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THE 



DUBLIN JOUKNAL 



OF 



MEDICAL SCIENCE 



EDITED BY 

SIR JOHN W. MOORE, M.A., M.D., M.Ch. Duel., D.Sc. Oxon., 

PAST-PRESIDENT OF THE ROYAL COLLEGE OF PHYSICIANS OF IRELAND, 

SENIOR PHYSICIAN TO THE MEATH HOSPITAL AND COUNTY DUBLIN INFIRMARY, 

CONSULTING PHYSICIAN TO CORK-STREET FEVER HOSPITAL, 

EX-SCHOLAR AND DIPLOMATE IN STATE MEDICINE 

OF TRINITY COLLEGE, DUBLIN. 

HONORARY PHYSICIAN IN ORDINARY TO H. M. THE KING IN IRELAND ; 

and 

T. GILLMAN MOORHEAD, B.A., M.D. Dubl., 

FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS OF IRELAND, 

PHYSICIAN TO THE ROYAL CITY OF DUBLIN HOSPITAL, 

CONSULTING PHYSICIAN TO THE CLONSKEAGH FEVER HOSPITAL, 

DIPLOMATE IN STATE MEDICINE. 



VOL. CXXXVL 

JULY TO DECEMBER, 1913 



DUBLIN; 

FANNIN & COMPANY. Ltd.. GRAETON-STREET, 

LONDON: SIMPKIN. MARSHALL & CO. 

EDINBURGH: JAMES THIN. 

PARIS: HACHETTE & CO. 

1913. 



^/ 



DUBLIN : PAINTED BY JOHN rALCONER, 53 UPPER RAOKVILLB-BTKEET. 




THE DUBLIN JOUKNAL 

OF 

MEDICAL SCIENCE. 



JULY 1, 1913. 



PART I. 
ORIGINAL COMMUNICATIONS. 



Art. I. — Clinical Report of the Rotunda Hospital for 
One Year, November 1st, 1911, to October Slst, 1912. ^ 
By Henry elELLETT, M.D. (Diibl. Univ.), F.K.C.P.I., 
Master; and David G. Madill, M.B. (Diibl. Univ.), 
and K. Marshall Allan, M.B. (Edin. Univ.), Assis- 
tant Masters. 

Midwifery Report. 

During the year ending October 31st, 1912, 2,339 
patients were delivered under the care of the Hospital in 
its Extern Department, and 2,474 patients were ad- 
mitted to the Maternity Wards. Of the latter number, 
338, who were not in labour, were discharged undelivered, 
and 2,136 were delivered. Thus a total of 4,475 labours 
in all were attended by the Hospital Staff, being an in- 
crease of 26 on the previous year. 

Ten deaths occurred in the Extern Department, and 
eleven in the Intern, being a percentage mortality of 0.42 
in the former and of 0.44 in the latter, or a mean per- 
centage mortality of 0.43. 

* Read in the Section of Obstetrics of the Royal Academy of Medicine 
in Ireland on Friday, April 18, 1913. 

VOL. cxxxvi. — ^NO. 499, third series. a 



ft rv 



Clinical Report of the Rotunda Hospital. 



The mortality percentage and average in the Intern 
Maternity Department is calculated on the total admis- 
sions, and not, as heretofore, on the total deliveries. 
The reason lor lliis is obvious. Formerly if a woman was 
under treatment for eclampsia at the sixth month and 
died she was counted amongst the deaths, whereas if she 
recovcHMl and lel'l the ll()s[)ital undelivered, she was not 
included under Ihe recoveries, thus giving an exaggerated 
idea of th(^ actual mortahty rate. 

Extern Department. 
Taiujc I. — Nature and Number of Cases Treated. 



Total Deliveries 


- 


2,3.30 


Operations — 

Manual removal r.»f 




Presentations — 






placenta 


18 


Vertex - 


- 


l,9.-)2 


Forceps - 


54 


,, Face to piibes 


- 


12 


\'ersion - 


8 


Face 


- 


8 


Suture of periiueal lareni- 




Brow 


- 


4 


tions - 


18H 


Broecli - 


- 


()() 






Transverse 


- 


5 


Maternal niurtality — 


10 


Twins 


. 


32 






Triplets 


- 


1 






Hydramnios 


- 


1 


Infantile mortality — 




\^'sicnlar mole 


- 


2 


Recent - 


54 


Abortions and Miscarriages 


324 


Afacoratod 


8 


HflBmorrhasos — 










Unavoidable 


- 


5 


Foetal abnormalities — 




Accidental 


. 


4 


Anencei)lialus 


3 


Post partuni 


- 


11 


Spina bifida 

11 ydrocephalus - 


2 

4 


Prolapse of Cord - 







iiypo!5i)atlias 


1 



I regret to say that four deaths from ante-partum 
hoBinorrliage occurred in the Extern Maternity, two 
being fi-om unavoidable haemorrhage and two from 
accideiilal luiomorrhage. One of these patients — a case 
of unavoidable haemorrhage — was moribund on the arrival 
of the Clinical Clerk. In another — a case of accidental 
hii'inoi rliMge — the vagina was jilugged in the usual 
manner; live hours hiter the patient got strong uterine 
contractions, and consequently the plugs were removed. 



^ 



By Dr. Henry Jellett, Master. 3 

The haemorrhage again started, and as, the pulse was 
getting weaker, and the cervix was sufficiently dilated, 
the Clinical Clerk applied the forceps and delivered a dead 
foetus. The patient, however, collapsed shortly after- 
wards and died. 

The details of the other fatal cases wall be found in 
Table II. 

The principal event of the year was the opening of the 
new Labour Wards. I have already described these fully 
in my former Keport, and so need not again discuss them. 
With the ill-luck that attaches itself to the opening of 
new buildings of this kind, the first thing that happened 
was a violent outbreak of sepsis, from which two patients 
died. Where the sepsis originated I am unable to say. 
For a considerable time I considered that it was probably 
coming from the new tanks which supplied water, and 
with this idea I stopped using anything but sterilised 
water in the Labour Ward, even for the washing of 
hands. The infection immediately ceased, and I had the 
tanks carefully disinfected, and then began to use them 
again. Everything went well for some months, and then 
infection occurred again. The use of the tanks was 
stopped a second time and sterilised or boiled water sub- 
stituted, with the disappearance of the outbreak. We then 
had alterations made in the tanks, which are now in 
duplicate, and it is an easy matter to work from one and 
disinfect the other, so that regular sterilisation can be 
carried out. I adopted a similar course in the case of the 
tanks supplying the Lying-in Wards, and here it is pos- 
sible to disinfect one tank at a time, without interfering 
with the water supply from the other tank. It is, how- 
ever, very questionable whether the infection really came 
from the tanks or not, as the same water was being used 
at the same time in the operating theatre, and there was 
no outbreak of infection in the Gynaecological Wards. In 
spite of this outbreak of septic infection the morbidity 
rate was lower than the previous year, and is represented 
by the figure of 5.53 per cent, as against 6.64. 



clinical Ucport of Uic Holiiuda Hospital. 



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By Dr. Henry Jellett, Master. 



Intern Department. 
Table III. — Total Admissions and Deliveries. 





Nov. 


Dec. 


Jjin 


Feb. 


Mar. 


Apr. 


May 


June 


July 


Aug. 


Sept. 


Oct. 


Total 


^otal deliveries - 

^atients admitted 
not in labour - 


160 

16 

176 


169 

25 


181 

41 


165 
22 


190 

25 



215 


180 
26 

206 


180 
36 


198 
27 


190 
38 

228 


182 
25 

207 


174 
31 

205 


167 

26 

193 


2,136 
338 


Total admissions 


194 


222 


187 


216 


225 


2,474 



Table IV. — Nature and Number of Caftes Treated. 




Total admissions 


2,474 


Abnormalities of cord — 




Total deliverie.s 


2,136 


Velamentous insertion 


1 


Primiparae 


726 


Prolapse - 


10 


Multiparse 


1,410 






Presentations — 




Accidental Complications 




Vertex, normal rotation 


2,020 


Epilepsy - 


1 


,, face to pubes 


17 


Phthisis - 


2 


Face 


11 


Myomata of uterus 


1 


Brow 


2 


(Edema of vulva (renal) - 


2 


Breech ... 


53 


Cardiac Disease 


I 


Transverse 


9 


Spleno-medullary 








Leukaemia 


1 


Twins 


31 






Complications of Pregnancy- 


_ 


Eclampsia - - - 


14 


Hyperemesis 


2 


Crural phlegmasia - 


7 


Hydramnios 


3 


Mastitis . . . 


1 


Abortions and miscarriages 


59 


Parotitis 


1 


Haemorrhages — 








Unavoidable 


7 


Operations — 




Accidental, external 


1 


Pelvimetry 


16 


Post partum 


7 


Induction of labour and 




„ internal traumatic 




miscarriage — 




(hsematoma vulvae) 


2 


for haemorrhage 
,, toxaemia and dead 


1 


Lacerations of genital tract— 


- 


foetus 


4 


Perinaeum 


546 


Episiotomy 


4 


Cervix (serious) - 


2 


Impacted shoulders 


2 


Uterus (complete rupture) 


2 


Cleidotomy 

Suture of perinaeal lacera- 


1 


Contracted pelvis - 


24 


tions — 








Complete 


3 


Placental abnormalities — 




Incomplete 


543 


Adherent - 


20 


Suture of cervical lacera- 




Praevia 


7 


tions 


2 


Battledore 


1 


Forceps - 


79 


Succenturiate 


1 


Version . - - 


22 



G Clinical Brport of the Rniinuhi Hospital 

Table IV.— Nature and Number of Cases Treated - con. 



Cajsarean Section — 
Abdominal conserva- 

tivo (classical) - 4 

„ radical - 1 

Pubiotomy - - 3 

Craniotomy - - 6 

Manual removal of placenta 20 

Excision of thrombosed 

ovarian vein - - 2 

Panhysteroctoiny - - 2 

S\ipra- vaginal Hysterectomy 2 
Ovariotomy (associated with 

Csesarean Section) 1 

Morbidity (B. M. A. standard) — 
Average - 1 in 18 .06 

Percentage - - 5.53 

Mortality — {vide page 22) 

Total - - - 11 

Average - - 1 in 225 

Percentage - - 044 



Infant statistics — con. 
Children born alive "yho 

died in hospital - 38 

Total born dead or died 

in hospital - - 130 



Infant statistics — 






Total births 


- 


2,108 


Alive - 


- 


2,016 


Dead - 


- 


92 


Premature - 


35 




Full term — 






Recent 


24 




Macerated 


33 





Foetal abnormalities — 
As<-itcs 
Anencephalus 
Cleft palate 
Cleft mouth and occlusion 

right ear 
Patent foramen ovale 
Congenital sy})hilis 
Cenu recurvatum 
Hydrocephalus - 
Spina bifida 
Talipes - 



Infantile complications — 
Cephalhspmatoma 
Cerebral hremorrhage 
Fractured clavicle 
Hernia 
Hyphoemia 
Cangrono of arm 
Im])orforatc anus 
Mol<T?na 
Ophthalmia 



1 
6 
1 

1 
1 
2 
1 
2 
3 
10 



Table V. — Pelvic Presentnftous. 



Para 


Total 


Dead Children Ukkakks 


Priinipara) 


17 

36 


Recent 1 j 
Maccra-ed 1 
Total 2 


One was ass(»(iated with pro- 
la])sc of cord 

Thrci' occurrcij in twin preg- 
nancies 

One associated with fractureil 
<'laviclc 

One occurred with eclampsia 

Stnon occurred in twii» preg- 
nancies 

One had fractured clavicle 

One was ])remature 

()n<* associatnl with prolapse 
of cord 

One occurred with placenta 
pr.Tvia 

One associatoil with acci- 
dental hamorrhapre 


Multipara,' 


Recent 4' 

Macerated 5 

Tntal 9 

Total 1 1 
( 


ToUls 


53 



By Dr. Henry Jellett, Master. 
Table VI. — Twins. 



Both males 
Both females 
Male and female 
Tocai 




But for the septic cases that occurred during the year 
one would express oneself as being entirely satisfied with 
the new Labour Wards, and with the increased facilities 
which they afford. I trust that at the end of my next 
year I may be able to point to a very considerably re- 
duced morbidity and mortality. 

I mentioned in my last Eeport that I had allowed and 
encouraged patients to get out of bed at a much 
earlier period than is usually considered advisable. 
Provided their confinement was normal, and that 
there had been no perinaeal laceration, they were 
allowed and encouraged to sit up in bed after the first 
twelve hours, and to get out of bed to pass water if 
they wished to do so. After forty-eight hours, if they con- 
tinued well, they were made to leave their bed at least 
twice in the twenty-four hours to pass water. After 
seventy-two hours they were allowed to take a few steps 
or to sit for a few minutes on a chair or on their bed, the 
tinie they remained up being gradually increased so long 
as their state of health continued good. During the past 
year I have made no change in this plan, and I have found 
it most satisfactory. T cannot find the smallest evidence 
that it has been anything but beneficial to the patients. 

T will now briefly refer to the different complications of 
labour met with during the year. There were seven cases 
of unavoidable hapmorrhage, in four of which the placenta 
was situated centrally over the cervix. In all cases the 
mother recovered. The usual routine treatment of Braxton 
Hicks' bipolar version was adopted. There was one case 
of accidental haemorrhage. It was successfullv treated by 



Clinical Urport. of the Uolmidn Uospiial. 



pillaging the vagina. There were twenty-four cases of 
contracted pelvis. In eight of these delivery was spon- 
taneous, in three the forceps was apjilied, in three 
pubiotomy was done, in four CoQsarean section was done, 
and in four craniotomy. In the cases of craniotomy the 
child was found to i)e dead, and so no other method of 
delivery was tried. All the mothers recovered. There were 
ten cases of prolapse and presentation of the cord, which 
were treated in different ways. All the mothers recovered, 
and five children were born alive. There were fourteen 
cases of eclampsia, some of which were of a very severe 
type. The treatment introduced by my predecessor, Dr. 
Tweedy, was continued. Twelve mothers recovered, and 
two died, whose history I will discuss later. The forceps 
was applied on seventy-nine occasions. One mother died 
as a result of hyperemesis, from which she had been 
suffering for some time. Sixty-nine children were born 
alive, and ten dead. There were five cases of Cirsarean 
section. All the mothers recovered, and all the children 
who were alive when the operation was undertaken, were 
delivered alive. One child was delivered dead and putrid, 
as the mother had been for a considerable time in labour 
before admission. I refer to this case later. There were 
tluee cases of pubiotomy, in all of which the mothers re- 
covered, and the children were delivered alive. In one 
of the cases the child was recognised to be slightly hydro- 
ce|)hali('. It wns, however, alive, and 1 was unwilling to 



Taulk 


Vli 


. — Morhii 


litil— 


-B. 


M. . 


4. Standarc 










o 


Dec. 
Jmn. 

Feb. 




a. 
< 




» 

c 
a 

192 


•-» 
184 


be 

9 
< 




c5 
o 


"3 


Total Deliveries 


166 


160 


177 


ICO 


187 


176 


174 


179 


168 


164' 2077 


Cafles Morbid - 


9 


9 


6 


9 


20 


4 


7 


11 


11 


11 


7 


11 115 


Percentage 


5.76 


5.62 3..^H 


5.62 


10.6^ 


2.27 


4.02 


0.72 


5.92 6.14 


4.04 


6.70 5.63 


Total number of morbid cases • 116 

Total pcrcMMitiif^t' morbidity - ^.oS 
Total avorage nmrbidity 1 in IH.oi) 



By Dr. Henry Jrllett, Master. 



