greater increase and stimulation of inventive
power, but it was chiefly directed to the carrying on of war measures,
with all their destructive and devastating effects. The moral and
material well-being of the nation was left, to some extent at least, in
a condition of suspended animation.

Almost all meetings and societies devoted to science and art ceased
their efforts, and much loss to civilisation and national progress has
thereby been caused. It is devoutly to be hoped that the whole
nation will now close its ranks, as it did when Germany threatened it
with national destruction, and that all classes will work together with
brain and hands to make up the loss of those dark and dangerous
years of war.

400 Reports of Societies

Our profession has many interesting and difficult questions and
problems before it waiting for solution. There are changes, too,
impending which may alter the whole tone and course of our
professional life.

Let us endeavour to look reasonably on the Governmental changes
which are coming, and if we cannot all see eye to eye, at least let us
try to preserve that feeling of brotherhood and comradeship which has
always been the distinguishing mark of our profession. With those
few imperfect remarks I reopen the meetings of our Society, but
while we congratulate ourselves on the happier times upon which we
hope we are entering, it is only right and becoming, and I am sure
you will all expect it of me, that I should refer to the blanks in our
numbers which have been caused by the war, and that I should ask
the Society to offer to the bereaved and sorrowing relatives of
those who have fallen an expression of its deepest and heartfelt
sympathy. It is not the time nor the place, I feel, to make any
eulogistic statement regarding the members of this Society who
have thus given their lives for their country. Besides, it is not
necessary, as you all knew them as well, if not better, than I did, and
their loss has touched you as deeply as it has me. I content myself
with mentioning their names — Dr. Eussell Wood, Dr. Melville Dunlop,
Mr. Denis Cotterill, Dr. W. Guthrie Porter, Dr. E. F. T. Price,
Dr. A. A. Ross. While these are, so far as I know, all our friends
and fellow-members who have died in the service of their country, it
does not by any means represent the total loss which the members
of this Society have sustained. Some have lost sons or other near
relatives, and I am sure I am right in stating that several members of
our Society, over-worked and over-anxious, through the absence of
so many of their fellow-practitioners, have died, and thus as truly
given their lives for their country as those who died on active
service. The medical profession of Edinburgh has, I think, reason to
be proud of what it has done to help to win the war. Nearly 50 per
cent, of its members have been on active service, and of that number
a not insignificant proportion have been faithful " even unto death."

INTRODUCTION TO DISCUSSION ON THE INFLUENZA

EPIDEMIC.

By Professor EUSSELL.

In March 1890, twenty-nine years ago, this Society devoted one of its
meetings to the discussion of the influenza epidemic then prevailing.
The discussion was opened by Dr. Brackenridge in a long paper replete
with careful clinical observations and containing references to and
opinions on points under discussion at that time. The names of those

Reports of Societies 40 1

who took part in the discussion were Surgeon-Major Black, Drs.
M'Bride, Andrew Balfour, Buchan, Allan Jamieson, Clouston, Little-
john, Barrett, Chiene, Caverhill, Craig, James Ritchie, K. M. Douglas,
and Felkin. Dr. Brackenridge thought the disease was " probably
due to a micro-organism " but he referred all the symptoms to the
nervous system. From the record of the discussion in the Society's
Transactions there is no doubt that the malady of that time was
essentially the same as that which has swept over the world in recent
months.

In the fifteen minutes allowed to me in opening the discussion
to-night I cannot do more than suggest the lines which the discussion
might follow.

We naturally begin with clinical phenomena, and from that
standpoint we can define the present epidemic, which is really
pandemic, as an acute febrile infective disease primarily attacking the
respiratory system. The degree and extent of involvement of this
system vary greatly. It is often an intense inflammation and con-
gestion, confined apparently to the lower part of the trachea and the
two main bronchi ; it often involves the whole bronchial system, and
it is frequently associated with great congestion and oedema of lung
alveoli. In some of these cases there are limited areas of consolidation,
with bronchial breathing. These cases provide the special and irregular
respiratory phenomena of the epidemic. To these, however, have to
be added many cases of true lobar pneumonia, of pleuro-pneumonia,
and of empyema following upon the latter. That all these have been
swept into and included in the term " influenza " is undoubted. The
clinical phenomena presented by this composite mass of cases have
doubtless been noted by every member of the Society and have elicited
more or less satisfactory explanations. I need not dwell upon them.

The next point I submit is that the epidemic is micro-organismal
in origin. This point will be accepted presumably without question
by the Society. On this assumption it is unnecessary to do more than
remind you that the determination of the character of the attacking
organism or organisms is of first-rate importance even from the stand-
point of therapeutics. And when that knowledge is attained, we have
to remember that the virulence of definite pathogenic micro-organisms
varies, and that the susceptibility of individuals and of communities
varies greatly not only to the toxins of micro-organisms but to other
toxins. The result is that micro-organismal diseases vary in their
clinical manifestations within very wide limits — a fact known to all
medical men who are responsible for the diagnosis of maladies and the
treatment of individual sick persons.

Before passing, in the next place, to the micro-organismal factors in
the present pandemic I would venture to remind you of an important
fact accepted by all of us, namely, that certain diseases are due to a

402 Reports of Societies

micro-organism getting lodgment in the human body. Such diseases
are tuberculosis, cholera, bubonic plague, tetanus, diphtheria. In the
present epidemic, called influenza, there is no such reservation. We
have here to deal with a group of micro-organisms which either
separately or conjunctly find entrance to, and a more or less suitable
growing and breeding place in, the respiratory tract, while the products
of their activity may affect every system in the body and produce a
grave or fatal toxaemia.

The principal organisms present are the influenza bacillus, the
pneumococcus, and a streptococcus. To this has probably to be added
a diplo-streptococcus, the relations of which to the pneumococcus and
to the streptococcus is, I believe, being at present investigated. A
filter-passing coccus is also claimed to be present in some cases of
so-called influenza.

That the first three organisms mentioned have been the prominent
ones in the epidemic has been established, I think, beyond question.
The position of the influenza bacillus by itself has yet to be determ ned.
The pneumococcus by itself has been the potent organism in many
cases, varying greatly in the severity of the symptoms, affecting in
some the respiratory tubes only ; in others the alveoli of a lobe, or
part of a lobe, and presenting, then, the features, and running the course
of, classical croupous pneumonia. Streptococcal cases have been most
common in certain conditions of living, as on shipboard ; amongst
certain communities and races, as in South Africa, India, and else-
where ; and the virulence has evidently been very great.

Association or copartnery of these organisms has also been estab-
lished. The presence of the influenza bacillus with the pneumococcus
or the streptococcus has been definitely established in many cases.
The association of the influenza bacillus and the pneumococcus leads,
in my experience, to widespread involvement of the respiratory system,
a long and anxious illness, and often to death. Clinically, these cases
are quite different from the unassociated pneumococcal cases. Of
streptococcal cases I have had no experience, unless a coccus, which
becomes a diplococcus and forms chains, is the organism referred to.
Of the association of the influenza bacillus with the streptococcus I
cannot therefore speak from personal experience, although I, of course,
know that the association occurs, and I should surmise that the
combination must be very hurtful.

Of the high virulence of these organisms separately, or in such
combination as has been mentioned, during the epidemic there seems
to be no doubt. It seems to me that while we call this pandemic
"influenza," the influenza bacillus is only one of a group of micro-
organisms which have attained what we may hope is their acme of
virulence. The conditions which have determined this exaltation
of virulence we do not know ; and if we turn for an explanation of

Reports of Societies 403

prevalence and mortality, of vulnerability and immunity to war con-
ditions or to food rationing, we have again to acknowledge ignorance
of the problem or problems underlying the assumption. We know of
diminution and of accentuation of virulence ; we know of degrees of
susceptibility and of immunity ; the further problems are for the future
to solve.

In addition to prolonged myocardial enfeeblement and general
depression of nervous energy the most interesting complications,
accompaniments, or sequelae I have seen include three cases of what
I venture to call " post-influenzal delirium" : one of the patients was
supposed to be going insane, two others were thought to be beginning
with meningitis. The three recovered. I have had one case of pneumo-
coccal meningitis which was rapidly fatal ; five cases of empyema ;
one of acute parotitis which did not suppurate ; one subacute abscess
underneath the gluteus muscle due to the pneumococcus.

