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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 followin g 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. Dastre 9 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 paper 12 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 quotation 9 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 wound 1 
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 

3 3 9 

3 9 4 6 

4 6 5 3 

5 3 6 



6 



6 



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 


100 


18 15 


£535 




£84 



£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 
78 15 


£348 


15 


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-life 1 ? 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 taught 1 ? 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 T Vg. 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 S r - 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 S r - 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 Brumpt 3 
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 surgery 1 ? (2) What 
should be the scope and extent of the teaching 1 ? (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 from 1 ? 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 W T right & 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 
Ch chemSt e ^ 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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LlPE-HlSTORY OP THE MALARIA PARASITE. 

a Tlie asexual cycle in man. /. The female cycle in man. m. The male cycle in man. 
/i, m 1 . Female and male gametes which conjugate in the mosquito to form a zygote — the ookinete. 
This forms an oocyst, different stages of which are shown under the epithelium of the stomach of 
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cyst ruptures these reach the salivary glands and from there may be passed into the blood of man. 



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 T 5 ^ 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 
ordinarj r 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 
Tra Smoners Pital were merel y 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. 

Bulloch 7 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 first 3 
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 th e 
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 surgery 1 ? 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 - 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> 




2 
o 
* 




« 

■ 
Q 


dead of 
cases 
traced. 




' Constant 


26 


22 


2 


20 


91-0 




Marked after pre- 
















Alterna- 


mature beats 


16 


12 











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 











4 


100-0 


Auricular 
fibrillation 


(2) With ectopic 
















beats 


11 


7 


1 


1 





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 accident 9 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 
wi