Table VIII. A. 
Comparison of Morlidity in Primiparce and MultiparcB, 

PRIMIPAR^. 





> 
o 


i 


a 

1-5 




1 


< 




2 

3 


•-5 


< 




o 


o 
H 


Total deliver- 


51 


54 


55 


54 


64 


52 


79 


78 


62 


69 


51 


57 


72e 


ies 




























Cases Morbid 


3 


3 


4 


3 


9 


3 


4 


5 


7 


8 


3 


9 


61 


Percentage - 


5.86 


5.55 

i 


7.27 


5.55 


14.06 


5.76 


5.06 


6.41 


11.27 


11.59 


5.88 


15.79 


8.40 




Total average morbidity - 1 in 11.9 




Total percentage morbidity - 8,4 






MULTIPARA. 


Total deliver- 


105 


1 
106 


122 


106 


128 


124 


95 


114 


122 


110 


117 


107 


1351 


ies 




























Cases Morbid 


6 


6 


3 


5 


U 


1 


3 


6 


4 


3 


4 


2 


54 


Percentage - 


5.71 


5.66 


2.45 


4.78 


8.94 


.80 


3.15 


5.26 


3.2^ 


2.72 


3.41 


1.86 


3.99 




Total average morbidity - 1 in 25.01 




Total percentage morbidity - 3.99 



Table VIII. B. — Extra-genital Causes of Morbidity. 

















Phthisis 


- 




- 






2 


Mastitis 






- 






1 


Nephritis - 






- 






2 


Lobar pneumonia - 






- 






3 


Cystitis 






- 






1 


Parotitis - 




- 


- 






1 


Rheumatism 


- 


- 


- 




- 


1 










Total 


- 


11 



10 Clinical Report of the Rotunda Hospital. 






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By Dr. Henry Jrllett, Master. 11 

Table IX. A. — Duration of Stay in Hospital of Morbid Cases. 



Under 10 days 
10-19 „ 
20-29 „ 
Over 29 „ 

Total 



60 cases, including 8 deaths ♦ 
28 ,, ,, — 

15 ,, 5, 2 deaths 

12 „ „ 1 death 



115 



11 deaths 



Table IX. B. — Duration of Temperature. 



Under 5 


days 


5-9 


j> 


10-19 


>> 


Over 19 


>j 



73 cases, including 6 deaths * 
19 „ ,, 3 deaths 

1^ jj j> — 

11 „ „ 2 deaths 



Total 



115 



11 deaths 



Table IX. C- 


— Highest T'emperature Recorded. 


F 100°-100.9° 
101°-101.9<' 
102°-102.9° 
103°-103.9° 
104° and over - 


- 


39 cases, 
28 „ 
25 „ 
13 „ 
10 „ 

115 „ 


including 3 deaths * 

2 

>> 2 „ 
„ 1 death 
„ 3 deaths 

„ 11 deaths 


Total 



* Two of these patients died within a few hours of their admission. 
Table IX. D. — Treatment, of Morbid Cases of Genital Origin. 



Utero-vaginal douching - 
Administration of vaccine 
Extirpation of thrombosed ovariap vein - 
Laparotom}^ and Drainage 
Hysterectomy .... 



86 patients 

47 „ 
2 „ 
2 „ 
1 patient 



Table IX. E. — Utero- Vaginal Douches. 





34 patients had 1 douche 
33 „ „ 2 douches 




" >> >> 

3 ., 
1 patient 


3 

4 
5 
6 


>> 

>> 


Total 


S5 







12 Clinical Urpnrt of the Uoiundn Hospital. 

perforin craniotomy. After birth it turned out to have 
a spina bifida also, and died in ten minutes. In this case 
there was an extensive tear involving the vaginal wall and 
bladder, and on the forty-seventh day after the delivery 
a piece of necrosed bone came away through the vagina. 
The patient, however, was subsequently discharged, 
walking well. The bladder wall was stitched immediately 
after the pubiotomy, and there was good union. I have 
seen this patient since, and in spite of the fact that the 
piece of bone between the symphysis and the saw cut is 
missing, she suffers in no way from weakness of the pelvis 
or difticulty in walking. The other two cases of pubi- 
otomy were entirely uneventful. I did one radical 
Caesarean section and one complete hysterectomy to effect 
delivery in the case of a myomatous uterus. Both these 
patients were septic before operation. The case of myoma 
died on the sixth day ; the other patient recovered rapidly. 
T refer to both these cases later. I also performed a 
hysterectomy during the puerperium on account of 
pyoRmia. The patient, however, died. The use of 
vaccines has bccMi continued as in the previous year, and 
Tabh' X. shows the iialiiic and iiiinihci- of cases in which 
they were used, and Table XT. the number of injections of 
vaccine in each patient. 

I referred ii^ my last Report to the fact that T had sub- 
stituted MJ one period the use of argyrol foi* nitrate of 
silvei- ill llie prophylactic treatment of ophthalmia, and 
that ] had subsequently returned to the nitrate of silver 
as the argyrol did not seem to give good results. The use 
of nitrate of silver has been continued during the past year, 
and though cases of ophthalmia occurred, the number is 
smaller than in th«* previoiis year, and the type was not 
so severe. 

1 must diaw particular attention to tlu* introduction 
during the year of the operation of excision of thrombosed 
veins in cases of pyainia. 1 should do so at some length 
hut foi- llie I'acl that I liave already published an article 
on the siibjeel. wliicli will subscMpienf 1\ be found in the 



By Dr. Henry Jellett, Master. 



13 



Table X. — Nature of Infection and of Vaccine in Cases in which 

Vaccine was used. 



No. 










of 


Infection 


Vaccine Used 


Results 


Remarks 


Cases 










27 


Streptococcus 


Rotunda stock 23 


All 
recovered 


In 2 cases serum was 
also given 






Do. of St. aureus 1 


Recovery 


~ 






Rotunda stock and 


Recovery 


(Septic pneumonia 






pneumonia 1 




after rupture of 
uterus 






Rotunda stock and 










autogenous and Ro- 










tunda Staph. 2 


2 Deaths 


Abscess of lung and 
abscess of spleen 


4 


St. aureus. 


Rotunda St. aureus 1 


Reco very 









Do. and Strepto. 3 


1 Death 


Death from acute 


3 


Streptococcus 


Rotunda Strepto. and 




peritonitis during 
secondary syphilis 




and St. aureus 


St. aureus 2 
Rotunda Strepto. 1 


Recover}/ 

>> 




1 


St. aureus and 
B. Coli 


Rotunda St. aureus and 
autogenous B. Coli 


>j 


Cystitis 


12 


Undiscovered 


Strepto. and S. aureus 4 


2 Deaths 


One death followed 
on panhysterec- 
tomj' ; one on 
abscess of ovary 


1 




Strepto. 6 
St. aureus 2 


Recovery 
1 Death 


Gangrene of limb 

1 



14 Cliuicdl llcport of the Hoiinula Hospital. 



Tablk XI. — Number of Injections of Vaccine in each Patient. 



No. 
of 
. Injections 


No. 

of 

Caues 


Results 


Remarks 


1 


~) 


All recovered 




2 


9 


7 


Onv death after })anhysterectoniy for 
inyoina ; one from general peri- 
tonitis during secondar}' syphilis 


3 


8 


7 


One death from j^angrene 


1 

4 


10 


All recovered 


— 


it 


»> 


>* 


— 


6 


1 


't 


— 


8 


o 


>» 


— 


9 


2 


»» 


— 


10 

1 


2 


2 D.Mtlis 


One from ah-icess of ovary ; one from 
abscess of spleen 


11 


2 


1 Death 


Abscess of lung 


12 


1 


Recoverctl 


— 


15 


1 


ff 




17 


1 


»» 


— 


25 


1 


»f 


— 



saiiK^ Transactions of the Royal Academy of Medicine 
in Irclimd ;is will Ihis Report. Consequently, T need only 
say here Mint I ()|)(i;ited on two cases in which 1 definitely 
reco«,Miised thr()nd)osis, and that hoth patients recovered. 
FiH'ther. that I oju'iated on a third ease heeanse T thon<:ht 
throiid)()sis was hkely to he present, althon^^h T ronld not 
liiid any evidence of it hy hi-nianiial examination. I 
found !i() further evidence of lhroinl)(»sis iifter opening' the 
ahdomeii. and I did a hysterectomy, as 1 lliou;:ht the in- 
fection nnist certainly he coming from the uterus. Jn this 



By 1)r. Henry Jellett, Master. 16 

case, however, the patient was in no way benelited, and 
died later of pyaemia. 

There were several cases of special interest, during the 
year, to which I should now like briefly to refer. 

Case I. — Large fibro-myoina coinpUcatiny pregnancy. — 
M. E., aged forty-five, first pregnancy, was sent to us from 
the country on the 6th of March. On admission her tem- 
perature was F. 102^, her pulse 140. She had evidently 
been in labour for some time, and the child was dead. On 
examination, a large tumour was found which completely 
occupied the lower half of the abdomen, and above which lay 
the pregnant uterus. The cervix could not be reached 
through the vagina. It was obviously impossible to make 
any attempt at delivering through the vagina, and conse- 
quently the abdomen was opened, and the uterus was 
brought out on to the abdominal wall and removed. It con- 
sisted of a very large myoma growing from the lower part of 
the uterus, whose cavity lay wholly above the tumour. The 
patient's condition improved for a couple of days — her pulse 
and temperature both dropping. The pulse, however, rose 
on the third day to 135, and persisted about that level until 
her death from sepsis four days later. The woman was 
obviously septic at the time of admission, and she had been 
subjected to a considerable number of examinations. 

Case II. — Ante-partiini Eclampsia with fatal results. — 
E. P., aged thirty-two, was admitted to the Hospital on the 
22nd of July. She was in her second pregnancy, and about 
six and a half months pregnant. Her previous pregnancy 
had ended as an abortion. On admission it was stated that 
she had had one fit, and another fit occurred immediately 
afterwards. The usual treatment was adopted, the stomach 
and rectum were washed out with sodium bicarbonate solution, 
and morphine was given. The urine was examined and found 
to become almost solid on boiling. The convulsions con- 
tinued at hourly intervals, and after the fourth the stomach 
and rectum were again washed out. A gi'ain of morphine in 
all was given in quarter-grain doses. Then, as the respira- 
tion had slowed to nine in the minute, the morphine was 
stopped. Tjater in the day four more convulsions occurred, 
all of which were accompanied by marked cyanosis, and in 
each the throat had to be well cleared in order to permit 



16 Clinical Ucpurt uj the llutunda lloapital. 

respiration. Sub-maniniary infusion and iX)ulticeB to the 
loins were tried. Although a considerable dose of mist, 
sennai co. was left in the rectum and in the stomach, only 
one slight action of the bowels could be produced by enema. 
The patient remained unconscious all day, and in the even- 
ing she died almost immediately after a convulsion. 
Artificial respiration, administration of oxygen, and clearing 
of the throat were tried without avail. 

Case 111. — Puerperal Eclampsia, with fatal results. — 
A. R., aged thirty-three, was admitted to the Hospital on 
the 8th of July. She was in her second i)reguancy, and at 
full term. She was delivered normally twelve hours later. 
Nine hours after confinement she had a fit, lasting eight 
minutes, and one hour later another fit occurred. Between 
these fits she was given a dose of mist, sennas co., which 
she vomited. From the second convulsion until death 
tile patient was unconscious. After the second convul- 
sion the stomach and rectum were washed out, and a 
purgative was left in both. At that time twenty-six ounces 
of urine were withdrawn from the bladder. Morphine was 
given in the usual manner — a grain in all being given. Six 
convulsions occurred during the night. The catheter was 
passed at regular intervals, and a fair quantity of urine — 
twenty-six ounces in all — was drawn off. The fits ceased 
the next morning, fourteen hours after the occurrence 
of the first. The i)atient, however, did not regain con- 
sciousness. Her pulse was very rapid, and digitalin in one- 
hundredth of a grain doses was given every three hours. 
louring the (hiy fomentations were apphed to the kidneys, 
antl tile patient was })laced in a hot i)ack, as only two 
ounces of urine were passed in all. Two pints of bicarbonate 
of sodium solution were injected under the breasts. The urine 
was quite black in colour, and contained granular casts in 
large (pianlities, a few epitlu'lial casts, red blood corpuscles, 
and mmu'rous bacteria. In the afternoon she was seen by 
Sir William Sniyly and Dr. Purefoy, who happened to be in 
the Hospital, and on their advice, as a last chance, venesec- 
tion was })erformed, and half a pint of blood was drawn 
off. The ])atient's breathing was very stertorous and 
lal)oured, her temi)erature was F. 104°, and she gradually 
sank, and died about fifty- three hours after the first attack, 
never having regained consciousness. 



By Dr. Henry Jellett, Master. 17 

I think these two cases show the futiHty of con- 
sidering that any treatment of eclampsia will be uni- 
formly successful. Here was a patient who came under 
treatment at a suitable time — namely, before any attacks 
had occurred, and w^hile she was still passing a sufficient 
quantity of urine — and yet, from the second convulsion 
on, her condition was practically hopeless. At the post 
mortem examination the liver showed fatty degeneration 
with haemorrhages on its surface. The uterus and 
appendages were normal, the spleen was large and hard 
and dark in colour, and the kidneys were granular. 

Case IV.- — Pregnancy ivith Malignant Ovarian Tumour 
and Ccesarean Section. — K. D., aged twenty-four, was ad- 
mitted to the Hospital on the 6th of May. She was pregnant 
for the first time and at full term. The patient stated that 
she had been in bed for the past five months, and that a 
doctor had been attending her for two months, during which 
time she complained of pain in the left side. The patient 
had also been in the Gynaecological Wards of the Kotunda in 
January, 1911, when I performed a right ovariotomy for 
her, and resected the left ovary. The ovariotomy was done 
for an ovarian cyst, and this cyst was subsequently reported 
by Dr. Rowlette to be papillomatous. From the subsequent 
history of the case it is obvious to me that I should 
have re-opened the abdomen and removed the remaining 
ovary, more particularly as there was a small cyst in it at 
the time of operation, which I had then resected. How- 
ever, I did not do so. On examination of the patient in hos- 
pital we found the abdomen greatly distended, with large 
veins running over the surface. The foetus could be felt in 
the uterus on the right side, while the left side was occupied 
by a semi-solid, semi-cystic tumour. I made a diagnosis of 
a malignant ovarian tumour associated with pregnancy, and 
as the tumour obviously obstructed the passage of the child 
into the pelvis, I decided at once to do a Cesarean section, 
and at the same time, if possible, to remove the tumour. 
Accordingly, on the 9th of May, I opened the abdomen in 
the middle line. There was a small amount of free fluid in 
the peritoneal cavity. The tumour was very fixed, and, in 
order to get access to it, I made a lateral incision across the 



18 Clinical Report of the Rotunda Hospital. 

rectus muscle on the left side at the level of the um- 
bilicus. The ovarian tumour was the size of a full term 
uterus, and contained a jelly-like substance. The base of 
the tumour was clamped, and the tumour was removed. I 
then quickly opened the uterus at the middle line, having 
got it into a more favourable position in the abdomen, and 
removed the fcetus. There was some haemorrhage from 
adhesions which had formed between the tumour and the 
intestine, but this was easily controlled. The patient made 
an entirely satisfactory recovery, and I understand that at 
the present time she is still doing well. The second tumour 
was also papillomatous in character. 