As regards treatment, we have all had our individual experience.
I have used alcohol, camphor in oil, digitalis occasionally, and quinine
urea hydrochloride. There is, I fear, no specific. My own belief is
that in the future vaccines will constitute our most valuable line of
treatment, but I have dealt with this and other points in a recent
number of the Lancet, and I shall merely add that I look to-night for
an expression of the experience of others on the use of vaccines.

NOTES ON THE INFLUENZA MORTALITY IN SCOTLAND
DURING THE PERIOD JULY 1918 TO MARCH 1919.

By J. C. DUNLOP, M.D., F.R.C.P.(Edin.).

Some statistical facts regarding the mortality caused in Scotland by
influenza during recent months are now available, and perhaps a few
notes on them will be of interest in the present discussion.

Three distinct epidemics of influenza have recently occurred. The
first was in July and in the earlier part of August last, the second in
October and November, and the third in February and March of this
year. These three epidemics can readily be traced in the weekly
reports of the Registrar-General. That series of reports deals with the
demographic records of the sixteen principal towns only, but as these
towns contain approximately half the total population of Scotland it
may be assumed that what is found to occur in them is indicative
of what is occurring throughout the country generally. It would
be more strictly accurate to state that there have been four recent
epidemics, for, in addition to the three well-marked ones, there was a
milder one recognisable in Glasgow in the month of May, but as it was
both more limited and milder than the three now being considered I
omit any further reference to it. (In it the Glasgow death-rate rose

404 Reports of Societies

from 14*1 to 20-l, and the weekly number of deaths from pneumonia
and bronchitis from 36 to 107.)

In June, that is, before the first of the three epidemics, the collective
monthly death-rate of the sixteen towns varied from 10*9 to 12-0 per
thousand. In July this rate rose markedly, being 13*9, 15-0, 17*4, and
14'2 in the four weeks respectively. During August and September it
was low, falling on one occasion to the unusually low figure of 9*4, but
in October and November it was again high, during the nine weeks
ranging between 190 and 30-5. In December and in January the
weekly death-rate remained within normal limits, varying between 1 4*8
and 19*8, but in February and in March was again excessively high,
being constantly over 20, and attaining a maximum of 40*0, that rate
occurring in the week ending 31st March. Since March the weekly
death-rate has again fallen and is now — May — within normal limits.

The same time-distribution of the epidemics is evident in the- varia-
tions of the Glasgow and Edinburgh weekly death-rates. In the July
epidemic the Glasgow death-rate rose from 11*7 to 15#9, and the
Edinburgh death-rate from 11*3 to 18-0. In the October-November
epidemic the Glasgow rate rose from 11*0 to 38*4, and the Edinburgh
from 10-8 to 46-2. In the February- March epidemic the Glasgow rate
rose from 14-9 to 48-3, and the Edinburgh from 189 to 52-1. When
quoting these figures I may draw attention to the great height to
which the death-rates of Glasgow and Edinburgh rose during two of
these epidemics ; higher rates occurred in some of the smaller of the
sixteen towns, but considering the large populations of Glasgow and
Edinburgh, and the consequent significance of changes in the death-
rate, better proof of the severity of the epidemics need not be sought.

During the period of these three epidemics, July 1918 to March
1919, influenza was named as a cause of death, either primary or
secondary, in 16,917 certificates, but there is every probability that
even this large number imperfectly shews the total mortality attribute
able to influenza, as almost certainly many died from complications of
influenza, more especially pneumonia, without influenza being stated
as a cause of death. This opinion is based on two facts, the one that
the increase of the total deaths registered was much larger than
accounted for by those certified as due to influenza, and the other that
deaths certified as due to influenzal pneumonia, or to pneumonia, or
bronchitis, or pleurisy along with influenza, were far -short of the
excessive number of deaths from pneumonia, bronchitis, and pleurisy
reported during the period. During the nine months July 1918 to
March 1919 the total deaths registered in Scotland numbered 72,731,
which number is 25,773 in excess of that registered in the period July
1917 to March 1918, and 18,457 more than the mean of the numbers
registered in the five previous July to March periods. It may be a
matter of. opinion which of these two comparisons is the more reliable

Reports of Societies 405

as a measure of the increased mortality caused by the influenza
epidemics, but whichever be taken it is evident that the total excess
of deaths outnumbers the deaths certified as due to influenza. Limiting
to the more severe epidemic periods, and using the figures of the three
periods 7th July to 10th August, 22nd September to 14th December,
and 26th January to 29th March, it is found that the total excess of
deaths in the sixteen principal towns from pneumonia, bronchitis, and
pleurisy over a strictly comparable five-year average amounts to 8952,
while the total deaths certified as caused by influenza in the same towns
and during the same period amounted only to 7453, the former, the
excess of pneumonia, bronchitis, and pleurisy deaths being 1499 in
excess of the latter. It is reasonable to ascribe this excess to the effect
of the epidemics and to infer that the true number of influenzal deaths
is correspondingly more than the number of death certificates found
with influenza as a named cause. This excess amounts to 20*1 per
cent, of the certificates with influenza named, and by applying that
proportion to the total number of such certificates the total number of
influenza deaths in Scotland may be assessed at 20,000.

Neither of the foregoing comparisons is an absolute and sure guide
as to the true number of influenza deaths, but both are such as, in my
opinion, to justify a statement that the total mortality caused by these
epidemics in Scotland should be assessed at over 20,000. It seems
hardly necessary to draw attention to the fact that this mortality is
greater than that caused by any previous epidemic in Scotland since
the institution of national registration, and that is since the year 1855.

A full tabulation of all the 16,917 death certificates on which
influenza is a named cause of death is not yet available, but I have at
my disposal such a tabulation of those registered up to the end of
December last, and this tabulation includes 10,797 such certificates.

Of these 10,797 deaths, 5662, or 52-44 per cent., were of females,
and 5135, or 47*56 per cent., of males, the female deaths outnumbering
the mala by 527. The equivalent annual influenzal death-rate is 4*38
per thousand, that of the male population being 4*30, and of the female
population, 4*46.

A study of the ages at death recorded in the 10,797 cases registered
as caused by influenza brings out the fact that the most frequent are
those between 25 and 35, these including adults in the prime of life.
The number of deaths of persons between 25 and 35 was 2729 and
constituted 25*28 per cent, of the total. Large numbers are also found
in age periods 15 to 25, and 35 to 45, the former being 1803, and the
latter 1286, the former constituted 16*70 per cent, of the total, and
the latter 11*91. Thus between age 15 and age 45 these influenza
deaths numbered 5818, and amounted to 53*89 per cent, of the total.

The highest age-group death-rates occurred in age-groups 75 and
over, and 25 to 35, the former being 7*87 per thousand, and the latter

406

Reports of Societies

7'12. High rates also occurred in age-groups under 1, and 65 to 75,
the former being 6*49, and the latter 5-53. The lowest age-group
death-rates are found in the groups which include children of school
age, 5 to 15, the death-rate in age-group 5 to 10 being 2*20, and in
age-group 10 to 15, T80.

The age-distribution of the 10,797 deaths and the death-rate of
each age-group is shown in the following tabular statement : —

Ages.

Influenza
Deaths.

Deaths per cent,
of Total
Influenza
Deaths.

Age-Group
Death- Rates.

Under 1 .

364

337

6-49

1 to 5

1177

1090

5-36

5 to 10

584

5-41

2 20

10 to 15

456

4-22

1-80

15 to 25

1803

16-70

3-95

25 to 35

2729

25-28

7-12

35 to 45

1286

11-91

4-14

45 to 55

935

8-66

404

55 to 65

639

5-92

4-17

65 to 75

529

4-90

5-53

75 and over

295

273

7-87

Tota

I

10,797

100-00

4-38

In 1749 cases, or 16*20 per cent, of the total, influenza was the sole
cause named in the certificates, or given as one of two causes, while the
other named was, from a medico-statistical point of view, insignificant
— such insignificant causes include heart failure, syncope, dropsy,
teething, and the like. Conversely, the death certificates which named
some complicating condition in addition to influenza numbered 9048
and constituted 83-80 per cent, of the total. The obvious deduction
from this is that influenza is comparatively seldom a cause of death
unless there be some serious complication.

The most frequent complication is found to be pneumonia, no less
than 7020, or 65-02 per cent, of the total being so certified. Of these
7020 deaths, 1974 were ascribed to influenza and broncho-pneumonia,
and the remainder, 5046, to lobar pneumonia or to pneumonia not
otherwise specified. The largest number of these pneumonia deaths
occurred in age-periods 15 to 25, and 25 to 35, that in the former being
1332, and in the latter 2061. The high frequency of pneumonia
deaths in these age-groups explains the heavy influenza mortality in
them. Of the total influenza deaths in age-group 25 to 35, 75-5 per
cent, were complicated by pneumonia, and of those in age-group 15 to
25, 73-9 per cent.

Bronchitis was returned as a complicating condition in 645

Reports of Societies 407

instances, and that is in 5*97 per cent, of the total. The majority of
these deaths were at ages 45 and over.

Other diseases named in comparatively great frequency in the
influenza death certificates include heart diseases (244), respiratory
diseases other than pneumonia and bronchitis (210), diseases and
accidents of pregnancy and parturition (182), pulmonary tuberculosis
(181), meningitis other than tuberculous or cerebro-spinal (179), other
epidemic diseases (77), and tuberculosis other than pulmonary (35).
The foregoing include all the 10,797 certificates, with the exception of
275, these being distributed in small numbers between a multitude of
causes.

The other epidemic disease named along with influenza in %he death
certificates in 4 cases was enteric fever ; in 9 cases, measles ; in 7, scarlet
fever; in 43, whooping-cough; in 8, diphtheria or croup; in 1,
dysentery ; and in 1, paratyphoid.

The comparatively large number of instances in which influenza
was named in death certificates, along with diseases and accidents of
pregnancy and childbirth, suggests that there is a considerable risk to
life when a pregnant woman is attacked by influenza.

To recapitulate these somewhat fragmentary notes I may formulate
the following conclusions, namely : —

1. Influenza deaths during the recent epidemics numbered at least
16,917, and probably numbered much more, 20,000 being a very
moderate estimate.

2. That influenza deaths are most frequent in the age-periods which
include adults in the prime of life, namely, ages 15 to 45.

3. That in a comparatively small number of instances was influenza
the sole named cause of death, while in the majority of instances some
complicating disease was named, by far the most frequent being
pneumonia.

(To he continued.)

408 New Books

NEW BOOKS.

Sir William Turner, K.C.B., F.R.S. : A Chapter in Medical History. By
A. Logan Turner. Pp. xvi + 514. With Portraits. Edin-
burgh: Wm. Blackwood & Sons. 1919. Price 18s. net.

A faithful biography of Sir William Turner could not have been
otherwise than " A Chapter in Medical History," and when Dr. Logan
Turner adopted this subtitle he was perhaps unconsciously recalling
Carlyle's dictum that " Universal history is at bottom the history of
the great men who have worked here." In his own sphere of activity
Turner may, without exaggeration, be placed among the great men —
"the leaders of men, . . . the modellers, patterns, and, in a wide
sense, creators, of whatsoever the general mass of men contrived to
do or to attain."

The early chapters of this most readable book reveal to us the
man we knew in the making, his boyhood differing from that of the
majority of boys only in that he showed a greater fondness for living
with Nature than for games; his apprenticeship, during which he
concentrated his attention on the fundamental sciences underlying the
practice of the profession he had adopted, and learned in the hard
school of experience the art of overcoming difficulties, both substantive
and subjective ; and, finally, his undergraduate struggles and triumphs.
As Turner left no autobiographical data, we learn less of his early life
than we could have wished, but enough to let us recognise the influences
which worked to mould his character and to guide his actions through
life. The scanty material at the disposal of his biographer has been
skilfully used to show that it was filial devotion that directed his
early efforts to overcome material difficulties, that self-reliance and a
determination to do with all his might whatsoever his hand found to
do were inborn qualities of the man, and that the early struggles of
his youth laid the foundations of that tenacity of purpose which
characterised his later life.

At the age of eighteen Turner left his native town of Lancaster
to begin his medical course at St. Bartholomew's Hospital, where he
met as fellow-students a number of men who subsequently took a high
place in the world of medicine — Thomas Smith, William Newman, John
Russell Reynolds, John Syer Bristowe, Frederick William Pavy, Henry
Enfield Roscoe, and Joseph Lister. Among this brilliant band Turner
took a leading place, and it is worthy of note that throughout his
undergraduate career he excelled in the more purely scientific subjects
rather than in those which were clinical. Chemistry was his favourite
subject, and anatomy was not even second.

New Books 409

Soon after joining Bart's Turner attracted the attention of Sir
James Paget, a circumstance which had a great influence in determining
his subsequent career. It led, among other things, to his re-editing
Paget's great work on Surgical Pathology — one of the surgical classics —
and, still more important, to his coming to Edinburgh as demonstrator
of anatomy under John Goodsir. What that meant to Edinburgh those
who were his students know, and those who had not that privilege will
fully realise on reading the fourth and fifth chapters of his Life. On
the science of anatomy he left an abiding mark ; as a teacher he was
both impressive and inspiring, and as a trainer of teachers his record
was unique. His pupils came to fill no fewer than twenty-three Chairs
of Anatomy, and many others left Edinburgh to become demonstrators
in other schools.

But Turner was more than a mere teacher of anatomy ; he was a
prolific scientific investigator, particularly in the field of anthropology,
a leader in all movements concerned with medical reform and with
university extension, and a great administrator. His biographer has,
wisely we think, dealt with these different spheres of activity in
separate sections, a plan which enables the reader to appreciate what
Turner did in each better than a chronologically arranged biography
would have done.

Space forbids that we should follow him through all these activities,
but we commend the record of them to our readers as a fascinating
chapter in the medical history of the sixty-two years during which
Sir William Turner served the University of Edinburgh, and through
it, the educational world at large. To those who are left to carry on
the traditions which he confirmed or established it is an inspiration
and an incentive to whole-hearted work ; to those of a younger
generation, on whom the burden may one day fall, it sets a standard
of single-minded devotion to duty and of loyalty to the Edinburgh
School of Medicine towards which they may aim.

We cannot stop without expressing our gratitude to Dr. Logan
Turner for the care and skill he has expended in making this record
worthy of his father's life, and congratulating him on the restraint he
has shown in accomplishing a difficult task.

Diagnostic Clinique. By Dr. A. Martinet. Pp. xii. + 912. Paris:
Masson et Cie. 1919. Price fr. 30 ( + 10%).

This seems to us an extremely good and practical students' handbook
of clinical diagnosis. It is divided into two parts : diagnostic methods
and symptomatology. There is also an admirable introductory chapter
on the causes of diagnostic errors, which no beginner could fail to
derive benefit from, and many advanced students might read with
advantage. The technical methods of diagnosis employed do not

29

410 New Books

appear to differ materially from those given in English text-books on
the subject. They include, however, some which we incline to regard
as within the province of the surgeon and gynaecologist rather than
the physician — cystoscopy, for instance. Some of the quantitative
urinary tests are very neat, in that the principle of using the number
of drops of a solution required to give an end point as a measure of
the quantity of the constituent being tested for is made use of. This
is applied to the determination of the total acidity, estimation of
chlorides, phosphates, sugar, etc., and it seems well worthy, on
account of its simplicity, of a trial in clinical urine analyses. The
illustrations are numerous and, on the whole, excellent, many of the
diagrams in particular being very instructive to the student. There
is a rather short chapter on clinical bacteriology, which, however,
contains a good account of the serological and bacteriological diagnosis
of syphilis, typhoid, and tuberculosis. Those to whom the language
is no obstacle could hardly find a more useful book on clinical diagnosis
than Dr. Martinet's admirable manual.

The After-Treatment of Wounds and Injuries. By R. C. Elmslie, M.S.,
F.R.C.S., Brevet-Major R.A.M.C.(T.R). Pp. vii. + 323. With
144 Illustrations. London : J. & A. Churchill. 1919. Pr^ce
15s. net.