Case V. — Contracted Pelvis, dead and decomposing 
Ffctiis, Ccesarcan Section followed by Hysterectomy. — 
K. H., aged twenty-three, was admitted to the Hospital on 
the 9th of June. She was in her first pregnancy, and at 
full term. On admission the patient's temperature was 
F. 100.2®, and her pulse 140. She came from the North 
Dublin Union, and she gave a history of having been in 
labour for seven hours. This history was, however, pro- 
bably wrong, and it was ^y j likely that the patient had 
been in labour for several ciu-ys. However this may be, the 
membranes had ruptured five days before admission, and 
the patient stated that during this period she had not 
felt fcetal movements. On examination she was found 
to be a rachitic dwarf, the uterus was very prominent, the 
presenting part not fixed, and the uterine muscles were 
tightly contracted down on the fcptus. On vaginal exami- 
nation, the OS was found high up, and admitted one finger, 
the membranes were ruptured, and the presenting part could 
not be distinctly felt. The true conjugate was so narrow 
that there was no necessity of measuring it, as it was 
obviously imi)ossible to effect delivery through it. It was 
decided to perform Cesarean section, and the only question 
was whether this should be carried out in the classical 
manner or whether the so-called " extra-peritoneal " 
operation should bo performed. I decided in favour of the 
former. Accordingly, the abdomen was opened in the middle 
line, and the uterus was brought right outside and isolated by 
wipes and sterilised towels from the rest of the abdomen. 
An opening was then made near the fundus, the uterus hang- 



Pole Ligation for HijiJerthyroidisDi. 19 

ing well over to one side, and the child was removed. The 
latter was dead and decomposing. The inside of the uterus 
was quite green. In consequence of the decomposition, 
hysterectomy was carried out. The patient stood the 
operation well, and made an entirely satisfactory con- 
valescence. It is customary to consider the green staining 
of the inside of the uterus in this type of case as the result 
of decomposition. I am bound to say that I question this, 
and that I think the green staining is more likely to be the 
result of meconium than of decomposition. I am not, 
however, able to bring forward any positive evidence in 
support of this view. 

{To be continued.) 



Art. II. — Pole Ligation for Hyperthyroidism:^ By 
William Pearson, F.K.C.S.I. ; Assistant Surgeon, 
Adelaide Hospital, Dublin. 

There is probably no disease which has been credited 
with a greater number of causes and treatments than 
the clinical syndrome which i^ ^^ariously termed Graves's 
disease, Basedow's disease, or fiiore generally exophthal- 
mic goitre. 

In 1886 Moebius propounded the theory of thyroid 
activity as the cause of the symptoms, and it is now 
generally agreed that hyperactivity of the gland and ex- 
cessive absorption of its secretion are constant accompani- 
ments of the condition. The essential change in the 
gland is one of parenchymatous hypertrophy. This 
change has been described by many observers, but the 
investigations of Wilson and Plummer, of the Mayo 
Clinic, have clearly demonstrated the constant and close 
relationship between the clinical picture as represented 
by the patient and the microscopic findings in the thyroid 
gland. From a study of the pathology of the glands from 
294 cases of exophthalmic goitre. Dr. L. B. Wilson (1) 
was able to conjecture accurately the stage and severity 
of the disease, without any previous knowledge of the 

» Read in the Section of Surgery in the Royal Academy of Medicine in 
Ireland on Friday, May 9, 191B. 



20 Pole Ligation for Hyperthyroidism. 

clinical facts in over 80 per cent, of the cases. Workint:^ 
on the cHnical side, Dr. li. 8. Plummer (2) has been able 
to foretell the degree of glandular hyper] )lasia present in 
1)5 [)er cent, of cases, from a study of the clinical findings 
only, in over 1,000 exophthalmic cases. In view of these 
results it is desirable to abandon the older nomenclature 
and to substitute one of the newer terms — thyrotoxicosis 
(Kocher) or hyperthyroidism (C. H. Mayo). 

Unfortunately, in spite of many theories, we have not 
yet determined what is the stimulus which excites this 
glandular hyperplasia, and consequently at the present 
time rational treatment is directed towards diminishing 
the hypersecretion and the excessive absorption from the 
gland. In the vast majority of cases this is effected with 
greatest certainty by surgical measures. Amongst the 
more recent methods employed for this pur|)ose are those 
which reduce its blood-supply by ligation of vessels — 
usually the superior thyroid vessels on one or both sides. 
However, as it is probable that the secretion of the thyroid 
is largely absorbed through the lynijihatics it seems wiser 
to produce lymphatic obstruction at the same time. 

To render the operation efticient, an accurate knowledge 
of the vascular and lymphatic circulations of the gland is 
essential : — 

The thyroid gland lies in the visceral compartment of 
the neck, between the pretracheal and prevertebral layers 
of the dee]) cervical fascia, and j^ossesses a very rich blood - 
su])})ly. Each lateral lobe is su})jilied by two arteries, 
while an occasional fifth vessel {tJnjroidca imd) runs u])- 
wards from the innominate in front of the trachea to 
reach the isthmus. The superior thyroid artery arises 
from the anterior asj)ect of the external carotid at the 
level of the thyro-hyoid membrane. It runs downwards 
and forwards under cover of the omohyoid, sterno-hyoid, 
and sterno-thyroid nmscles to reach the up])er |)ole of the 
lateral lobe, above which it divides into three main 
branches — i^osterior, external, and internal ; occasionally 
an anterior branch is also [)resent. The inferior thyroid 



By Mr. W. Pearson. 21 

artery springs from the thyroid axis of the first part of 
the subclavian vessel. It is deeply situated in the neck, 
running upwards and then inwards behind the carotid 
sheath to reach the deep aspect of the basal part of the 
lateral lobe, where it is closely related to the recurrent 
laryngeal nerve. It divides into two main branches — 
posterior and basal. The veins on each side form three 
groups : — The superior thyroid vein leaves the gland at 
its upper pole in close company with the corresponding 
artery ; it crosses the common carotid artery and termi- 
nates in the internal jugular vein. The inferior thyroid 
vein descends in front of the trachea, and frequently 
unites with its fellow of the opposite side to form a 
common trunk which opens into the left innominate vein. 
The middle thyroid vein (better termed the lateral group 
of veins, as there are frequently two or three separate 
trunks) leaves the lateral aspect of each lobe, crosses the 
common carotid artery and joins the internal jugular 
vein. The superior veins alone are closely associated with 
the arteries. 

The main branches of the blood-vessels ramify on the 
surface of the gland in the true capsule, and anastomose 
freely with one another. This anastomosis is freer 
between the various vessels of one side than between the 
vessels of opposite sides, though there is usually a well 
marked cross-branch of communication present on the 
upper border of the isthmus. 

The Lymphatics (3) form a network within the actual 
thickness of the capsule. From this network run ascend- 
ing and descending trunks. The ascending trunks form 
median and lateral groups. The median trunks pass from 
the upper border of the isthmus to reach the prelaryngeal 
gland ; the lateral accompany the superior thyroid vessels 
and terminate in the glands placed at the bifurcation of 
the carotid artery. The descending trunks also form 
median and lateral groups : the median reach the pre- 
tracheal glands ; the lateral pass to the glands of the re- 
current chain. 



22 Pole Lirfntion for Hyprrfhyroidifiw. 

Ligation may be 2)erformed on the vessels or on the 
gland itself ; on one or on both sides. The superior pole 
is almost invariably chosen, as being most readily ex- 
]iosed. Ligation of vessels was first performed by Wolfler, 
and is the method advocated by Mayo (4), who, in 1909, 
recorded his exjxniences in 225 cases. A few points in 
technique are important. Firstly, the ligature must be 
applied below the point where the vessels divide into 
their main branches, close to the upper pole of the gland ; 
if it is applied above this a reversal of the circulation may 
occur, owing to the free anastomosis — this was observed 
by Mayo in one of his cases, which necessitated a second 
operation. Secondly, \hv veins should be included to 
obstruct venous return as well as arterial flow. Thirdly, 
the vessels should not l)e isolated from their fascial invest- 
ment, but the ligature should be passed round the latter 
so as to include lym|)hatics and nerve filaments. Fourthly, 
the ligature should be non-absorbable, either of silk, linen 
thread, or even fine silver wire, to ensure ]iermanent 
occlusion. 

The techni(jue of " pole ligation," in which the ligatures 
are placed round the upj)er horns of the gland and not 
directly on the vessels, has been well described by 
.lacobson (5). I'loui anatomical considerations it will be 
Mppaiciil tlint llic capsule of the thyroid must be included 
ill tli<' ligature if the blood and lymph flow is to be effec- 
tively checked. 

1 regret that in bringing this subject before you T have 
only one case to record so far; but no previous commimi- 
cation on it has been made before the Section, and, so far 
as I know, this is the first case treated by this method in 
Dublin. These reasons must be my excuse*. 

Cask. — The patient, M. .7. J., feinaU', unmarried, aged 
thirty-three years, was admitted to the Adelaide Hospital 
on May 11th, 1012, complaining of persistent vomiting for 
three weeks past, unaffeeted by diet or drugs. 

Up to this she had latterly been in good health, but four 
years ])reviously a laj)arot<>niy had been performed for 



By Mr. W. Pearson. 23 

" stomach trouble." The nature of this operation, how- 
ever could not be determined. 

On examination, the patient was extremely nervous, thin, 
and wasted; her face was flushed, and she looked much 
older than her stated age. There was visible pulsation and 
well-marked thrill in the arteries of the neck and abdominal 
aorta; the pulse, as she lay in bed was 150 to the minute, 
regular, small, and compressible; the heart sounds were 
lacking in tone, but there was no evident dilatation. The 
blood-pressure was 100 m.m. in the right brachial artery. 
She suffered greatly from palpitations, and at times from 
breathlessness. She sweated freely; but her chief trouble 
was the persistent vomiting, which was so severe on ad- 
mission that even sips of water were rejected. Several 
attacks of diarrhoea had also occurred. There were well- 
marked muscular tremor and weakness. There was no 
clinical enlargement of the thyroid. With the exception of 
Moebius' sign and a very doubtful exophthalmos, all the 
classical eye symptoms were present. The urine was 
normal. The temperature varied between 98.4° and 100°. 

This was clearly a case of acute severe hyperthyroidism, 
in which the gastric symptoms predominated to such an 
extent that she had been sent to hospital as a " gastric 
case " — a diagnosis readily acceptable in view of her 
previous laparotomy. 

It is worth noting that the two signs — exophthalmos 
and enlargement of the thyroid — which have given to the 
disease its more common name — exophthalmic goitre — 
were both absent. These atypical cases, often termed 
pseiido or fruste, have been very frequently recorded, and 
emphasise the desirability of discarding this nomenclature. 

Owing to the patient's serious condition immediate sur- 
gical intervention was undesirable, and accordingly for two 
weeks preparatory measures were adopted, as advocated by 
Mayo, to check the vomiting and to improve the oonrlition 
of the heart. These consisted in absolute rest, hypodermic 
injections of digitaline and atropine, and the application of 
icebags over the heart. For the first few days rectal injec- 
tions of saline and nutrient enemata were given ; later on 



24 Pole Liffniion for IIupcrtlujroKJism. 

fluids in small quantities were given by the mouth until the 
patient was able to take milk and light diet freely. 

On the 28th of May I performed bilateral pole-ligation. 
At this time the pulse varied from 100 to 120, the tempera- 
ture had settled to normal, and vomiting and diarrhoea had 
ceased. The patient's weight before operation was 6st. 4lbs. 

The teehnicpie I adopted was a combination of Mayo's 
ligation of the superior thyroid vessels and " pole ligation " 
as described by Jacobson : — A transverse collar incision of 
two and a half inches was made over the thyroid cartilage, 
dividing the skin, platysma, and deep fascia in the line of 
one of the natural skin folds. At each end of the incision, 
by retraction of the tissues, the angle between the sterno- 
mastoid and anterior belly of the omohyoid muscles was 
easily defined, and by division of the pretracheal layer of 
fascia at these points the upper poles of the thyroid with 
their vascular pedicles were exposed. A double ligature of 
silk was passed round them on each side, care being taken to 
include the capsuK- of the gland and the fascial tissue sur- 
rounding the vessels in which the lateral superior lymph 
channels run. The upper ligature was tied on the vessels, 
close down to tlie superior i)ole, below their division into 
their main branches ; the lower was placed round the gland 
substance itself about half an inch lower down. This 
method appi'ared to offer the best j)rospect of permanently 
checking the vascular and lymphatic flow, while if partial 
thyroidectomy became necessary at a later date the up])er 
pole could bt' freed witlionl the application of a fresh 
ligature. The tissues were not divided between the liga- 
tures, but there would seem to be no objection to this 
being done at the same time. The fascia and platysma were 
closed with fine catgut, and the skin -with a " shotted " 
subcuticular suture as described by nie (>lsewhere (0). At 
operation the thyroid was considerably larger than clinical 
observation had suggested. 

Within a few days the patient ex])ressed herself as feeling 
niucli better, and st-eady improvement was noted in all her 
symptoms. There was no recurrence of vomiting or 
diarrhd-a; the nervousness, palpitations, and nniscular 
tremor were greatly diminished; the eye symptoms sub- 
sided, and her temperature remained normal, save that 
about once a week the evening record was 00° — during the 



By Mr. W. Pearson. 25 

last fortnight she remained in hospital it remained sub- 
normal. The pulse-rate did not improve so rapidly, but it 
gradually fell to an average of 90 per minute. The gain in 
weight was considerable — in the first week after operation 
there was an increase of 31bs., in the second week 51bs., in 
the third week 3|lbs., and when she left hospital on the 
7th of August — two months and ten days after operation — 
she weighed 7st 71bs., an increase of 171bs. 

After operation no special treatment was adopted, as I 
was anxious to test the effects of the operation per fie, so 
that I think we must credit it for having produced such a 
marked and rapid improvement in this case. 

Recent communication with the patient has elicited the 
reply that she feels so well that she does not wish to return 
for further treatment. 

It is, of course, impossible to draw any general conclu- 
sions from one case, but I would direct your attention to 
three questions of practical importance : — (1) In what 
cases should ligation be performed? (2) What are the 
results of this treatment ? (3) What is the operative risk ? 
Lastly, I will allude to one or two points in technique 
and after-treatment. 

(1) The cases which are suited to treatment by ligation 
may be divided into two groups, after Mayo (4) : — 

(a) Mild and' early cases which fail to respond to 

medical treatment, yet which do not warrant 

the more serious surgical intervention of partial 

thyroidectomy. 

(h) x\cute severe cases, especially in the presence of 

emaciation and cardiac dilatation. Here ligation 

finds its greatest field of usefulness, being a much 

safer surgical procedure than extirpation while 

toxsemia is severe. 

Perhaps we may include others if we say that all cases 

in which clinical enlargement of the thyroid is slight or 

absent should be submitted to ligation, rather than to 

partial thyroidectomy in the first instance. It is likewise 

apparent that cases with even mild thyrotoxic symptoms 



26 Pole Liqation for Hyprrthyroidifi))!. 

are best treated by ablation if there is marked enlargement 
of the gland. 

(2) The results of ligation are most encouraging. Tn 
many of the milder cases a cure is effected in a few weeks. 
In the severe cases marked improvement usually occurs, 
so that more radical o|)erative measures may be attem])ted 
subsequently with far less surgical risk. Indeed, in these 
cases it becomes in many instances a life-saving pro- 
cedure. 

In 1009 Mavo (4) was able to collect records of 138 
cases in which ligation had been performed sufficiently 
long to make their report of value. Excluding cases in 
which thyroidectomy had also been j^erformed, and a few 
doiil)tfnl cases, the results were : — 

Shght improvement - - 9 cases. 

Great improvement - - 44 ,, 

Very marked improvement - 11 

Absohitely well - - - 4 ,, 

The average gain in weight in these cases was 21 lbs. in 
four months. 