The After- Treatment of Wounds and Injuries is essentially a systematic
description of orthopaedic surgery as applied to the late results of war
wounds and injuries. Lesions of bones, joints, nerves, muscles,
tendons, and skin are dealt with in the earlier chapters, and the
special conditions of the upper and lower limbs are considered later.
Short chapters on the spine, on splints and surgical appliances, on
methods of using plaster of Paris and physiotherapy, complete the book.
Two and a half years' work in a hospital devoted exclusively to
orthopaedics has given Major Elmslie exceptional opportunities, and his
experience enables him to speak with authority in discussing the diverse
problems which have to be solved in trying to repair damaged limbs
and restore their lost function. While he has been able to draw on
the rich material at his disposal to emphasise special points, and, in
particular, to furnish numerous graphic illustrations, Major Elmslie
has wisely preferred to sj^stematise and generalise his experience rather
than record large numbers of cases, individually or in groups. As
the result he has produced a book of great practical value at the
present time, which cannot fail to be of use both to those specially
interested in orthopaedics and to general surgeons. The teaching all
through is sound and full of helpful suggestions, and, although chiefly
concerned with the treatment of war injuries, it inculcates general
principles which are applicable in civil as well as in military surgery.

New Editions 411

NEW EDITIONS.

Diseases of the Heart and Aorta. By Arthur Douglas Hirsch-
felder. Third Edition. Pp. xxvii. + 732. With 345 Illustra-
tions. Philadelphia and London: J. B. Lippincott Co. 1918.
Price 30s. net.

This volume presents an exhaustive presentment of its subject. It
opens with an account of the physiology of the circulation, followed
by a chapter on the blood-pressure. Practically all the forms of
sphygmomanometer are mentioned, but the description of them suffers
from undue compression, and the illustrations of the instruments are
on rather too small a scale. " For the exigencies of private practice "
the author recommends some pocket instrument of anaeroid type.
Importance is attached to Russell's view that the sphygmomanometer
does not record the blood-pressure but the arterial resistance. In the
paragraphs on the viscosity of the blood there is no mention of the
simple and convenient instrument of Watson. For the estimation
of total blood volume the author recommends the method of injection
of vital red and subsequent estimation of the staining of the plasma
by a colorimeter. Cardiac strain is regarded, we think rightly, as the
result of mechanical strain or early myocarditis, and the "thyroid
heart " is dealt with in a separate chapter. There is a useful account
of the action of drugs. The use of strophanthin is stated to have
passed the experimental stage, and its intravenous or intramuscular
administration in suitable cases is mildly advocated. The volume is
fully illustrated with diagrams and tracings. Many of the tracings
are combined with a small diagram indicating the supposed condition
of the heart or artery at the different parts of the graphic record.
These are necessarily drawn on very small scale and seem to us
hardly worth the trouble which must have been expended on them.
Numerous well-selected illustrative cases are quoted, and references to
literature are abundant enough to satisfy the most exacting.

Trench Fever. Report of Commission, American Red Cross Research
Committee. Second Edition. Pp. vii. + 446. With 7 Plates
and 7 Special Charts. London : Henry Frowde and Hodder
& Stoughton (Oxford Medical Publications). 1918. Price
21s. net.

Trench fever made its first appearance as a serious cause of wastage
in the British Armies in France and Flanders in the summer of 1915.
Already by the end of that year M'Nee, Renshaw, and Brunton experi-

412 New Editions

mentally transmitted the disease from man to man by the injection of
whole blood of trench fever patients. Early in 1917 Davies and Weldon
published a successful transmission of the disease by the bites of lice
fed on a patient. The American Commission began its investigation
in February 1918, taking over a British Field Hospital. It obtained
its original virus of trench fever from British patients, transmitting
this by means of lice and other channels of conveyance to some eighty
American volunteers. After less than two months of energetic and
brilliantly planned investigation, they were able to confirm and extend
the experimental data of these earlier observers. Their results showed
that the virus of trench fever is present in the blood plasma, that it is
resistant to heat, is filterable, and is usually conveyed from man to
man by the bite of infected lice. It may also be conveyed by the
rubbing into abraded skin of the sediment of urine, sputum, and saliva
of patients. A British Commission, working in England under Surgeon
General Sir David Bruce, has approached the subject along similar lines,
and has published several short interim reports.

The extent of wastage caused by trench fever in all the combatant
armies must have been enormous, and the very definite results
obtained by the American Commission were of immediate and cardinal
importance. In the present volume the story of this investigation is
fully told, with an account of previous work and writing on the same
subject. An important part of the work of the Commission was the
proof that enteric fever and its allies play no part in trench fever ;
this was established by numerous and complete bacteriological and
serological investigations. The closing sections of the volume are
devoted to clinical descriptions of the experimentally produced cases
of trench fever. Full case histories of the fifty-seven cases, with
temperature charts, are given.

The Commission beginning its work on 4th February 1918 were
compelled to evacuate the hospital on 27th March owing to the great
German attack and advance. They present, therefore, in this volume
a very brilliant record of investigation, notable in many ways — in its
able planning, its rapid execution, and in its very valuable results.

An Index of Prognosis and End-Results of Treatment. By Various
Writers. Edited by A. Rendle Short, M.D., B.S., B.Sc,
F.R.C.S.(Eng.). Second Edition. Revised and Enlarged.
Pp. xi. + 770. Bristol: John Wright & Sons, Ltd. 1918.
Price 30s. net.

The present edition of this valuable Index has been extensively revised
throughout and a number of new articles have been added. The
account of tropical diseases has been rewritten by Sir Leonard Rogers.
A new article by C. H. S. Webb on gas gangrene furnishes tables of

New Editions 413

the mortality of the two main types of the disease, of the results of
methods of operation in relation to site and the results of methods of
operation in relation to type. There is much fresh material in the
articles on tetanus, gunshot wounds, and septic peritonitis by the
editor, and the references to recent work add much to their usefulness.
In further editions of the Index the various writers would do well to
copy the editor in this respect. One or two have already done so, but
many of the important articles by other writers would be greatly
enhanced by following the editor's model.

The Operative Treatment of Chronic Intestinal Stasis. By Sir W.
Arbuthnot Lane, Bart., C.B. Fourth Edition. Pp. xii. +
328. With 133 Illustrations. London : Henry Frowde and
Hodder & Stoughton. 1918. Price 20s. net.

By his work and writing Sir Arbuthnot Lane has done much to focus
the attention of clinicians on his theory that "auto-intoxication " from
the gastro-intestinal tract is the primary factor in the causation of
many diseased conditions.

The fourth edition of his book takes the form of a collection of
papers by himself and others whose contributions need not be con-
sidered individually, as the most important and interesting of them by
Professor Arthur Keith, Professor Adami, and Sir James Mackenzie
contain nothing that has not appeared elsewhere. It is difficult to
resist the suggestion that they have been pressed into service to lend
some support to the rather slender foundation of the far-reaching
theories which Lane advances as the justification of surgical procedures
of the most serious nature.

All will cordially agree that root causes and not end-results are
what we should endeavour to get rid of in attacking disease ; but a
theory which postulates intestinal stasis as the primary cause of adenoid
overgrowth, diabetes, gastric cancer, cystic disease of the thyroid gland,
and as the precursor of all forms of tuberculosis in the human subject,
to name only a few of the diverse conditions attributed to it, demands
careful examination and the production of adequate evidence in its
support.

As Professor Arthur Keith remarks in his account of "The Great
Bowel from an Anatomist's Point of View," " Surgical practice, so far as
concerns the colon, has reached a point much in advance of the present
knowledge at the disposal of anatomists, physiologists, and pathologists."
In other words, proof of Lane's theories and justification for his drastic
operative remedies depends almost entirely on the clinical evidence
available. No detailed or even brief analysis of the clinical material
which has passed through his hands is presented for consideration. In
referring to the " marvellous consequences of freeing the ileal effluent "

414 New Editions

he states that " the evidence has now been before the world for a long
time and these patients have been observed by all the ablest and most
distinguished surgeons in the world. They still exist in increasing
numbers and are always at the disposal of any observer who will take
the trouble to investigate them." Is it too much to ask that in the
next edition of his book Sir Arbuthnot Lane should add to his most
interesting and suggestive paper an analysis of his results % There are
many who admire his independence of thought and his great surgical
ability, but regret his unwillingness to adopt the conventional method
of inducing others to follow in his footsteps. By following that course
he might strengthen the convictions of his followers and remove the
doubts of the unconvinced who can never have an opportunity of
accepting his suggestion that they should examine his material for
themselves.