Since then he has l)een doing more and more ligations 
each year, the great majority in severe cases as a prelimi- 
nary to thyroidectomy, ligating now usually only on one 
side, and lor the purpose of this ])aper I wrote to him to 
inquire particiilarly as to the permanency of the results. 
In his reply he says : — " Most of the ligated cases will re- 
lapse within from one to three years, although their con- 
dition will not be so bad as before the ligation." 

(ii) In regard to risk, ] think we may safely say that 
the o]ieration per se should have a mortality of nil. It is 
the desperate condition of tlH> patient which determines 
a fatal issue, and even the worst cases will usually be 
treated successfully it we employ suitable ]ire-operative 
treatment. 

"St. Mary's Hospital Keports " for the past three 
years show 184 cases of double ligation, with 4 deaths, a 
mortality of 8 per cent. ; and 581 cases of single ligation, 
with 9 deaths, a mortality ol 1.7 jur cent. ' 



By Mr. W. Pearson. 27 

The question of anaesthesia in these cases is one of im- 
portance. Personally, I prefer general to local anaesthesia 
in goitre operations. My chief objection to the latter is 
the free capillary haemorrhage which is apt to follow when 
the vaso-constrictor effects have passed off. The few cases 
in which I have employed it required a change of 
dressings the same evening, whereas cases operated on 
under general anaesthesia are left undisturbed till the 
following day. The best general anaesthetic is undoubt- 
edly " open ether," the popularity of which is every day 
increasing. In goitre operations it is preceded by an intra- 
muscular injection of omnopon, gr. J — §, scopolamine, 
gr. -YSo, into the left deltoid one hour previous to operation. 
With these is combined atropine, gr. yJo, as recommended 
by Mayo, which keeps the air-passages clear of mucus, 
and so preserves a free air- way for the patient. In the 
very worst cases only will it be necessary to resort to local 
anaesthesia. 

Gentle manipulation I regard as a matter of prime im- 
portance in operating on thyrotoxic cases. This will be 
gained by an accurate knowledge of the connections and 
fascial relations of the gland ; by good exposure through 
an adequate incision ; by careful methodical dissection ; 
and by avoidance of all unnecessary manipulation and 
massaging of the gland itself. I believe that the severity 
of the post-operative reaction in goitre cases is largely 
determined by the amount of handling to which the 
gland is subjected, and which determines a copious and 
rapid liberation of its secretion into the system. To an 
organism already overburdened, a further addition of the 
toxin is naturally a serious matter. 

In regard to immediate after-treatment, the most im- 
portant point is the administration of large quantities of 
fluid : during the first twenty-four hours rectal salines will 
be most efficient, and one pint should be administered 
every three or four hours. 

My best thanks are due to Dr. C. H. Mayo for supply- 
ing me with information as to his latest observations on 



28 Foot and Mouth Disrafir in Man. 

this subject ; to my senior colleat^ue, Mr. L. G. Giinn, for 
assistance at the operation ; and to Professor A. F. Dixon 
for material from the Anatomical Department in Trinity 
College for verifying the anatomical data. 

REFERENrp:S. 

(1) Wilson. The Amorican Journal of the Medical Sciences, Dec, 1908. 

(2) PluninuT. " Relation of the Syniptonioloiry and Pathology to opera- 
tive Mortality in Exophthalmic Goitre." Read before the Section on Prac- 
tice of the Artierican Medical Association. June, 1911. 

(3) Poirier. 'I'h(! Lymphatics. English Translation by C. H. Leaf. P. 
289. 

(4) Mayo, (.'. H. Annals of Surgery. Dec, 1909 

(5) .Jacol)son. Surgery, Gynitcology and Obstetrics. Nov., 1910. 

(6) Pearson, Wm. Medical Press and Circular. April 30, 1913. 



Art. tit. — Foot and Mouth Disease in Man: Aphthous 
Fever. '^ By C. M. O'Brtrn, M.D., Tj.R.C.P.L; 
I^hysician to, and Lecturer in Dermatology at, City 
Hospital for l^i.seases of the Skin and Cancer, Dublin ; 
Physician in sole charge of Finsen Light Department ; 
Honorary Member of J^ermatological Society, France; 
Fellow of the Medical Society, Tjondon. 

Amidst the grey routine of my daily grind, it has ever 
been \\\\ wont to bring under notice of the profession 
things within my [)uiview which appeared to nu' ol 
interest to it. 

I am happy in the belief that my hund)le efTorts in this 
respect have been fully justified by reason of the full, free, 
and unfettered discussion which they invoked on each 
occasion. Besides the novelty of recording a cutaneous 
iilTection which falls to the lot of few to meet with, aiul 
which fell to my lot through the friendly interference of 
the fickle J^'ates, there is to me in the j^resent instance 
an additional incentive — tantamount to j)ublic duty — to 
record this case owing to the fact that the subject of my 
present paper has already fornu^d the basis of a discussion 
in Parliament a few weeks since. In the course of that 

• Re.id bffnre tlie Section of iMedicine in the Royal Academy of 
Medicine in Ireland, on Friday, January 31, 1913. 



By Dr. C. M. O'Brien. 29 

discussion certain statements were made and widely circu- 
lated through the medium of the public Press, which, had 
they been left unanswered and uncorrected by me at the 
time, would have undoubtedly produced upon the public 
mind an impression not only prejudicial to the progress of 
scientific Medicine generally, but would probably have 
robbed medical certification in this country of half its 
worth and all its sanctity. 

The epidemic of foot and mouth disease in cattle which 
swept this land from shore to shore in 1912, and which 
created such financial havoc and black despair amongst a 
large portion of our population, enables me thus to relate 
my first and only experience of this malady as it affects 
mankind. Although the statement at first sight may 
seem somewhat paradoxical, it is nevertheless true to say 
that perhaps the most interesting feature associated with 
foot and mouth disease in man is the paucity of its bacteri- 
ological literature, and in search of this literature the 
point above all others which impressed me most is that in 
an age like jthe present, of modernism and medical re- 
search, how little, after all, we are helped towards a 
positive diagnosis in this as in many other cutaneous 
affections, by other than those senses which are the 
heritage common to all, and which served xEsculapius in 
such very good need long before the death of Grecian 
priest-craft, and even the dawn of medical history. 

It would appear that the first reliable record of foot 
and mouth disease in man was made in 1695 by Valentin, 
of Hesse. In 1834 three Continental veterinary sur- 
geons — named Hertwig, Mann, and Villain — while in- 
vestigating the disease in cattle, wished to know if it were 
communicable to human beings, and, as an experiment, 
voluntarily drank a quart each of the milk from a cow 
suffering from the infection. On the second day Hertwig 
suffered from fever, headache, and itching of the hands 
and fingers. Five days later vesicles appeared on the 
fingers, hands, tongue, cheek, and lips. Mann and 
Villain developed vesicles on the buccal mucosa. 



30 



Foot and Mouth Diaca.^c in Mau, 



In 1896, (luring an outbreak of foot and mouth disease 
m Berlin, several instances of its spread to man were re- 
ported and unhesitatingly confirmed by Virchow after an 
investigation, which, for minuteness and completeness of 
detail, could not fail to influence the most sceptical. 

A child, fed on milk of diseased cows, had chill and 
lever with gastric disturbances, and later an eruption of 
vesicles on lips, tongue, and the clefts between fingers 
and toes. A shepherd infected himself bv holdin- in^'his 
mouth the knife with which hr had i.aml the diseased 
feet of sheep. 

In 1883, Sir Charles Cameron, C.B., M.D Chief 
Medical (Jfficer of Health for Dublin, dm-ing the epidemic 
HI this country of foot and mouth disease in cattle, had 
under his care a man who contracted the disease thmu^di 
direct inoculation. Uash on both feet and hands, which 
developed into vesicles later. The throat, lips, and 
mucous membranes had also distinct vesicles. About the 
«ame time Professor Sir Clifford Allbutt saw the buccal 
eruption in three children during an epidemic of foot and 
mouth disease in Yorkshire. Cases of infection through 
butter made from infected milk are on record, of which 
the following is a good illustration. 

On the 18th of November, 181)0, a veterinary student in 
Berlin had been sent by his brother-in-law a packet 
<)«■ In'sh butter, made from the milk of cows suffering 
from foot and mouth disease. On th(> following day he 
ate some of the butter for the first time. During th(> next 
night he was feverish, and on the morning of the '2()ih he 
f''""i.l his l,,w«M- hp ,vd. swollen, and covered with 
vesicles which urre itchy. I.ater the vesicles spread to 
Ihe buccal mucosa. Sinularly, Schneider gives cases 
caused by infectcnl cheese, and Friedberger cases from 
virulent buttermilk. 

Instances of infection by inoculation have been ob- 
served, of which the following is perhaps the most in- 
teresting and instructive. As it presents many points in 
its clinical history which resemble the subject of my paper, 



By Dr. C. M. O'Brien. 31 

I am inclined to give full details as they appear in The 
Veterinarian, 1831. The patient was a farmer who had 
injured one of his fingers in drenching a cow suffering 
from foot and mouth disease. The wound took on an 
unhealthy action, and after some days he w^as taken ill 
with a cold, shivering fit. This occurred in the evening, 
and by the following morning the cold fit had been 
succeeded by fever. Twenty-four hours later vesicles 
formed on the gums and tongue. 

Instances of transmission of the virus of foot and mouth 
disease from the lower animals to man, both by inoculation 
and otherwise, could be further multiplied if time allowed 
or necessity demanded, but I feel convinced there are 
few, if any, serious thinkers amongst us to-day who en- 
tertain much doubt upon this particular point. For 
myself, I candidly own that if at any time in my career 
I entertained the least doubt as to the transmission of 
foot and mouth disease from the lower animals to man that 
doubt is dissipated for all time by the undermentioned 
case, notes of which, tout ensemble, constitute a clinical 
picture not easily counterfeited. 

Case. — G. J. B. consulted me in my study on August 
12th, 1912. lu the cause of science he now permits me to 
publish the following, viz. : — Veterinary Inspector, Irish 
Agricultural Department, M.E.C.V.S., aged thirty-five; 
married. Family history unimportant. Personal history. — 
Of temperate habits; had scarlet fever at the age of ten, 
otherwise he always enjoyed very good health. On July 
9th, 1912, while in discharge of his duty as veterinary in- 
spector to the Irish Agricultural Department, he got bitten 
by a sheep on index finger of left hand while examining the 
beast for suspected foot and mouth disease on an infected 
farm at Swords, County Dublin. Having applied an anti- 
septic dressing to the wounded finger, and used a thin 
rubber finger-stall as an additional protection, he con- 
tinued his daily examinations without intermission, not 
anticipating any serious results. About three weeks later 
the wound appeared to form an abscess, to which the patient 
applied an abscess knife, with every antiseptic precaution. 



32 Foot and Mouth Disease in Man. 

There was no pus found, the local pain and tenderness con- 
tinued, and tlie wound did not heal. 

As his colleagues of the Department were all fully occu- 
pied coping with the outbreak, and as his services as a 
result were badly needed, he declined to lie up. On the 
morning of the 11th of August redness and swelling 
ai)p('ared on both hands and fingers, accompanied by great 
itching of the parts, with a few small raised white swellings, 
like little lumps under the skin, especially around the nails. 
By night time, slight itching of the upper part of both feet, 
accompanied by a sensation of pin-pricks in the soles, which 
became more prominent when walking. He also complained 
of feeling out of sorts for a day or two previously. Bowels 
confined, slight headache, with loss of appetite, and some 
colicky pains. Having received the foregoing jiarticulars, 
I proceeded to examine the patient, a thick, well set up 
man, about 5 feet 8 inches in height, of exceptionally good 
muscular development, rather younger in a})pearance than 
stated age. The fingers and dorsal aspect of both hands 
were markedly swollen, and covered over with a dull, 
reddish, raised rash, which stopped short somewhat 
abruptly an inch above the wrists. Examining closely, im- 
mature vesicles were observed here and there over surface 
of rash, more es])ecially in the clefts between the fingers 
and immediately above and around the finger nails. A 
sensation of great itching over this region was complained 
of. Oil removing the dressings of injured finger the edge 
of wound gaped, and, although no pus exuded on pressure, 
nevertheless it exhibited few signs of healing. There was 
no perceptible involvement of the lymphatic glands. Ex- 
amination of throat exhibited congestion of fauces, with 
some vesicles. Vesicles were also observable on the inside 
of lips, gums, and side of tongue. The latter aj)i)(^ared 
swollen and tender. Mastication, deglutition, and talking 
were painful. The saliva was increased, and the voice less 
distinct than noinial. The temperature registered in (he 
mouth was just 100^, and never exceeded this during the 
entire illness. The kidney secretion was high-eokMU'ed, 
acid reaction, specific gravity 1020; sugar and albumen 
absent. The heart, lungs, and other organs appeared quite 
normal. The ])atient complained of increasing itchiness 
over dorsal aspect of both feet, and, excepting a slight red- 



By Dr. C. M. O^Brien. 38 

ness above and inside both knees, no rash was perceptible 
on lower extremities at this stage. But a sensation of 
sharp pin-pricks over soles of both feet, rendering locomo- 
tion troublesome. Knee-jerks normal. iVnkle clonus 
present 

Condition of patient on August 13th, 9 30 a.m. — Except- 
ing the slight rash on inside of thighs, which has now en- 
tirely disappeared, all the previous symptoms are more pro- 
nounced. Vesicles, fully formed, about the size of peas, on 
lips, tongue, and fauces. Saliva trickles from the mouth. 
Swallowing and speaking more painful, while, in addition, 
the dorsal aspect of both feet presents a rash precisely 
similar to that previously described on hands; the rash ex- 
tending to ankles, stopping short at this point on both feet. 
Vesicles in process of formation are also observable between 
the clefts of toes and around the toe nails. Temperature 
99.50. 

The same evening the patient was seen by Sir Charles 
Cameron, C.B., M.D., Principal Public Health Officer for 
Dublin, in consultation with me. Vesicles were present on 
throat, side of tongue, fauces, and inside of lips. 

The contents of vesicles, which in the early stage were 
clear, had now become somewhat turbid. In some instances 
the vesicles on mucous membrane had coalesced and 
ruptured, leaving small, shallow ulcers, with dark red base. 
Sir Charles Cameron, after a careful examination of the 
patient, said the case presented symptoms precisely 
similar to a previous case of foot and mouth disease in man 
which he met with in the epidemic of 1883. Saliva con- 
tinued to trickle from the mouth, and the painful swallowing 
permitted now of liquid nourishment only. The progress 
of the case continued without much alteration, the tem- 
perature remaining between 99° and 100°. 

On August 15th the rash on the hands began to fade, 
the vesicles ruptured, and further vesication ceased ; but the 
soreness of throat and free flow of saliva continued for 
some days. On August 17th Sir Thomas Myles, F.R.C.S.I., 
saw the patient in consultation with Sir Charles Cameron, 
M.D., and myself. This was the seventh day of the illness. 
Fresh vesicles had by this time ceased to appear, and only 
the remains of previous ones were in evidence on throat, 
lips, and on both feet. These, with the copious saliva and 

O 



34 Foot and Mouth Disease in Man. 

difficult deglutition, were the only data to guide us now. 
Sir Thomas Myles examined the patient's feet, throat, and 
hands very minutely. He also examined the wounded 
finger. He said that as a result of his examination, from 
all he had seen, and from the history given by the patient, 
he believed the case to be one of foot and mouth disease. 
But seeing it on the seventh day after the acute attack, it 
was impossible for him at that stage of the illness to jxjsi- 
tively confirm the diagnosis. 

Thus briefly stated is the clinical history of my case, 
and all hough 1 claim no triumph over any one of the many 
mysteries which surround its bacteriology, nevertheless 
the picture painted is true to life, which fact may con- 
done any lack of originality in technique, or seeming dis- 
regard for the due proportion of light and bhade so essen- 
tial to the masterpiece. 