A Text-Book of Midwifery. By R. W. Johnstone, M.A., M.D., F.R.C.S.
Second Edition. Pp. xxvi. + 482. With 264 Illustrations.
London : A. & C. Black, Ltd. 1918. Price 12s 6d. net.

The second edition of this excellent text-book of midwifery does not
differ very greatly from its predecessor. Various corrections and
additions have been made in order to bring the book up to date. A
short note on the use of pituitary extract in labour has been added,
and there is a really useful and highly practical new section dealing
with the scopolamine-morphine anaesthesia, or so-called "twilight
sleep." Dr. Johnstone here writes with first-hand knowledge and
from considerable experience. His directions for the successful
employment of this undoubtedly valuable method of narcosis are
thoroughly sound and well-balanced. He wisely strikes a note of
caution when he warns the young practitioner to avoid this treat-
ment until experience has made him thoroughly familiar with the
course and conduct of ordinary labours

Amongst the many excellent modern manuals on midwifery Dr.
Johnstone's book has quickly gained much popularity with both
students and practitioners.

A Text-Book for Midwives. By John S. Fairbairn, M.A., B.M.,
F.R.C.P. Second Edition. Pp. xiii. + 350. With 3 Plates
and 113 Illustrations. London: Henry Frowde and Hodder
& Stoughton. 1918. Price 20s. net.

We are not surprised to find that a second edition of this excellent
text-book for midwives has been issued. The lengthening of the
period of study from three to six months now gives the pupil-midwife
a much better opportunity of obtaining fuller information on the

New Editions 415

various subjects which relate to the management of pregnant,
parturient, and puerperal women. Dr. Fairbairn deals lucidly with
the essential points in the physiology and pathology of pregnancy,
and in view of the part that the midwife is called upon to take in the
management of pre-maternity cases, and in her duties under the new
schemes for maternity and child welfare, we think the whole plan and
special characteristics of this book are altogether admirable. For the
more educated class who are now anxious to qualify for maternity and
child-welfare work the addition of a fresh chapter on antenatal hygiene
and treatment is specially valuable.

We congratulate the author on having produced a book for midwives
so comprehensive and complete that hardly any improvements can be
suggested.

A Short Practice of Midwifery for Nurses. By Henry Jellett, B.A.,
M.D. Fifth Edition. Revised. Pp. xiii. + 464. With 6
Plates and 169 Illustrations. London : J. & A. Churchill.
1918.

The appearance of the fifth edition of this work is a sufficient proof of
the favour with which it continues to be regarded by midwifery nurses.
As a practitioner and teacher of unusually large experience Dr. Jellett
insists upon the importance of training the nurse, first and foremost,
to recognise when to send for medical assistance. She must also stand
by the patient till help arrives, and should then be able to assist the
doctor intelligently. A certain amount of knowledge of general
medicine is therefore essential in her training, and Dr. Jellett's book,
which is both well arranged and clearly expressed, seems to fulfil this
purpose admirably.

Obstetrics : Normal and Operative. By George Peaslek Shears, M.D.
Second Edition. Pp. 734. With 419 Illustrations. Phila-
delphia and London : J. B. Lippincott Co. 1917. Price
30s. net.

The appearance in less than two years of a second revised edition of
this text-book has justified the opinion we expressed of the work
when it first appeared, and testifies to the popularity with which it
has been received. The author claims to have based his work on a
somewhat different plan from that most generally adopted, and has
certainly introduced the essentials of practical obstetrics wherever
possible. With this objective he has expressly omitted the traditional
preliminary chapters on anatomy and embryology.

A chapter is devoted to the important subject of antepartum
examination, the importance of which could not be better emphasised

416

New Editions

than by the introduction of such an excellent series of original
photographs.

The pathology of the puerperium is well handled, and the author's
principles of treatment in puerperal infection are extremely sound.

"Twilight sleep," which is still attracting so much attention, has
received full discussion.

The operations of obstetric surgery have been brought thoroughly
up to date, and are exceedingly well illustrated.

The author is to be congratulated on having produced an eminently
practical book for the use of both student and general practitioner, and
we are not surprised that there has been an early demand for a second
edition.

Notes on Books 417

NOTES ON BOOKS.

In 1916 the French Army Medical Service instituted a series of
schools of instruction for the education of medical officers, non-
commissioned officers, and orderlies in the problems of medicine and
surgery as especially applied to war. One of the principal schools
was established at Bouleuse, and men who were recognised as experts
upon certain branches gave a series of lectures dealing with their
various specialities. Under the direction of C. Regaud these lectures
have been collected and published (Masson et Cie) as a volume (Lemons
de Chirurgie de Guerre). It is unnecessary to give in detail the various
subjects which have been dealt with, but the surgical propositions which
are met with in war are fully and efficiently treated. The series is
introduced by a lecture upon the general considerations of war wounds,
with special reference to their treatment. Other sections deal with
the various branches of war surgery. There is an excellent article
upon radioscopy, and the various methods of localising foreign bodies
is dealt with in detail. The collection is one of the most instructive
we have seen, and it forms an excellent memoir of the surgical principles
which have been evolved and so successfully applied by our ally.

In the introduction to The Orthopaedic Effects of Gunshot Wounds
and their After-Treatment (Henry Frowde and Hodder & Stoughton,
price 7s. 6d. net) Dr. S. W. Daw gives a general account of the
factors which cause persistent disability after war wounds, and of the
principles which underlie their treatment. In the remaining chapters
the more common conditions are separately described. All forms of
treatment receive adequate attention, the paragraphs on the use of
splints and mechanical appliances being particularly good. The
account of the details of operative treatment is also good, though
condensed. A chapter upon functional paralyses by Dr. Cuthbert
Morton contains useful hints upon treatment, but is somewhat spoilt
by failure to distinguish between mere hysterical conditions and the
reflex group of paralyses described by Babinski and Froment. Printed
upon good paper and well illustrated, the book is a worthy addition to
the Oxford War Primers.

Fractures : Being a Monograph on " Gunshot Fractures of the Extremities"
by Lieutenant-Colonel Joseph A. Blake, M.C., U.S.A. (D. Appleton &
Co., price 7s. 6d. net), is divided into two parts, in the first of which
the author gives a brief general survey of the mechanism, repair, and
operative and mechanical treatment of gunshot fractures in general,
while in the second he indicates the methods he has found best in the
treatment of wounds of individual bones and joints. For those

418

Notes on Books

unfamiliar with war surgery the book is of special value, as it is
written from the author's personal experience, and the practical
points in regard to splints and apparatus are discussed in detail and
clearly illustrated by diagrams.

Technic of the Carrel Method, by J. Dumas and Anne Carrel (Wm.
Heinemann, price 6s. net), is specially written for the instruction of
nurses and orderlies, and to those it can be highly recommended. It
describes in detail the apparatus employed and the method of use in
clear, simple, and direct language. The illustrations are instructive and
are beautifully executed. The translation is by Dr. A. V. S. Lambert.

A Medical Field Service Handbook, by Lieutenant-Colonel C. Max
Page, D.S.O. (Henry Frowde and Hodder & Stoughton, price 6s. net).
The importance of front line medical work during a campaign cannot
be overestimated. A full experience, coupled with close observation
and controlled by sound common sense, is here recorded in clear and
concise form. The armistice may have robbed some chapters of their
mord immediate interest and use, but as long as large bodies of men
are collected together in relatively small ai*eas, either for the prosecution
of war or for the purposes of labour, so long will many of the problems
here discussed retain their importance. Medical officers in charge of
the health and welfare of such formations will find much that will help
them in this record of the author's experience.

The Sixth International Dental Congress, which met in London
early in August 1914, was unfortunate in having to disperse owing to
the sudden outbreak of war, but, in spite of this, a number of valuable
reports and papers were submitted and demonstrations given. The
Transactions, which we have just received, contain articles covering a
wide range of subjects, the majority of which are naturally of special
interest only to the dental surgeon, but there are a number which
are equally interesting to the medical man. Amongst these latter,
some are of purely scientific interest, whilst others, again, are of a
very practical nature. Thus there are several papers on histology,
comparative human anatomy, on industrial dentistry, and on educa-
tion. Naturally, pyorrhoea alveolaris, in all its various aspects, claims
considerable attention, and there are valuable papers on the causation
of dental caries and its prevention and treatment. Cysts of the jaws
are discussed in several papers, as are cleft palate and diseases of the
maxillary antrum. Anaesthesia, local and general, has always been
intimately associated with dental surgery, and there are some instructive
papers of general interest bearing on this subject. The volume is well
illustrated, and its production under most difficult circumstances is a
great credit to the editor, Mr. Brooks, and to the publishers at the
offices of the British Dental Association.

The character of Lecture- Notes on Chemistry far Dental Students, by
H. Carlton Smith, Ph.G. (Chapman & Hall, price 13s. 6d. net), is

Books Received 419

well described by its title, but the notes are sufficiently extensive to
make it readable and to render it of great value as a book of reference.
It is very properly of a practical nature, and it is presumed that the
student has already had a good grounding in general chemistry. The
information covers a wide field, including the chemistry of dental alloys,
amalgams, cements, etc., the chemical examination of urine, saliva,
teeth and tartar, and such portions of organic and physiological
chemistry as have a practical bearing on dentistry, together with
inorganic qualitative analysis with specially adapted blowpipe and
microscopical tests. The author rightly insists on the prime import-
ance of laboratory work, and a large number of simple experiments
are described so plainly that this in itself should stimulate the reader
to do them. There are some misprints and misstatements which
should not occur in a third edition, and some omissions, such as the
failure to notice rubber and the process of vulcanisation, but the book,
as a whole, is so excellent that it is a pleasure to recommend it to those
for whom it is specially written.

JiOOKS RECEIVED.

Anderson, H. Graham. The .Medical and Surgical Aspects Of Aviation

{Henry Frowde, Hodder & Stoughton) 12s. 6d.
De Lee, Joseph B. Principles and Practice of Obstetrics. Third Edition

(IV. B. Saunders Co.) 36s.

Flack, Martin, and Leonard Hill. A Text-Book of Physiology . (Edward Arnold) 25s.

Gleason, E. B. A Manual of Diseases of the Nose, Throat, and Ear. Fourth Edition

(W. B. Saunders Co.) 14s.

Hartridoe, Gdstavus. The Retraction of the Eye. Sixteenth Edition

(J. & A. Churchill) 7s. 6d.
Hirst, John Cooke. A Manual of Gynecology .... (W. B. Saunders Co.) 12s.

Howell, Wm. H. A Text-Book of Physiology. Seventh Edition (IV. B. Saunders Co.) 21s.

Jordan, Edwin O. A Text-Book of General Bacteriology. Sixth Edition

(W. B. Saunders Co.) 17s.

Love, James Kerr. Diseases of the Ear in School Children (John Wright & Sons, Ltd.) 5s. 6d.
M'Junkin, F. A. Clinical .Microscopy and Chemistry . . (W. B. Saunders Co.) 16s.

Macphail, Jamkk M. Eyes Right. Second Edition . (Butterworth & Co. (India) Ltd.) R.l.

Mallorv, F. B., and J. B. Wright. Pathological Technique. Seventh Edition

(IV. B. Saunders Co.) 17s.

Mott, Frederick W. War Neurosis and Shell Shock

(Henry Frowde, Hodder & Stoughton) 16s.

Riviere, Clivk. The Early Diagnosis of Tubercle. Second Edition

(Henry Frowde, Hodder <& Stoughton) 10s. 6d.
Rogers, Sir Leonard. Fevers in ihe Tropics. Third Edition

(Henry Frowde, Hodder & Stoughton) 30*.

INDEX.

(46*.) = Abstract. (Ed.) = Editorial Note.

Abstracts —

Dermatology, 261
Medicine, 318, 390
Obstetrics and Gynecology, 326
Pathology, 257
Surgery, 322
Therapeutics, 394
Adams, J. Barfield, The Doctors in
some Modern French Novels,
237
Almoners, Trained Hospital (Ed.), 209
Amblyopia, Three Cases of Quinine

(H. M. Traquair), 169
Amoebic Dysentery in England (Abs.),
395

Dysentery, Treatment of (Abs.),

394
Aneurysm of the Popliteal Vessels,
Two Cases of Arteriovenous
(Frederick C. Pybus), 315
An Unusual Obstructing Band

(Charles F. M. Saint), 383
Appointment, Dr. Lewis Thatcher,

275
Arteriovenous Aneurysm of the Pop-
liteal Vessels, Two Cases of
(Frederick C. Pybus), 315

Bactericidal Action of Sunlight
(Abs.), 260

Ballantyne, J. W., Abstracts on Obstet-
rics and Gynecology, 326

Bone and Joint Disease in Relation
to Typhoid Fever (Abs), 257

Boyd, Francis D., Experiences of a
Consulting Physician on Duty
on the Palestine Lines of Com-
munication, 276

Bramwell, Edwin, Acute Poliomyelitis,
345

Broad-Ligament Cyst, Pyosalpinx
resembling (Charles F. M.
Saint), 386

Burns, John, Income Tax Information,
35

Carcinoma of the Liver associated
with Infection by Clonorchis
Sinensis (H. L. Watson-Wemyss),
103

Cardiac Disease, Prognosis in (AbsX

318
Casualties, 1, 73, 143, 214, 275
Cervix Femoris, Fracture of the, in

Children (D. M. Greig), 75
Chair of Medical Chemistry, 143
Chorion-epithelioma of the Ovary,

Primary (John A. Kynoch), 226
Cinchonism. Eye Symptoms in (Abs.),

397
Clinical Records, 103, 315
Clonorchis Sinensis, Carcinoma of the

Liver associated with Infection

by (H. L. Watson - Wemvss),

103
Collins, E. Teacher, The Teaching

of Ophthalmology to Medical

Students, 48
Congenital Oedema (David M. Greig),

230
Gotterill, Denis, Obituary Notice of, 45
Cutaneous Aspects of Tuberculosis

(Abs.), 390

Dental Surgery for Medical Students

(William Guy), 105
Surgery, The Teaching of, to

Medical Students (J. H. Gibbs),

106
Dermatitis, Staphylococcal (Abs.),

264

Venenata (Abs.), 263

Dermatology, see Abstracts

The Teaching of —

(Norman Walker), 173
(F. Gardiner), 177
(R. Cranston Low), 178
Diaphragmatic Hernia following a

Gunshot Wound, A Case of

(David M. Greig), 357
Diarrhoea, Emetine (Abs.), 394
Diets in Use in the Edinburgh Roval

Infirmary in 1843, -234
Disease in Macedonia (Robert A.

Fleming), 215
Displacement of the Mandibular

Meniscus (Abs.), 322
Doctors in Some Modern French

Novels, The (J. Barfield Adams),

237

420

Index

421

Donaldton, Robert, A New Method
of Wound Treatment by the
Agency of Living Cultures of
a Proteolytic Spore - Bearing
Anaerobe Introduced into the
Wound, 3

Dunlop, J. C., Notes on the Influenza
Mortality in Scotland during the
Period July 1918 to March 1919,
403

Ear, Nose, and Throat, Diseases of, in
Medical Curriculum —
(A. Logan Turner), 109
(J. Malcolm Farquharson),
111

Eason, John, Abstracts on Medicine,
318

Emetine-Bismuth-Iodide in Amoebic
Dysentery Carriers (Abs.), 395

Emetine Diarrhoea (Abs.), 394

Experiences of a Consulting Physi-
cian on Duty on the Palestine
Lines of Communication (Francis
D. Boyd), 276

Eye Symptoms in Cinchonism (Abs.),
397

Farquharson, J. Malcolm, The In-
struction of the Undergraduate
in Diseases of the Ear, Nose,
and Throat, 111