It is agreed that neither sex nor age, race nor class, 
affords exemption from f(X)t and mouth disease, ll is also 
ngnHMJ, thanks to the research and logical deductions of 
Loltler, that the bacillus, virus, or whatever else it nuiy 
be termed, which causes foot and mouth disease, is sufli- 
ciently small to allow of its passage through the tiiu'st 
poi'cd [)orcelain filter, and so elude tlu> most powerful 
microscope. jjike tin* biblical grain of nuistard seed, 
liiis virus, or bacillus, gives rise to results in man which 
\vd\v taught me the lesson derived from p(Msonal obser- 
vation and experience, that apparently slight cases, if 
neglected, may lead to grave results. Whether tiiesc 
results depend on tissue changes ettected l)y the direct 
action of the bacillus or its toxins ai'e (piestions still in 
the woiiil) of time, and al present fai' uioie readily asked 
than answcicd. 

In conclusion I take this opportunity of expressing my 
indebtedness to Sir Charles Cameron. From all the 
literature within my reach (both local and foreign) bear- 
ing on this subject 1 think 1 am correct in saying that Sir 
Charles has the unique distinction of being not only the 
onlv medical man in ibc I'nited Kingdom, but the only 



By Dr. C. M. O'Brien. 35 

medical man alive to-day who can speak from practical 
personal experience of two separate cases of foot and 
mouth disease in man due to direct inoculation from the 
low^er animal — one so far back as thirty years ago, during 
the epidemic of 1883, the other which is the subject of 
the present paper. 

I am also indebted to Sir Thomas Myles, M.D., 
F.R.C.S.I., Surgeon to His Majesty the King. Surgeon to 
the Richmond, Whitw^orth, and Hardwacke Hospitals, 
who also saw^ the case in consultation with me. The mere 
mention of this fact at once establishes the belief that 
any ambiguity in diagnosis which might arise from a 
surgical standpoint at once disappears. 

I am also to thank Mr. T. T. O'Farrell, F. E.G. S.I. , 
Bacteriologist to the City Skin Hospital and to St. 
Vincent's Hospital, for his examination of the epithelial 
debris and contents of vesicles with negative results. 

My thanks are in an especial manner due to my former 
patient, Mr. George J. Bell, M.R.C.V.S., who, in the 
cause of veterinary and medical science, permits me to 
bring this case before the Royal Academy of Medicine in 
Ireland, which is, as far as 1 know, the first published 
case of its kind in Great Britain. 

LITERATURE. 
Virchow's Archiv, Path. Anatomie. 
Law's Veterinary Medicine. 
Hewlett's Manual of Bacteriology. 
Allbutt and Rolleston's System of Medicine. 
Berliner klin. Wochenschrift. 
Veterinarian, 183L 
Osier's Medicine. 
Taylor's Medicine. 



PART II. 
REVIEWS AND BIBLIOGRAPHICAL NOTICES. 



Food and Feeding in Health and Disease: A Manual of 
Praetieal Dieteties. By Chalmers Watson, M.D., 
F.J{.C.1\E. ; Assistant Physician, Royal Infirmary, 
Edinbur^di ; Editor of the " Encyclopivdia Medica." 
Second Edition, revised. Edinburgh and London : 
OHver & Boyd. 1913. Demy 8vo. Pp. xvi + 638. 

When a work of this kind attains its second edition 
within three years it may be conchided that a want has 
been siip[)Hed and that the book is a good one. To these 
conchisions we had ah'eady come after reading the first 
ecHlion. This will be proved by a reference to a notice 
of the work which was published in the number of this 
journal for Ajuil, 1911 (Vol. 131, Third Series, No. 47'2). 

In his first chapter— on the nutritive value of foods — 
the author points out that a knowledge of the nutritive 
value of food may be gained in the following ways : — 
1. By a study of its chemical com))osition ; '2. by ascer- 
taining its heal vahie, expressed in calories: 3. by refer- 
ence to its physiological [)roperties — the ease with which it 
is digested and absorbed. 1 )i'. Watson very properly 
points out that the digestibility of food, and the ease with 
which it can be absorbed in the intestine are the most 
important facts to he considered in connection wiiii any 
food. Accordingly, he dwells l(>ss on I he chemical com- 
position of the heat values of food ;nid moic on its in- 
fluence on the (hgestive and bacterial processes in the 
digest iv(> tract. 

This plan, he observes, has been deliberately adopted 
as being in strict accordance with the general trend of 
recent advances in oui knowledge of the physiology of 
digestion, and also nioic in harmony with the teaching of 
clinical experience. 



Watson — Food and Feeding in Health and Disease. 37 

The practical application of this principle is fully illus- 
trated in Ohapter XI., on diet at different periods of life ; 
in Chapter XII. , on under-feedinor and over-feeding ; and 
especially in Chapter XVI., on dietary in fevers and acute 
infective diseases. In the last-named chapter, the section 
on typhoid or enteric fever is particularly valuable and 
worthy of praise. The short section on " Pneumonia or 
Pneumonic Fever " (page 288) includes an excellent 
statement as to the administration of alcoholic stimu- 
lants. Dr. Watson writes : — " In the general run of 
cases, alcohol in any form is not called for. In elderly 
people and in alcoholic subjects the use of stimulants is 
more frequently indicated. The early routine use of 
alcohol in these cases cannot be too strongly deprecated. 
When the heart's action becomes weak, irregular, and 
intermittent, and the general condition of the patient 
indicates increasing weakness, a stimulant is called for. 
It may be given in the form of w^hisky, brandy, or cham- 
pagne. An average dose would be half an ounce of 
whisky in twice the amount of water every four hours. 
In exceptional cases, when distinct benefit is apparently 
resulting from the stimulant, a considerably larger amount 
of whisky or brandy may be administered." 

In recent years we have become very chary of ordering 
alcoholic stimidants in any, and especially in fever, cases. 
Our experience is that hypodermic injections of strych- 
nine and digital ine, and strophanthus, caffeine, or camphor 
given internally will tide a patient over the dangers of 
heart-failure in convalescence more satisfactorily than 
alcohol. Nevertheless, we may accept Dr. Watson's 
views as thoroughly sound and practical. 

The same remark applies to the author's very full 
advice as to diet in renal disease, which is the subject of 
Chapter XXIV. In it a section on the treatment of 
chronic nejihritis by a chloride-free diet will be read with 
advantage by all practising physicians. 

The last two chapters in the book are among the most 
valuable of its contents. Under the heading " Special 
Diet Cures," vegetarianism, purin-free dietary, Salisbury 



.38 Reviews and Bibliographical Notices. 

diet, the «^rape-ciire, milk and whev cures, soured milk 
buttermilk, &c., are discussed in Chapter XXXT. 
Hospital dietaries form the subject-matter of Chapter 
XXXIl. , in which a plea is advanced for makin^r instruc- 
tion in dietetics an essential ])art of the medical student's 
curriculum. We conclude by quoting? from this same 
chapter a para^^raph, the advice in which medical prac- 
titioners would do well to follow : — " There is no doubt," 
writes T^r. Watson, " that too much food is often j?iven to 
hospital patients by over-zealous nurses who are anxious 
to hasten convalescence. The desire to feed is a kindly 
feminine instinct which should be carefullv rep^ulated by 
the practitioner. The medical man should always ex- 
plicitly indicate the nature and the amount of food, and 
the frecpiency of administration, which he considers 
advisable for each patient." 

A very full Appendix, printed in lon^ primer ty|ie, and 
runnin<^^ to nearly GO pa^es, comprises a series of jiapers 
which have been published in the past few years on the 
influence of diet on the structure of the tissues. 



TJw Duhliii University Calendar. Vol. TTT. Bein^^ a 
Special Supplciiicnlal Volume for the \v\\x 1012-101.'^. 
Dublin : Ilod^res, Fi^^^is ^' Co. 1913. 8vo. Pp. xi + 

Five years have elapsed since a third volume of the 
" Dublin T^niversity Calendar " was jMiblished. .And 
now, for the third time, a third volume of the Calendar 
makes its welcome a]i|)earance. Of all three issues the 
editor has been Mr. M. W. J. Fry, F.T.C.D., and to him 
we tender our hearty congratulations on the successful 
result of his extremely onerous editorial duties. 

The present edition of Volume^ Fll. is a ^n'eat advance 
on its predecessors. Th(» editor tells us that " a Preface 
has become necessary in order to record the names of 
those who have generously p^iven valuable contributions to 
the History of the Fniversity, so far as it is dealt with in 
this volume, or kindiv assisted the editor bv notin;^ im- 



AuERB ACH — Headache . 3 9 

perfections or makino- suggestions." He expresses his 
special acknowledgments to the Kev. J. P. Mahaffy, D.D., 
S.F.T.C.D., who placed his annotated copy of the last 
(1907) edition at his disposal; to Mr. G. D. Burtchaell, 
M.A., who has contributed a most valuable series of notes 
on the early Fellows and Scholars ; and to the Kev. T. K. 
Abbott, Litt. D., S.F.T.C.D., who has contributed several 
interesting notes, including one dealing with the old 
Dublin Philosophical Society, founded in 1842, and recog- 
nised by the Board of Trinity College in February, 1845. 
It was the predecessor of the University Philosophical 
Society— familiarly called the " Phil." 

In this edition lists of Doctors in Divinity, Doctors in 
Law^s, and Bachelors in Jjaw appear for the first time, by 
order of the Provost and Senior Fellows. The three 
cumbrous lists of Bachelors in Medicine, in Surgery, and 
in Obstetric Science have been incorporated into one com- 
prehensive list. Notwithstanding this condensation, the 
present edition contains 90 more ])ages than the edition of 
1907 (664 compared with 568 ])ages). This will give some 
idea of the amount of additional matter included in the 
work. As a frontispiece to the volume there is an inter- 
esting view of Trinity College in 1681, from the unpub- 
lished portion of the journal of Thomas Dingley (or 
Dinely) in the possession of Sir Francis Winnington, 
Bart." 



Headache: Ufi Varieties, their Nature, Recognition, and 

Treatment. A theoretical and practical treatise for 

students and practitioners. By Dr. SiECiMi nd Auer- 

BACH, Chief of the Polyclinic for Nervous diseases in 

Frankfurt a/M. Translated by Ernest Playfair, 

M.B., M.K.C.P. Oxford Medical Publications. 

London : Henry Frowde and Hodder & Stoughton. 

1913. Cr. 8vo. Pp. vii + 208. 

This is a convenient little book. It deals in a practical 

way with the differential diagnosis and treatment of the 

symptom, headache, and is well worth reading by every 



40 Reviews and Bibliographical Sutices. 

medical practitioner. Tt contains nothing specially new 
or illuminating, but summarises in handy form all that 
there is to be known on the subject. The writer lays 
o^reat stress on the recognition of nodular or rheumatic 
headache, a condition which he believes to be compara- 
tively common. In this belief we fully a^ree, as we have 
met with many cases in which distinct rheumatic nodules 
in the muscles of the back of the neck and in the 
occipito-frontalis were associated with severe and ]nn'- 
sistent headache, relieved finally only by massaf^^e and 
radiant heat. Bromides are stron^^ly advocated for 
mi^Taine, ^nven as a j^rophylactic between attacks, rather 
llinn as a curative remedy for the actual attacks them- 
selves. Nasal and ocular headache ; the headache due to 
increased intracranial tension, and intoxication headache 
are all fullv dealt with. The translator has done his work 
well. 



Tlic * NdnJici))} " Trcatvicut of Diseases of tJie Heart 
and Cireiflatio)}. By TjESLTR Thorne Trornr, M.D., 
B.S. Durham: M.R.C.S. En-.; [..R.C.P. Lond. ; 
Consultint^ Physician (in London) to the St. John's 
House of Rest, Mentone. Fourth Edition. London : 
Baillirre, Tindall c^- Cox. 1018. Cr. Svo. Pp. viii + 
104. 

The fact that this little book has reached a fourth edition 
proves that it supplies a demand on the part of the pro- 
fession. Dr. Thorne is well known as an advocate for 
the more ffenerni employment of the Nauheim treatment 
in diseases of the luNirt, and the careful description of the 
baths and exercises here supplied should do much in 
familiarisin*,' medical men with the mc^thods to be em- 
ployed and the n^snlts that can be obtained by their use 
at home. 

Very careful details of the make-uj^ of the baths is 
j^iven. but we wish that a more explicit account had been 
f^iven as re^^^rds (piantity of the " one half of a carbonated 
efff^rvescin;: bath." which is referred to on pa^c I'.). It 



MiNETT — Diagnosis of Bacteria and Blood Parasites. 41 

is the absence of such minor details as this which annoy 
a medical man who is anxious to try the baths and refers 
to a book of this sort for full and complete directions. In 
every other respect the detail is excellent — the account 
of the graduated exercises being illustrated by a full list 
of photographs which almost renders the explanatory text 
superfluous. An account of indications for and against the 
adoption of the treatment in any individual case is sup- 
plied, and there are also some records of results obtained 
in actual cases. 



Vicious Circles in Disease. By Jamirson B. Hurry, 
M.A., M.D. (Cantab.) Second and enlarged edition. 
London : J. & A. Churchill. 1913. Pp. xiv + 280. 
The vicious circle or the correlations of tw^o or more dis- 
orders, so that they reciprocally aggravate and perpetuate 
each other, is commonly met with in medical and surgical 
practice, and is generally recognised. It now for the first 
time, however, is accorded a monograph of its own. 
Whether working these interactions into " circles " makes 
them clearer is open to question, but the author has dili- 
gently collected and classified, and the result is worth 
reading. 

Diarjnosis of Bacteria and Blood Parasites. By E. P. 
MiNETT, M.D., D.P.H., D.T.M. and H., &c. ' Second 
Edition. London : Bailliere, Tindall & Cox. 1913. 
Cr. 8vo. Pp. viii + 80. 
This is the second edition of this useful and concise little 
book. The author has added sections dealing with tro]')ical 
diseases which are short and clear, and sufficient to assist 
the student or practitioner. The whole book is written so 
as to concentrate what is essential into a small space, and 
this necessitates the omission of lengthy descriptions of 
technique. Though a student might not succeed in carry- 
ing out lengthy reactions with this book as his only guide, 
it would be quite sufficient to enable a man accustomed to 
laboratory work to accomplish the Wassermann reaction 



42 Reviews and Bibliographical Notices. 

and other newer methods of diacrnosis. The fact that the 
book has so soon reached its second edition is a ^ruarantee 
of its popularity. 

AheVs Lnhorafory Handhnok of Bacteriologij. Second 
EngHsh Edition. Translated from the Fifteenth German 
Kditioii by M. H. (ioRDON, M.A., M.D., &c. With 
additions by Dr. A. (\ HorsTON, Dr. T. G. Horder, 
and the Translator. fjondon : Henry Frowde, and 
lloddcitS: Stoii^liton. Oxford Medical Publications. 
1913. Or. 8vo. Pp. xi+251. 

This is a convenient laboratory handbook, and contains a 
^a'cat deal of information in a short space. The new 
edition has short additions by the translattn' and Drs. 
i {order and Houston. These contain information as to 
the examinnlion of diisl, water, and aii', the examination 
of blood wiih regard to iniuiunity, and a short account of 
methods of procurin^^ material for cultures. The descri]v 
tions of culture and stainin^- methods are ^ood and fairly 
complete. There are excellent descriptions of the best 
methods of is()latin<i typhoid. ]iara-typhoid, and cliolera 
iniciobcs fioin llic f;pces. All tlu^ iicwci' methods for the 
detection of InlxMch* bacilli in sputum aic ^aven at lenfj^th: 
Tbc text is excellently written, and does not betray that 
it is a translation. 