Fergus, Freeland, The Place of Ophthal-
mology in the Medical Curricu-
lum, 52

Field Ambulance in Gallipoli, Egypt,
Palestine, and France ("James
Young), 288

Finlay, T. Y., Suggestions for the
Utilisation of the Poor Law
Hospital for Teaching Medical
Students, 181

Fleming, Robert A., Disease in Mace-
donia, 215

Fracture of the Cervix Femoris in
Children (D. M. Greig), 75

Gardiner, F., Abstracts on Derma-
tology, 261

The Teaching of Dermatology,

177

Gibbs, J. H., The Teaching of Dental
Surgery to Medical Students,
106

Goitre, Intestinal Disinfection by
Benzonaphthol'in (Abs.), 395

Goodall, Alexander, Malaria in Mace-
donia, 156

Graves' Disease, Treatment of (Abs.),
396

Greig, David M., Case of Diaphrag-
matic Hernia following a Gun-
shot Wound. Attempt to bring
about Radical Cure by Thoraco-
plasty, 357

Congenital GZdema, 230

Fracture of the Cervix Femoris

in Children, 75
Groins, Ringworm of the (Abs.), 263
Guy, William, Dental Surgery for

Medical Students, 105
Gynecology, see Abstracts

Hemorrhage, Turpentine in (Abs.),

397
Hernia, Diaphragmatic, following a

Gunshot Wound, A Case of

(David M. Greig), 357
Hospital Almoners, Trained (Ed.),

209
Hypertrophic Pyloric Stenosis in

Infants (Abs.), 325

Income Tax Information (John

Burns), 35
Incontinence of Urine, Operation for

the Cure of (Abs.), 324
Infection, Puerperal (Abs.), 326
Influenza Epidemic, Introduction to

Discussion on (Professor Russell),

400
Mortality in Scotland during

the Period July 1918 to March

1919 (J. C. Dunlop), 403
Inguinal Hernia, Two Unusual Cases

of (Charles F. M. Saint), 388
Intestinal Obstruction, Multilocular

Mesenteric Cyst with, 384

Knee, Ruptured Internal Lateral
Ligament of the (Abs.), 323

Knox, Robert, The Place of Radiology
in the Medical Curriculum, and
the Need for Co-ordination in
Teaching, 118

Kynoch, John A., Primary Chorion-
epithelioma of the Ovary, 226

Ligament of the Knee, Ruptured

Internal Lateral (Abs.), 323
Liver, Carcinoma of the, associated

with Infection by Clonorchis

Sinensis (H. L. Watson-Wemyss),

103
Low, R. Cranston, The Teaching of

Dermatology to Undergraduates,

178
Lumbar Puncture (Abs.), 320
Lundie, Robert Alexander, Obituary

Notice of, 42

422

Index

Macedonia, Disease in (Robert A.

Fleming), 215
Mackinnon, Frank J., Obituary Notice

of, 201
Malaria in Macedonia (Alexander
Goodall), 156

Chronic, Quinine Bihydro-

chloride, Sodium Cacodylate in
(Abs.), 397
Mandibular Meniscus, Displacement

of the (Abs.), 322
Medical Curriculum (Ed.), 141
Medical Education —

Dental Surgery (Gibbs), 106

(Guy), 105
Dermatology (Cranston Low), 178
„ (Gardiner), 177

(Walker), 173
Ear, Nose, and Throat —

„ „ (Farquharson) 111

„ (Turner), 109
Eye Diseases (Paterson), 64

„ • (Sym), 60
Ophthalmology (Collins), 48
(Fergus), 52
Poor Law Hospital, Utilisation of

(Finlay), 181
Radiology (Knox), 118
Report of the Pathological Club,

187
Report of the Students' Societies,
186
Medicine, see Abstracts
Medico - Chirurgical Society, Report

of, 399
Meniscus, Displacement of the Mandi-
bular (Abs.), 322
Multilocular Mesenteric Cyst with
Intestinal Obstruction (Charles
F. M. Saint), 384

Obituaries —

Cotterill, Denis, 45
Lundie, Robert Alexander, 42
Mackinnon, Frank J., 201
Obstetrics, see Abstracts
Obstruction, Intestinal Multilocular

Mesenteric Cvst with (Charles

F. M. Saint), 384
CEdema, Congenital (David M.

Greig), 230
Operation for the Cure of Incon-
tinence of Urine (Abs.), 324
Orr, John, Abstracts on Therapeutics,

394
Orthopaedic Surgery (Ed.), 273
Ovarian Fibroid with Ascites (Charles

F. M. Saint), 385
Ovary, Primary Chorion-epithelioma

of the (John A. Kynoch), 226

Palestine Lines of Communication,
Experiences of a Consulting
Physician on Duty on the
(Francis D. Bovd), 276

Passes, 2, 74, 214

Paterson, J. V., The Teaching of
biwases of the Eye to Medical
Students, 64

Pathology, see Abstracts

Pensions, War (Ed.), 212

Physiology, The Position of, in
Medicine (Sir E. S. Schafer), 144

Pigmentation of the Skin (-46*.), 261

Poliomyelitis, Acute (Edwin Brain -
well), 345

Poor Law Hospital for Teaching Medi-
cal Students, Suggestions for the
Utilisation of (T. Y. Finlay), 181

Popliteal Vessels : Two Cases of
Arteriovenous Aneurysm of the
(Frederick C. Pybus), 315

Post-Graduate Teaching in Edin-
burgh (Ed.), 142

Primary Chorion-epithelioma of the
Ovary (John A. Kynoch), 226

Prognosis in Cardiac Disease (Abs.\
318

Psoriases (Abs.), 262

Puerperal Infection (A 6s.), 326

Pybus, Frederick C, Two Cases of
Arteriovenous Aneurysm of the
Popliteal Vessels, 315

Pyloric Stenosis, Hypertrophic, in
Infants (Abs.), 325

Pyosalpinx resembling Broad-Liga-
ment Cyst (Charles F. M. Saint),
386

containing a Round Worm

(Charles F. M. Saint), 387

Quinine Amblyopia, Three Cases of
(H. M. Traquair), 169

Radiology in the Medical Curri-
culum (Robert Knox), 118

Rad i um Treatment, Notes on ( Da wson
Turner), 79

Register of Scottish Nurses, 275

Report of the Edinburgh Pathological
Club on the Training of the
Student of Medicine, 187

Reports of Students' Societies, 186

Reports of Societies —

Edinburgh Medico-Chirurgical
Society, 399

Reviews —

Aaron, Charles D., Diseases of the
Digestive Organs, with Special
Reference to their Diagnosis and
Treatment, 338

Index

423

Reviews — continued

Alisina, Reminiscences of a Student's
Life in Edinburgh, 138

Allen, Carroll W., Local and
Regional Anesthesia, including
Analgesia, 340

Anderson, Daniel E., The Epidemics
of Mauritius, with a Descriptive
and Historical Account of the
Island, 268

Ballenger, H. C, and A. G.Wippern,
Eye, Ear, Nose, and Throat : A
Manual for Students and Prac-
titioners, 67

Barrett, Jaines W., The i'win
Ideals; An Educated Common-
wealth, 138

Bayliss, W. M., Intravenous Injec-
tion in Wound Shock, 207

Bemheini, Bertram M., Blood
Transfusion, Haemorrhage, and the
Anaemias, 133

Blake, Joseph A., Fractures: Being a
Monograph on " Gunshot Fractures
of the Extremities," 417

Borradaile, L. A., A Manual of
Elementary Zoology, 270

Candy, Hugh C. H, see Luff, A. P.