Cm out : Its .Ktioloqy, Patholoqy, and Trentnicvt. By 
James Lindsay, M.D. (Kdin.); M.R.C.P. (Lond.); 
PTon. l^hysician, formerly Hon. Path()lo«,qst, and l^es. 
Med. Ofticer, Royal Mineral Water Hospital, J^aih. 
Oxford Medical I^ublications. London : Henry Frowde 
and IIodd(>r .V Stou^hton. 1918. 8vo. Pp. xii -f '21*2. 

This is a pleasantly written little book, not too learned 
or too crowded with bibliographical references, but prac- 
tical and readable. The writer has had the opportunity 
of studying,' nearly GOO cases of j^'out, nuiinly at the Royal 
MiruMiil Water Hospital, Path, and, in consecpience, may 
be accepted as speakin-^ with some authority. He de:ils 



New and Non-offlcial Rem^edies. 43 

with the disease systematically, and discusses in 
succeeding chapters, the aetiology, morbid anatomy, sym- 
ptoms, diagnosis, and treatment of gout. There is 
nothing very new in the book, but the various facts and 
theories discussed are illustrated by analysis of the cases 
observed. We are glad to notice that the author does not 
associate himself with that school of thought which pre- 
tends to believe that uric acid and its salts have nothing 
whatever to do with the development of gouty symptoms. 
Undoubtedly, the public lay too much stress on the evils 
wrought by uric acid, and, further, the common diagnosis 
that a patient is " full of gout," or simply " a storehouse 
of uric acid," is as often as not more convenient than 
true; but this is no reason why we should, as a protest, 
blind ourselves to the fact that 'uric acid does at times 
exist in excess in the blood of gouty patients, and that the 
actual paroxysms of gout are accompanied, and doubtless 
caused, by a precipitation of uric acid salts in the tissues. 
In the chapter on the treatment of gout the writer gives 
an excellent, though brief, account of the different spas 
which have acquired a reputation for the relief of gouty 
symptoms. He discusses carefully the result that may 
be expected from a course of treatment at any of them, 
and indicates the type of case for which each is suitable. 
We have read through the book with pleasure and profit, 
and can recommend it. 



New and Non-official Remedies, 1913. Chicago : Press 
of American Medical Association, 535 Dearborn 
Avenue. 1913. 8vo. Pp. 320. 
T?TTS volume contains descriptions of the medicinal sub- 
stances w^hich have been examined by the Council on 
Pharmacy and Chemistry of the American Medical 
Association prior to January 1st of the present year, and 
acce[)ted as having complied with the rules adopted by 
that Council, and printed at pages 9, 10, and 11 of the 
book. 

Among the members of the Council are some of the 



44 Reviews and Bibliographical Notices. 

first names of the Professors of Medicine, Therapeutics, 
Pharniacolocry, and ■Materia Medica in the United States 
of America, so that the contents of the book may be 
looked upon as having successfully run the f/auntlet of a 
severe and searching criticism. 

It is chiefly as a work of reference that this work is 
vahjable, and a vrry full and clear general index much 
enhances its value. This general index is followed by a 
useful index to manufacturers. It is proposed to issue an 
edition of "New and Non-official Remedies" year by 
year. 



JIECKNT WORKS ON MJDWJFEnY. 

1. Guide to Midwifery. By David Brrrv Hart, M.D., 
r.E.C.r.E. : I.ecturer on Midwifery, School of the 
Royal Colleges, Edinburgh ; formerly Obstetric 
Physician, Royal Maternity and Simpson ^lemorial 
Hospital, Edinburgh; some time Examiner in Mid- 
wifery and Gynaecology in the Universities of Edin- 
burgh, Oxford, Liverpool, Birmingham, &c. Pp. xv 
and 705. With 4 Illustrations in colour and 268 Dia- 
grams. Uoudon : Rebmnn, Ijimited. 1012. 

•2. The Priueiple.^ and l^nieiiee of Ohsfetriefi. By Joseph 
li. i)i: IjRR, A.M., M.D. ; Professor of Obstetrics at the 
North Western University Medical School: Obstetrician 
to the Chicago Tjying-in Hospital and Dispensary, and 
to Wesley and Mc^rcy Hospitals; Consulting Ob- 
stetrician to Cook County and Provident Hos|)itals, ^c. 
Pp. xiii and KUK). With OPS Illustrations, 150 of them 
in colours. Philadel|)hia and Ijondon : W. B. Saunders 
Company. \\)\:]. 

1. Dr. Bkrrv Hart's book is the latest British contribu- 
tion to the lilcratiiic ol obstetrics, and deserves a very high 
place in that literature. It treats very fully and carefully 
the dilTcrcnl niatlcis introductory to the practice of mid- 
wilciy. Mild .'ilinost ('(jually cMrcliilly thr practice itself. 



Recent Works on Midwifery . 45 

As a result, a handy volume is formed which will be of the 
greatest use to students and practitioners. 

The book is in two parts, the first of which includes all 
that is usually found in a work of the kind, while the second 
jjart is quite an original addition to a w^ork of the kind. It 
consists of an elaborate series of notes and discussions 
relating to the chapters in Part I., with the object of 
elucidating difficult points, and also of an extensive biblio- 
gra|)hy. This second part will be found of the greatest 
value not alone by the general practitioner but by 
specialists in midwifery and writers on obstetrical sub- 
jects. As an instance of the subjects treated may be men- 
tioned an elaborate article on " Evolution in Obstetrics," 
in which the importance and relation to midwifery of 
Darwinism, Weismannism, and Mendelism is clearly 
shown. 

We have much pleasure in congratulating Dr. Berry 
Hart on his work and in wishing it every success. 

2. This thoroughly American work probably establishes a 
record — so far as works on midwifery in the English lan- 
guage are concerned — for size and number of illustrations. 
It aims particularly at meeting the necessities of the 
general practitioner and the student, and if it does not 
succeed in doing so their necessities must indeed be great. 
])iagnosis has been made a special feature, and the re- 
lation of obstetric conditions and accidents to general 
medicine and surgery have been fully brought out. 

The subject-matter is divided into four i)arts : — The 
Physiology of Pregnancy, Labour and the Puerperium, 
tlie conduct of the same three, the Pathology of the same 
three, and Operative Obstetrics. With but few^ exceptions, 
the illustrations are original ; but it is evident that the 
artists have derived much assistance from Btunm's work 
on the same subject — an assistance w^hich the author grate- 
fully acknowledges. 

Dr. de Lee's work is monumental, and though, to the 
British way of thinking, it is too* large for either the 
student or the practitioner, save as a work of reference, it 



46 Reviews and Bibliographical Notices. 

will be found of the ^a-eatest value by the specialist, and, 
to all, its illustrations will prove of use. The enormous 
labour that has been devoted to its production, the re- 
search which it has entailed, and the personal and j)rac- 
tical experience it embodies alike call for praise and 
emulation. 



West Africa. Report on Certain Outbreaks of Yellow 
Fever in 1910 and 1911. By Drs. A. E. Horn and 
T. F. G. Mayer, of the West African Medical Staff. 
1913. London : Published for the Crown Agents for 
the Colonies by Waterlow & Sons. 1913. Folio. Pp. 
108. Maps 6. 
The most striking thin^i^ about this report is the way in 
which sanitation ])roblems are attacked by men in the 
Colonial Medical Service, and the whole conduct of the 
affair is typical of the splendid work they are doing. If 
it were possible to deal with ei)ideniics of infective diseases 
at home with the same thoroughness and celerity, nuich 
more might be done to stamp them out. During 1910- 
11)11, cases of yellow fever occurred s|)oradically or in 
small epidemics in various i)arts of West Africa from Ca[)e 
Verde to Lagos, and this report gives notes on 01 cases 
and the conclusions drawn from them. The history of 
the epidemics in seven centres, and the measures taken 
to suppress them, is given in fnll. and nuich credit is 
given to Drs. Kennan and Rice, Senior Sanitary Officers 
of Sierra Leone and the (lold Coast resj)ectively. Among 
other appendices are rej)orts by the late Sir Rupert Royce 
on the epidemics at Free Town and on the Gold Coast, 
a report by J)r. Kennan on " Bayloo," an endemic native 
disease, [)()ssibly identical with mild yellow fever, which 
largely attacks the children, and is sometimes fatal, and 
a report on yt^llow fever in Togoland ; and maps are added 
to show the distribution of the disease and the ascertained 
distribution of the Stegomyia niosfpiito, now universally 
considered to be the only carrier. The interest of the 
whole mattcM- lies in the (piestion : — Is yellow fever 
endemic among the natives of West Africa; was it 



Fraser — A Manual of Immunity. 47 

carried thence to America with the slaves, and are these 
ej^idemics due to the spreading of the disease to the non- 
imninne population, the natives although not absolutely 
immune having mostly been exposed to infection during 
infancy? It ap2)ears likely that this is the case, and that 
in the past yellow fever, unrecognised or confused with 
severe malaria, has been the greatest cause of the mor- 
tality from which Sierra Leone has been called *' The 
Whfte Man's Grave." 



A Manual of Immunity for Students and Practitioners. 
By Elizabeth T. Fraser, M.D. (Glas.) ; late 
Assistant Bacteriologist , Glasgow Eoyal Infirmary ; 
Beit Eesearch Fellow. Glasgow : James MacLehose & 
Sons. 191-J. Cr. 8vo. Pp. x+ 199. 

The study of the problems of immunity has reached a 
stage of such complexity that it is extremely difficult for 
any but those actually engaged in laboratory work to keep 
pace with its constant advance, and the very terms used 
are so many an'd so new^ and outlandish that they are 
enough to scare the general practitioner from any attempt 
to study the subject. Yet the results — vaccines, serum 
diagnosis, and so forth — have come so much into every- 
day practice that it is important for all who wish to 
understand the theory as well as the practice of modern 
Medicine to have clear ideas on the fundamental facts of 
this new science. The book under review is an attemi^t 
to explain, within modern compass, the science of im- 
munity and the results obtained from its study. The six 
chapters deal with a historical survey of the subject ; the 
body fluids, the body cells, and the micro-organisms as 
factors in immunity ; immunity reactions employed for 
therapeutic and diagnostic purposes, and, finally, ana- 
phylaxis. Thus we learn about anti-toxins, opsonins, 
agglutinins, and so forth, about ]^hagocytosis, and about 
the changes which take place in bacteria when grown in 
the living body, and following from these the chief points 
about serum and vaccine therapy, and the uses of the 



48 Reviews and Bibliographical Notices. 

Widal, Wassermann, and kindred reactions, the opsonic 
index, and tuberculin diagnosis. The whole question of 
acquired sensitiveness or ana]ihylaxis, resulting practi- 
cally in serum disease and other phenomena, is one of 
great interest. Little is really definitely known about it, 
but the main points already established are carefully 
explained in the chapter devoted to this subject. 
Altogether the whole book explains clearly enough a diffi- 
cult subject, and the addition of a full glossary is a great 
hel[). The actual methods used in such processes as the 
Wassermann test or the estimation of the opsonic index 
are also given fully, although, as is natural in a book of 
this size, some of the processes in use, such as Fleming's 
modification of Wassermann, are omitted. An ap|)endix 
explains Ehrlich's " side-chain " theory of immunity, 
and gives some account of his work in the production of 
such drugs as salvarsau. 



IIHCENT AMFJUCAN '' TRANSACTIONSr^ 

1. Transactions of the Anicricaii I\(Uatric Sociitij. 
Twenty-third Session. Edited by J^iNN.VEi s Edfokd 
L.v Fetra, M.D. 

•J. The Transactions of the American Pediatric Society. 
Twenty-fourth Session. Edited by Linnakis Edfokd 
LA Fetha, M.D. 

1. The meetings of the Twenty-third Session of the 
American IV'diatric Society wow held at Jjake Mohonk, 
N. Y., May 81st to June'-Jnd, ]<)11. The Transactions 
for this Session occupy ii88 pages, and are well edited. 
They contain BO papers. In his short presidential address, 
Dr. Henry J)wight Chapin deals with " the Fundamental 
Principles of Pediatrics," and lays stress on the advan- 
tages of a sound knowledge of physical and biological 
science in undertaking the welfare of children. The first 
four [)apers discuss infant nutrition from various points of 
view, as protein metabolism, the role of mineral salts, «&c. 
There are several important papers on the [)revention, 



Recent American " Transactions, 4^ 

management, and isolation of infectious diseases in chil- 
dren's hospitals. Dr. Northrup reports good results in the 
Presbyterian Hospital, by screening off infectious cases in 
general wards, and by using spray instead of tub baths. 
Koplik discusses the box system. Six papers are devoted 
to infantile i)aralysis, its occurrence, the cerebral form, 
the control of epidemics, &c. Among the papers on food- 
stuffs, Professor Holt explains a ready method of calculat- 
ing milk formulas of various percentages and the caloric 
value of the same. A fair share of the articles comprises 
clinical reports on unusual or rare cases, as amyotonia 
congenita, Mikulicz' disease, diabetes mellitus in a seven 
months' old child. 

The 1911 volume contains a fair amount of original 
research, and its value is enhanced by a number of good 
illustrations, tables, and charts. 

2. Twenty-five papers are reported in the Twenty- 
fourth (1912) Volume of the Transactions of the 
American Pediatric Society. That is about a dozen less 
than the previous year. This number also contains the 
Index of Volumes XV. to XXIV., inclusive. The meet- 
ings were held at Hot Springs, Virginia, from the •29th 
to the 3 1 st of May, 191-2. The president. Dr. Walter Lester 
Carr, gave his address on " The Relation of the x\merican 
Pediatric Society to the Reduction of Mortality in Infancy 
and Childhood." 

The subjects discussed by the members covered a good 
deal of medical and pathological work, but surgical sub- 
jects are conspicuous by their absence. There is a long 
paper on the coagulation time of blood in infants and 
children by Drs. Carpenter and Gettings. Dr. Nicoll, on 
' ' Inclusion Bodies in Scarlet Fever Blood as a means of 
Differential Diagnosis," reports the results of examina- 
tions of 115 cases, and 80 controls. x\s he wished to 
ascertain the practical value of this work, the controls 
were taken, as far as possible, from patients with patho- 
logical conditions clinically resembling scarlatina. He 
concludes that these bodies will be found in every case of 



60 Reviews and Bibliographical Notices. 

scarlatina (except the fulminating type, the subjects of 
which die before the tissues have time to react), up to and 
including the fourth day of the disease ; that they will not be 
found in anti-toxin rashes, measles, rubella, various toxic 
rashes due to drugs or intestinal absorption, probably not 
in ordinary tonsillitis, but regularly in general sepsis. 

Dr. Griffith, in an interesting account of 75 cases of 
enteric fever in infants under two and a half years, shows 
that the rash ap[)ear8 earlier, and the onset generally is 
shorter, than in adults. In only 16 cases was the disease 
l)resent in other members of the family. 

Dr. Churchill investigated the blood of 101 infants by 
the Wassermann and the Noguchi reactions, and found 
that 88 per cent, were syphilitic. Thirty-seven per cent of 
these showed no symptoms. 

Other papers deal with infant feeding, the employment 
of salvarsan, and the report of cases of interest. 

The printing and illustrations of the volume are all that 
can be desired. 



Sex Antagonif>ni. By W.\lter Heape, M.A., F.R.S. 
London : Constable & Company, Ltd. 1913. Demy 
8vo. Pp. 217. 

The tangled series of the problems of sex — as has been so 
truly stated of poverty and its multitudinous complica- 
tions — is always with us. And if we but once allowed 
ourselves the rash licence of prophesying in connection 
with the future history of any of the features^ of liuman 
nature in its cosmo[)olitan totality, we should feel a 
greater degree of contidence in risking our soothsaying 
reputation with posterity by staking it on the statement 
that the forDicr of the two great crucial queries stands, in 
the very nature of things, animate and inanimate, in sure 
and constant expectation of becoming the latter in date of 
arrival. For the ghastly datum of destitution presents no 
impossible (piality of which the resistance cannot be 
successfully overcome by a series of 1 liberal Budgets, and 
philauthro[)ic utilisation of the same — in fact, it depends 



He APE — Sex Aiitcigonism. 51 

on the things external to the personaUty of homo aapicns. 
But the imperishable crux of " sex antagonism " (which 
has existed at least since the memorable occasion on which 
Eve overcame the reluctance of Adam to taste the apple, 
and the latter sought partial shelter from the immediate 
terrors of conviction by shifting the blame on to the 
shoulders of his ill-advised helpmate) has been all too ob- 
viously built into the deepest internal recesses of the 
human frame, while manifesting itself superficially by un- 
mistakeable indications — of functional capability — sugges- 
tive of the relative value of the mediceval interpretation of 
Nature's hieroglyphic system of signatures, and of the 
elaborate system of Aristotelian physiognomy which was 
worked out with so refined detail by Giovanni Battista 
Porta. Accordingly, in keeping with the circular pro- 
gress of scientific evolution in the present day, w^e find the 
British apostles of light and leading waking up to recog- 
nition of the unavoidable necessity of examining the com- 
prehensive questions of sex function and sex relationship — 
and the education of their contemporaries, and upbring- 
ing of the rising and all future generations, in a thoroughly 
illuminated sexual atmosphere. As usual, they are a good 
bit behind time — even in this decade of miraculous ad- 
vances ; in distribution of education, in wireless trans- 
mission of instantaneous thought, and in the long un- 
dreamed-of velocity of aerial transit. 

We have perused Mr. Heape's contribution to the study 
of this subject with genuine pleasure and instruction. 
The "Introductory" chapter is, in itself, a thoroughly 
philosophic presentation of a skilled expert's view of a 
problematic position of engrossing importance ; of a vista 
which, having been always present to superficial observa- 
tion , failed to excite special curiosity from the very fact of 
its familiarity, till some explosive changes therein led us 
to discover the unreliability of our position and its protec- 
tive structures — as a rude shock sometimes brings down 
the edifices of which the very substantial-looking wooden 
pillars of support have long been in receipt of the internal 
attentions of the insect whose industry excited the peren- 



62 Reviews and Bibliographical Notices. 

nial admiration of the wisest of men. In plain language, 
such as the skilled teacher prefers to use for purjx)ses of 
instruction, he tells his readers that : " The existence of 
sex antagonism per sc is sufficiently accounted for by the 
fact that the Male and Female are differently organised, 
and that Nature has set them different tasks to perform 
in conjunction with one another." This statement of the 
author's view-point naturally suggests comparison with 
that of the " liberty and equality " which appear (nomi- 
nally) to be the objects of the suffragette. Perhaps it is 
but a structural item of the monstrous labyrinthine 
fortress of (rather unskilled) sophistry which represents 
the Babel tower of this democratic generation : the thesis 
that man and woman are actually equal — which in- 
cludes the conjoined imj)lication that the Creator was 
guilty of a grievous la[)se in constructing distinctive organs 
so obviously and unchangeably different in structure and 
function. We cordially corroborate Mr. Heape's state- 
ment of o))inion : " It is obvious that, given a satisfactory 
environment, if tli(> Male and Female concerned them- 
selves only with the duties Nature has determined for 
them, sex antagonism would be latent." 

It is, of course, but a manifestation of the inevitable to 
find the experts differing in (ex])ression of) opinion re- 
garding some of the mixed (juestions associated with the 
relations of the sexes. The primitive juactice of c.vogannj 
and the alleged horror of incest are energetically discussed 
here : they have received a great deal of attention lately 
from the s[)ecialist in anthropology and folk-lore. 
Exogamy is regarded by Mr. Heape as "a product of the 
Masculine mind " — in this respect contrasting with 
totemism. The collateral item of infornuUion is given : 
*' The scarcity of women, their caj)turc, the religious sen- 
timent regarding menstruous blood, and the instinctive 
aversion to sexual intercourse with those who have lived 
together from youth ; are all based on thi« idea of Male 
supremacy." In the remote villages and congested dis- 
tricts of the Jrish " Western World " of half a century 
and less ago, the state of education and of superstition 



Heape^ — Sex Antagonism. 53 

was decidedly primitive ; the patriarchal system of family 
government being thoroughly recognised and established. 
And the match-maker v^as found almost invariably to look 
abroad ; the father of the prospective bridegroom could 
press more firmly for amount of dot, v^-hile his son would 
be placed at a relatively safe distance from the ever- 
dreaded mother-in-law — who, with the correspondingly 
vicious step-mother would appear to have constituted 
vital arguments in every age and locality of the world 
against the granting of extensive material powers to the 
physically weaker female ! Some of us are thoroughly 
satisfied that these arguments still hold good. We must 
here emphasise our agreement with Mr. Heape's state- 
ment that [semi-] savage life inculcates shrew^d observa- 
tion, that skirmisher of intelligence. We are utterly 
sceptical regarding the coiicejHional totemism. of the Banki 
Islanders — while admitting the occasional recognition 
among many primitive peoples of impregnation by the 
Spirit : of the air (or aether, or " heaven ") above, or of the 
animal or plant on, or even of the waters under, our earth. 
But we are not quite sure that Dr. Frazer, our encyclo- 
paedic authority on, as well as advocate of, this curious 
statement of belief has personally examined those remote 
islanders and received in trustful confidence the native 
view. Most beliefs associated with the "modern" dis- 
covery (or invention) of totemism have to await, we still 
believe, their final formulation in Western language. We 
are not satisfactorily enlightened even by Mr. Heape's 
statement regarding human intelligence, deliberation, and 
will. "These faculties of the human mind themselves 
have arisen in accordance with biological law." It sounds 
so very " modern " : we almost are induced to look for- 
ward to having the facts and effects of this biological law 
weiefhed and measured — and then valued — ' ' in accord- 
ance with " biometrical practice. Are we ever to see an 
end to the substitution of polysyllabic terms for reliable 
facts and logical reasoning? We find that the unique 
authority on anthropology and folk-lore is here quoted for 
his penetrating statement : " Some Australian tribes re- 



54 Reviews and Bibliographical Notices. 

pard the acceptance of food from a man by a woman not 
only as a marriage ceremony but also as the actual cause of 
conception." There we leave Dr. Frazer to the indulgent 
consideration of the reader ! 

As the subject dealt with by the learned author em- 
braces all aspects of the inter-sexual relationship which is 
so seldom wholly freed from the decidedly mysterious 
element of antagonism, he has felt called on to discuss all 
the (leading features, at least, of the) complex influences, 
active and j)assive, of the representative posterity of Eve. 
Birth-marks, for instance, are alluded to; and medical 
testimony is cited. But it is on such ground that our 
scientific Samson appears as if recently emerging from the 
arms of his Delilah. We have hitherto encountered no 
exception to the rule regarding the danger of contact with 
professional subjects — even in case of the most accom- 
plished outsider. Better stick, in this and germanic 
cases, to the folk-lore evidence. And we can offer him one 
or two items. The Irish |X)pular account of the genesis 
of the birth-mark was that : when a susceptible pregnant 
wonmn had an object abruptly thrown to her, the first 
part of the cutaneous surface which she then touched 
would determine the appearance of \\\v birth-mark impres- 
sion : in the form of an " image " of the missive, on the 
corresponding artni of the skin of the unborn infant. .\nd. 
as the illiterate had a morbid horror of such deforming 
objects appearing on the face — the part most likely to be 
touched — instantaneous digital attention to the skin of 
the gluteal I'egion was |)rescribed as tlu* only eligil)le pro- 
phylactic piocedure. A soniewhat analogous case arose 
Vvhcii a hare, crossed her path while engaged in her bare- 
foot peregrinations in the fields. The only safeguarding 
procedure in this case was to stoop at once and tear a 
vertical slit in the lower border of Ikm' " home-made " 
flannel petticoat. And so-forth. 

The late Mr. .Andrew T^ang has inevitably had some of 
his views reproduced here : the only eff'ect on the present 
reviewer being to feel some (necessarily useless) regret that 
he, as well as I>r. I'^razer — and manv other Caledonian 



pROFT — Elementary Hygiene and Sanitation, 55 

geniuses of greatly daring intellect and enterprise — had 
not left the subjects of physiology and heredity quite 
cautiously, if not severely, to stand all alone. But, in the 
present muddled state of the current of British scientific 
literature, the intrusion of their published views was, of 
course, a deplorable necessity. Anyway, Mr. Heape has 
presented them clearly in every instance, and — we are 
very pleased to be able to add — discussed them destruc- 
tively, as well as lucidly, in some of their more flagrant 
divagations. And we close this very imperfect notice of 
an important and ably-prepared volume, by cordially 
thanking the author for the genuine pleasure and intellec- 
tual profit which we feel that we have derived from its 
perusal. J. F. K. 



Our Baby: for Mothers and Nurses. By Mrs. J. 
Langton Hewer. Fourteenth Edition. Illustrated. 
Bristol : John Wright & Sons, Ltd. 1913. Cr. 8vo. 
Pp. viii + 192. 

The fourteenth edition of this well-known and excellent 
little book shows that not only is its past standard of ex- 
cellence maintained, but valuable new additions have been, 
made. The chief of these is a chapter on " Baby in the 
Tropics," which should be of great value to mothers in 
India. 



Lessons on Elementary Hygiene and Sanitation, with 

Special Reference to the Tropics. By W. T. Prout, 

C.M.G., M.B., CM. (Edin.); Medical Adviser to the 

Colonial Office; late Principal Medical Officer, Sierra 

Leone, &c. Third Edition. London : J. & A. 

Churchill. 1913. Pp. xx + 184. Fig. 60. 

This elementary text-book, which is in the form of 

lectures, was written originally for the use of schools in 

the Tropics. Intended as a complete course, it has to 

include some elementary anatomy and physiology, to 

which four out of the fourteen chapters are devoted. The 



66 Reviews and Bibliographical Notices. 

other ten inclucle lessons on vegetable and animal para- 
sites, malaria having two chapters to itself; on food, 
water, air, dwellings, clothing, and personal hygiene. 
Altogether the book in its present form gives very full and 
clear teaching on tropical hygiene and sanitation, and 
might be read with advantage not only by those for whom 
it was intended, but also by those who are about to live 
in a tropical climate, and wish to know how to take care 
of their health when abroad. 



Bdhicfi : (I Boolx for Maternity Nurses. By Margaret 
French. London : Macmillan & Co. 1018. Pp. 80. 

The author of this little book deserves very hearty con- 
gratulation. Tt has been said that nothing is harder to 
write than a small, simple text-book, and, to judge by the 
munerous indifferent books of this type that are constantly 
being produced, it seems as if the remark might be true. 
PTere, liowever, we have a small text-book containing 
almost everything that a maternity nurse can learn from 
books about a baby, and yet nothing unnecessary is 
given, and the whole is presented in a clear, readable 
form. 

T\w book also includes some tables and charts which 
should be very useful. We cordially recomuicnd it to all 
infants' nurses. 



lewis's pockkt cask nooK. 
We have received from Mr. H. K. TiOwis a n(>w P(H'ket Cnsi' 
Hook designed for the use of students and practitioners. 
The book is neatly hound in limp cloth, and tlie pngi* 
measures 8 inches by .") inches. It is arranged for 25 cases; 
fom- pnpes are allotted to each ease, and the headings are 
arranged for the record of the usual particulars, ineludin^^ 
})ersonal history, family history, and present condition. 
There are also diagrams for the marking of physical signs, 
space for diagnosis, prognosis, and extra space for the 
record of treatment and ])ro^ress. ineluding a miniatiu'e 
chnrt which sliouk] he very useful. The price is Is. Od. net. 



PART III. 
MEDICAL MISCELLANY. 



Reports, Transactions, and Scienti/iG Intelligence. 



BOYAL ACADEMY OF MEDICINE IN IRELAND. 



President— Walter G. Smith, M.D., F.R. C.P.I. 
General Secretary— J. A. Scott, M.D., F.R.C.S.L 

SECTION OF OBSTETKICS. 

President — Sir Andrew J. Horne, F.E. C.P.I. 
Sectional Secretary— G. FitzGibbon, I\I.D., F.E.C.P.I. 

Friday, April 18, 1913. 

Dr. E. D. Purefoy, P.E.C.S.I., in the Chair. 

Congenital Cystic Tumour (illustrated by photograph). 

Dr. Spencer Sheill exhibited a photograph demonstrating 
this condition in an infant. The tumovu' was present at 
birth, and gradually increased in size during the first few 
days, after which it remained stationary until operation. It 
was situated in the mammary line on the right side, and 
seemed to cause the child inconvenience when the binder 
was tightened round him. He allowed the tumour to remain 
for two months, and then, as there were no signs of sub- 
sidence, he evacuated it with trocar and canula, withdraw- 
ing one ounce of serous fluid. It, however, again filled up, 
and he hoped to open the tumour next week and treat it as 
an open wound. He gave details of a former case somewhat 
similar, and regretted not having photographs of the con- 
dition to show. 

The Chairman said he was sure Dr. Sheill was correct in 
looking on this as an uncommon form of tumour, and he in- 
quired if the fluid in both cases were similar in appearance. 
He looked forward to hearing the result of the treatment 



58 Royal Academy of Medicine in Ireland. 

indicated by Dr. Sheill, and hoped that some additional infor- 
mation would be gained in regard to the nature of the growth. 
Dr. Sheill, replying, said he had not tested the fluid 
microscopically, but the naked eye appearance was similar 
in both cases. 

Clinical Report of the Rotunda Hospital. 

Dr. Jellett read the Clinical Eeport of the Rotunda 
Hospital for one year ending October 31st, 1912. [The first 
instalment of this Report appears in our present number, 
at page 1. The remainder will be published in the number 
of this journal for August.] 

The Chairman said the fatal cases of accidental haemor- 
rhage brought home to them what a terrible complication of 
labour this haemorrhage was. He thought a considerable 
number of the fatal cases were due to the fact that accidental 
hsemorrhage is met with in those patients who are suffering 
from organic disease, and, consequently, they were called 
upon to deal with this serious condition where the patient is 
badly able to stand the shock attending the hemorrhage. 
He was inclined to think that in these cases vaginal tampons 
might be left in a little longer; however, those who have 
charge of the cases can best judge. He considered that one 
of the greatest risks and most serious mistakes was the 
undue anxiety to empty the uterus quickly and before the 
patient had time to rally from the haemorrhage which had 
already occuin'd. He did not quite understand the advan- 
tage that the Master of the Rotunda Hospital claimed for the 
introduction of early rising of [)atients after their confinement. 
That it was contrary to the usual practice, and present teach- 
ing need not be taken as a fatal argument against it; but 
he was by no means convinced froni what he had heard tliat 
the practice was to be recommended, nor did he consider the 
fact that no accidents had been reported in the cases treated 
as sufficient argument in favour of it. He suggested that 
the treatment might in future produce a number of patients 
suffering from misplacements, Scv. He would like to ask if 
Dr. Jellett had found this method beneficial in his private 
practice, as it should be borne in mind that most of the 
patients admitted to the Rotunda Hospital were in poor cir- 
cimistanees. and the rest they enjoyed diu-ing their stay in 
hospital was generally nnich neede(l, 



Section of Obstetrics. 59 

He agreed with the Keport as to the treatment of puerperal 
eclampsia — i.e., that there are cases which defy all efforts 
to save life, and he recalled his own experience as Master 
when very nearly as good results were obtained; but even 
then sometimes a run of fatal cases was recorded. 