Carrel, Anne, see J. Dumas

Chandhuri, T. C, Sir William Ram-
say as a Scientist and a Man,
139

Christie, Arthur C, Manual of
X-ray Technic, 138

Clarke, Ernest, The Errors of
Accommodation and Refraction
of the Eye and their Treatment,
341

Cumberbatch, E. P., Morton's
Essentials of Medical Electricity,
271

Davis, Gwilym G., Applied An-
atomy, 343

Daw, S. W., The Orthopedic Effects
of Gunshot Wounds and their
After-Treatment, 417

Deane, H. E., Gymnastic Treatment
for Joint and Muscle Disabilities,
137

Doyen, E., Surgical Therapeutics and
Operative Technique, 206

Dumas, J., and Anne Carrel,
Technic of the Carrel Method, 418

Duval, Pierre, War Wounds of the
Lung, 136

Elmslie, R. C, The After-Treatment
of Wounds and Injuries, 410

Fairbairn, J. S., Text-Booh for
Midwives, 414

Fisher, Lewis, see Isaac H. Jones

Reviews — continued

Ford, Joseph H., Details of Mili-
tary Medical Administration, 138

Gay, Frederick P., Typhoid Fever,
Considered as a Problem of Scien-
tific Medicine, 334

Ghosh, R., Materia Medica and
Therapeutics, 340

Graves, William P., Gynecology, 341

Hayes, Reginald, The Intensive
Treatment of Syphilis and Loco-
motor Ataxia by Aachen Methods,
269

Hirschl'elder, A. D., Diseases of the
Heart and Aorta, 411

Hirst, Barton Cook, A Text Book of
Obstetrics, 69

Howden, Robert, Edited by, Gray's
Anatomy, 343

Hughes, Basil, War Surgery : From
F\ring Line to Base, 135

Hull, Alfred J., Surgery in War,
136

Hurford, Phelps G., see Tuttle

Jellett, H, A Short Practice of
Midwifery for Nurses, 415

Johnstone, R. W., Text-Book of
Midwifery, 414

Jones, A. Basset, see Llewellyn

Jones, Isaac H., and Lewis Fisher,
Equilibrium and Vertigo, 335

Keef'er, F. R., Military Hygiene and
Sanitation, 138

Keen, W. W., Treatment of War
Wounds, 343

Knapp, Arnold, Medical Ophthal-
mology, 134

Roll, Dr., Diseases of the Male
Urethra, 271

Kolmer, John A., Infection, Im-
munity, and Specific Therapy, 68

Lane, W. Arbuthnot, Operative
Treatment of Intestinal Stasis,
413

Llewellyn, J., and A. Basset Jones,
Pensions and the Principles of their
Evaluation, 330

Lloyd, Lt., Lice and their Menace to
Man, 267

Loeb, Jacques, Forced Movements:
Tropism and Animal Conduct, 266

Luff, Arthur P., and Hugh C. H.
Candy, A Manual of Chemistry, 343

Lusk, Graham, The Elements of the.
Science of Nutrition, 338

Luys, Georges, A Text-Book on
Gonorrhoea and its Complications,
70

MacCurdy, John T., War Neuroses,
332

424

Index

Reviews — continued

Macdonald, R., St. John, Field

Sanitation, 138
Mackenzie, Win,, Colin, The Action

of Muscles, 137

M'Leod, J. J. R., Physiology and

Biochemistry in Modern Medicine,

265

Martinet, A., Diagnostic Clinique,409

May, Percv, Chemistry of Synthetic

Drugs, 206
Mayer, Leo, The Orthopedic Treat-
ment of Gunshot Injuries, 136
Mavo Clinique, Collected Papers of

the, 1917, 343
Medical Annual for 1918, 71
Morison, Rutherford, Bipp Treat-
ment of War Wounds, 71
Muir, E., Kala-Azar : its Diagnosis

and. Treatment, 268
Muir, Robert, and James Ritchie,

Manual of Bacteriology, 269
Page, C. Max, A Medical Field

Service Handbook, 418
Paramore, R. H., Tlie Statics of the
Pelvic Female Viscera, in which
the Evidence of Pathology, Phi/lo-
geny, and Clinical Investigation,
etc., is Surveyed, 333
Prentice, C. W., A Laboi-atory
Manual and Text-Book of Em-
bryology, 139
Regaud, C, Lecons de Chirurgie de

Guerre, 417
Report of the Episcopal Hospital,

Philadelphia, 271
Ritchie, James, see Robert Muir
Roddy, John A., Medical Bacteri-
ology, 208
Shears, George Peaslee, Obstetrics:

Normal and Operative, 415
Shera, A. Geoffrey, Vaccines and
Sera in Military and Civilian
Practice, 137
Short, A. Rendle, Index of Prognosis

and Treatment, 412
Smith, H. Carlton, Lecture-Notes
on Chemistry for Dental Students,
418
St. Thomas's Hospital Reports, 271
Stewart, G. N., A. Manual of Physi-
ology, 339
Surgical Board of the Women's Hos-
pital in the State of New York, 271
Thomson, William Hanna, A
Treatise on Clinical Medicine, 337
Todd, James Campbell, Clinical

Diagnosis, 337
Transactions of the American Gyne-
cological Society, 1917, 271

Reviews — continued

Transactions of the American Paedi-
atric Society, 72

Transactions of the Sixth Interna-
tional Dental Congress, 418

Trench Fever, Report of American
Red Cross Commission, 411

Turner, A. Logan, Sir William
Turner, K.C.B., F.R.S.: A Chapter
in Medical History, 408

Tuttle, Geo. N., and Phelps G.
Hurford, Diseases of Children, 69

Wellcome Photographic Exposure
Record and Diary, 139

Wheeler, Wm. I. de C, Handbook
of Operative Surgery, 70

Whiting, A, Aids to Medical Diag-
nosis, 138

Whittaker, R. C, Hughes' Nerves of
the Human Body, 270

Wiley, Harvey W., Foods and their
Adulteration, 68

Wilson, R. M., The Hearts of Man,
133

Wippern, A. G., see Ballenger

Yealland, Lewis R., Hysterical Dis-
orders of Warfare, 66
Ringworm of the Groins (Abs.), 263
Ruptured Internal Lateral Ligament

of the Knee (Abs.), 323
Russell, Professor, Introduction to
Discussion on the Influenza
Epidemic, 400

Saint, Charles F. M., An Unusual
Obstructing Band, 383

Schafer, Sir Edward Sharpey, The
Position of Physiology in Medi-
cine, 144

Sciatica, Treatment of (Abs.), 398

Scopolamine-Morphine Narcosis or
Twilight Sleep (Robert Wallace),
87

Shennan, Theodore, Abstracts on Patho-
logy, 257

Sinuses Persisting after War Wounds,
The Treatment of (Arthur J.
Turner), 253

Skin, Pigmentation of the (Abs.\
261

Staphylococcal Dermatitis (Abs.), 264

Stenosis, Hypertrophic Pyloric, in
Infants (Abs.), 325

Sunlight, The Bactericidal Action of
(Abs.), 260

Surgery, see Abstracts

Surgery, Orthopaedic (Ed.), 273

Sym, George William, The Teaching
of Eye Diseases in the Curri-
culum, 60

Index

425

The Treatment of Sinuses Persisting

after War Wounds (Arthur J.

Turner), 253
Training of the Student of Medicine,

see Medical Education
Traquair, H. M., Three Cases of

Quinine Amblyopia, 169
Tuberculosis, The Cutaneous Aspects

of (Abs.), 390
Turner, A. Logan, The Teaching of

Diseases of the Ear, Nose, and

Throat in the Undergraduate

Curriculum, 109
Turner, Arthur J., The Treatment of

Sinuses persisting after War

Wounds, 253
Turner, Dawson, Notes on Radium

Treatment, 79
Twilight Sleep, Scopolamine-Mor-

phine Narcosis or (Robert

Wallace), 87
Typhoid Fever, Bone and Joint

Disease in Relation to (Abs.),

257

Urine, Operation for the Cure of
Incontinence of (Abs.), 324

Walker, Norman, The Teaching of
Dermatology, 173

Wallace, Robert, Scopolamine-Mor-
phine Narcosis or Twilight Sleep,
87

War Pensions (Ed.), 212

War Wounds, The Treatment of
Sinuses persisting after (Arthur
J. Turner), 253

Watson-Wemyss, H. L., Carcinoma of
the Liver associated with Infec-
tion by Clonorchis Sinensis,
103

Whooping-Cough, Vaccine Treatment
of (Abs.), 396

Wilkie, TJ. P. D., Abstracts on Sur-
gery, 322

Wound Treatment, A New Method
of, by the Agency of Living
Cultures of a Proteolytic Spore-
Bearing Anaerobe introduced
into the Wound (Robert Donald-
son), 3

Young, James, A Field Ambulance in
Gallipoli, Egypt, Palestine, and
France, 288

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