He thought it was very interesting to notice that the 
patient who was already septic on admission recovered so 
satisfactorily from the formidable operation of Caesarean 
section and hysterectomy. It appeared to him that there has 
been an undue dread of performing Caesarean section in cases 
in which there was a possibility of sepsis, and he considered 
the cases recorded in the report showed that there was no 
need to despair even where a slight degree of sepsis existed. 

Referring to the outbreak of sepsis during the year, he had 
very great difficulty in accepting the explanation that it was 
due to the water supply, and he was somewhat relieved to 
find that the Master does not adhere to that explanation of 
it now. Although, with our present knowledge of sepsis, it 
was somewhat humiliating that such an outbreak should 
occur, yet he considered that it should not be disheartening, 
but should lead to redoubled efforts to deal with the con- 
dition when it did arise. 

He was not enamoured with the use of gloves in ordinary 
obstetric cases, as if their use in the management of ordinary 
cases became a habit he thought it might lead to carelessness 
in the disinfection of the hands and arms. 

Dr. Spencer Siieill, referring to the early rising of 
patients, said he was greatly in favour of it, and in private 
practice he had got nothing but the best results by its adop- 
tion. The practice, he considered, was contra-indicated in 
cases which had shown signs of prolapse or other complica- 
tion. The advantages accruing from early rising, he con- 
sidered, were — stronger patients, quicker return to normal 
health, less constipation, and — he thought the most impor- 
tant point — a distinctly more rapid involution of the uterus. 

In Case III. in the Report he noted that " as a last chance 
venesection was performed." He took exception to the term 
" last chance," because he considered that if this were done 
sufficiently early in eclampsia it would be followed by bene- 
ficial effects. 

He considered that the Report raised a very important 
point regarding cases of pubiotomy and symphysiotomy. If 



60 Royal Academy of Medicine in Ireland. 

this patient, in whom a piece of bone came away, could walk 
after the operation all the power of the argument against such 
procedure disappeared. 

He inquired the natin-e of the microbe found in the case 
of general peritonitis, and whether the streptococci, if they 
were present, were introduced from without. 

He considered it doubtful that the water tanks had any- 
thing to do with the introduction of sepsis. He suggested 
that the personal element should have been inquired into, 
and also the form of the sepsis that occurred, if investigated, 
might help in the solution of the mystery. 

Dr. Tweedy considered a little fuller information might, 
with advantage, have been given on some points. This was 
noticeable in the case of eclampsia, where no mention was 
made of the quantity of fluid given. Again, in dealing with 
sepsis, the steps taken to discover the cause of the infection 
were withheld. He considered it deplorable that the cause 
was not found, for if the infection arose from anything wrong 
with the new wards it would be a very serious matter to have 
to admit it ehided detection. Tf a table had been presented 
showing the day of infection, for if it could be shown that 
the majority were cases of late infection the labour wards 
would have been put out of count. He could not accept the 
view that the tank water was a source of the sepsis, though 
the fact that these tanks had to be employed was a source 
of anxiety. He inquired what aiTangements the Master had 
made to cleanse them. When he was Master of the Rotunda 
Hos[)ital he ])referred to h»ave the tanks alone rather than 
run the risk of infection through so-called cleaning. When 
he had seen that twenty-five cases of prolapse had been 
recordcMl he immediately thought that the (\arly rising might 
have brought this high figure al)out; but on looking closer 
at the Re})ort he saw that cases were included under this 
lieading which it is usual to classify under the headings of 
rectocele and cystocele. He did not, therefore, think there 
were a greater number than heretofore. 

Referring to the last |)aragraph in the Report he considered 
it hardly fair to calculate the mortality percentage on the 
number of admissions rather tliau the total deliveries, for 
the majority of patients who were sent out not in lal")Our had 
no more to say with tlu' hospital than had the visitors. 

Dk. Bethel Solomons said the diminished morbidity was 
eminently satisfactory, especially when one takes into con- 



Section of Ohsietrids. 6l 

sideration the ill-fortune attendant on the opening of the 
new labour wards. He wished to know if the cervix was 
removed and if drainage was employed in Cases I. and V. in 
the Obstetrical Keport. Case IV. was a typical example of 
the necessity for very radical operations in cases of papillary 
cyst of the ovary. The number of cases of failure of primary 
union after perinaeorrhaphy is omitted in this Report. The 
operation of removal of septic thrombosed veins is one of the 
greatest advances in obstetric surgery. There is no doubt 
that the first case in the Mortality Table would probably 
have lived if an operation had been performed, and Dr. 
Jellett is to be congratulated on saving the lives of at least 
two patients by his prompt and daring operations. The 
statistical papers in the March number of " Surgery, 
Gynaecology, and Obstetrics," on the subject of cancer of the 
uterus, make one wonder at the small number of cases of 
malignant disease of the uterus in this Report. Five 
operable cases presented, and of those only one was cervical 
cancer. It would be of interest to have the opinion of the 
Master of the Rotunda Hospital as regards operability, and 
whether he has adopted Byrne's method of the galvano 
cautery. Gellhorn in the above paper, notes that those who 
operate on most cases have the greatest percentage of cures, 
and quotes the figures of Franz, who operated abdominally 
on 82 per cent, of the cases seen. As Franz has better 
results than any one else, his teaching seems a beneficial one 
to follow. 

Dr. Gibbon FitzGibbon said that the Report had shown 
that ]^r. Jellett was a strong advocate of myomectomy in 
preference to hysterectomy whenever possible. Referring to 
the table of Wertheim's operations, there was one case 
which he considered needed a little further elucidation — i.e., 
why was the Wertheim done in the case of cystic papilloma 
of the ovary. He inquired if anything was to be gained in 
doing Wertheim's operation where the primary disease was 
ovarian. 

He drew attention to the disparity between the figures for 
suture of perineal lacerations in the Extern and Intern 
Maternity. In the former the number was 186 ; in the latter, 546. 

He considered that a table of cases which return to hos- 
pital for subsequent confinement where myomectomy or sus- 
pension operations had previously been performed on the 
patients would be most instructive, and such a table would 



62 Royal Academy of Medicine in Ireland. 

be useful as a guide as to the results to be anticipated from 
such operations. 

Dr. Crofton suggested that a bacterial examination of the 
water might have discovered what the infecting organism 
was. He suggested that a vaccine might have been found 
useful in the cases of o])lithalmia that occurred. 

J)r. Jellett replied to Dr. Purefoy's fear that early rising 
would give j)lace to displacements, prolapse, &c. He (Dr. 
Jellett) saw no reason that because midwifery practice had 
been managed on abnormal lines it should continue to be 
so managed. He considered that in the first j^lace drainage 
of the uterus was prevented by keeping the patient in bed. 
It also favoured backward displacements, interfered with the 
action of the bowels, and was detrimental to the general well- 
being of the patient. He thought that in hospital practice, 
at any rate, it was contrary to the wish of the i)atients, as his 
experience was that they liked to be allowed up early. He 
attributed the reduced morbidity shown by the Report to the 
fact that the j)atients were allowed up early, and he |)ointed 
out that no patient was allowed up exce])t everything was 
normal. He looked forward to the time when obstetricians 
would be agieed on the practice of allowing patients up soon 
after their confinements. 

Kcgarding the outbreak of se})sis he was not at all pre- 
pared to abandon the consideration that the outbreak was in 
part due to the new buildings and to the infection of tlie 
water tanks. Tho only j)oint against the latter theory was 
that there was no se))sis in the oi)erating theatre. He re- 
ferred to the fact that when the Ciynieeologieal Hospital was 
first oj)ened violent sei)sis occurred amongst the operation 
cases, while the labour wards were (juite clear of it. He 
thought that there was always a tendency to sepsis wliere 
buildings were being interfered with. He detailed the 
iiietliods ado|)te(l in eleansing the tanks. Replying to a ques- 
tion from Dr. Sheiil, he said that the rearrangement of the 
nursing staff went on hand-in-hand with the opening of the 
new wards. Referring to eclampsia, venesection might, he 
thouglit, do g<K^d in certain cases. Witli regard to the case 
of pubiotomy he agreed with Dr. Sheiil when he said that it 
clearly proved that loss of the |K)wer of walking cannot result 
from failure of union of the pubic bone. Referring to Dr. 
Tweedy 's comment on prolapse operations, he (Dr. Jellelt) 
did not think marked cystoccle and rectocele which called for 



Section of Anatomy and Physiology. 63 

prolapse operations could be included under any other head- 
ing than " prolapse." The number of cases in which the 
uterus was prolapsed was about 70 per cent, of the total given 
in the tables. 

Myomectomy had been done on a far more extensive scale 
than usual, and he was satisfied with the results. The only 
cases in which myomectomy was not performed was where 
the retention of the uterus was not of consequence owing to 
age or other considerations, or where the number of tumours 
was too great. 



SECTION OF ANATOMY AND PHYSIOLOGY. 

President — B. J. Collingwood, M.D. 
Sectional Secretary— A. A. M'Connell, M.B., F.R. C.S.I. 

Friday, April 25, 1913. 

The President in the Chair. 

The Formation of Creatin in the Anifnal Body: Effects of 
Administering Argimn with Betdin and Cholin. (Illus- 
trated with lantern slides). 

Professor W. H. Thompson referred to a previous conunu- 
nication ("Transactions: British Association," 1912), in 
which he had shown that arginin, when given with the food 
or parenterally led to an increased excretion of creatinin and 
also to the appearance of creatin in the urine of the dog. Of 
the total* arginin-nitrogen, 6 to 16 per cent, reappeared in 
this way. 

Further observations were made to test whether the 
addition of methyl compounds would increase the output of 
creatin-creatinin. In these, arginin was combined with 
methyl benzoate, betain, or cholin, but in no case could it 
with certainty be claimed that the output of creatin-creatinin 
was greater than that caused by arginin alone. 

The PREsmENT said that he would like to hear more as 
to the bearing of arginin on metabolism, also what propor- 
tion exists between creatin formation and urea formation. 

The search for methyl he considered most interesting. It 
appeared to him that the methyl supplied artificially was 
ignored, and the organism seemed to fall back on the 
methyl found normally in the body. 



64 Royal Acade)}nj of Medicine in Ireland. 

He inquired if the arginin was converted into creatin and 
creatiiiin where did the alteration take place? 

Pkokessor Barky inquired the age of the animals with 
which the experiments had been conducted, and asked how 
the age of the animals affected the process. 

He was also anxious to know if any controlled experiments 
had been carried out beforehand to ascertain the normal out- 
put of nitrogen. 

Professor Thompson, replying to the remarks, said that 
about 90 per cent, of the arginin-nitrogen came out as urea 
and from 5 to 10 per cent, as creatin. It had been shown 
that there was sufficient arginin in dead food to supply the 
arginin needed in the body. He considered that it was not 
the amount of methyl administered that determined the 
amount of creatin. It might be that the arginin withdrew 
its methyl from what was administered, but he thought 
there was some other unknown influence at work. 

He mentioned that fusion experiments had been conducted 
hist summer which showed that there was slight formation 
of creatin in the liver, and when arginin was added there 
was a slight increase in the amount of creatin obtained. He 
considered that the liver was not the only place in wliich 
creatin was formed. 

The animals with which the ex))eriments were carried out 
were dogs from one to two years of age. They were fed on 
a known diet, and preliminary observations of the output 
of nitrogen were taken over a period of nine or ten days. 

The Spinal i'ard in rchitinn to the liCiipiidtonj Xcrvoit.s 

Mcclutnisni. 

I'rokkssok D. '] . H.\RRV first gave a short historical survey 
of the above subject. Gad, in 1880, demonstrated pre- 
dominant expiratory effect of the vagus; inspiratory of 
minor im|K)rtance. Head's experiment in 1880 in refutation 
of Gad's view was not acce])table, because collapse of lung 
j)roduced by Head is not a normal stimulus. 

In a series of ral)l)its ami cats Dr. Bairy showed that 
by cutting the cervical cord the response to blocking the 
tracliea in the expiratory ])hasc was abolished. Excising of 
the stellate ganglion in the eat before cutting the cord showed 
that the res|K)nse was interfered with, but not altogether 
abolished. Oonclusion. — Afferent stinuili for inspiration j)aKs 
normally up the cord, and the vagus conveys in the main 



Section of Anatomy and Physiology. 65 

expiratory stimuli. The inspiratory afferent stimuli are — at 
least in part — muscular in origin. 

The President asked if the effects produced were due to 
carbon-dioxide accumulation, or to the action of the nerve 
centres. _He thought if carbon-dioxide and any changes in 
the blood were excluded, it was clear that there must have 
been a nerve influence. He pointed out that the amount of 
operative interference during these observations must have 
produced a certain amount of shock, and that it would be 
difficult to properly estimate the influence of this shock on 
the results of the experiments. He considered it clear that 
the lungs exerted a good deal of influence on the respiratory act. 

Professor Thompson felt convinced that Professor Barry 
had shown that there w^as mainly only one form of afferent 
nerve. It also appeared that there was conduction of the 
respiratory impulse along the cord. He did not see any 
difficulty about the sympathetic or vagi acting as afferent 
nerves. He did not think that the respiratory movements 
were confined to the muscles of respiration, but involved the 
muscles of the limbs, and that both of these nmscles act in 
harmony. 

Professor Geddes suggested that the respiratory move- 
ments were not confined to the respiratory muscles. He 
pointed out that all four-footed animals used their limb 
muscles as part of their respiratory mechanism, and as these 
animals spent the greater part of their lives on their four 
limbs a complete respiratory mechanism was developed 
apart from the diaphragmatic. He maintained that cats 
came into an intermediate class as they had a more impor- 
tant diaphragm from the respiratory point of view. 

It was of importance that an altogether extraordinary set 
of muscles of respiration should not be taken, and the ordi- 
nary muscles of respiration ignored. He mentioned that the 
horse could live and work with his phrenic nerve cut. He 
could not say what the stimulus was, but there were two 
possibilities — one being the chemical due to an accumula- 
tion of the CO2, and the second that the muscles spent most 
of their lives pre^paring to be called into play. 

Professor Barry, in replying to the remarks, said as to 
the nature of the stinmlus, he believed it to be a mechanical 
effect, but in many cases the response seemed to be 
chemical, due to the accumulation of CO 2 in the lungs. 

He thought that no one would deny the existence of ordi- 



66 Royal Acade^ny of Medicine m tretand. 

nary sensory fibres in the lung, and insUmced the production 
of pain by a central j)neumonia. Tliis pain was generally 
believed to pass through the stellate ganglia. He admitted 
that there was considerable shock following the operation of 
cutting the spinal cord, and suggested that the shock might 
account for the lack of response, but he thought that the 
diagrams shown i)roved that this definite change brouglit 
about by cutting the cord must be due to more than shock. 
There was always the possibility of afferent fibres in the 
phrenic, and that diaphragm impressions could never be ex- 
cluded. Kef erring to the cervical centres in the cervical 
spinal cord, it was found that, even with the phrenics cut 
and the vagi cut, impulses did take place at the centre. 



SECTION OF MEDICINE. 

President— J. O'Carroll, M.D., F.R.C.IM. 
Sectional Secretary— F. C. Purser, M.D., F. P. C.P.I. 

Friday, May 10, 1913. 

Dr. H. C. Drury in the Chair. 

Tiro Unumial Cases of Enteric Fever. 

Sir John Moore described two cases of enteric fever pre- 
senting unusual features. In one the original fever was 
succeeded by a recrudescence lasting about twenty days. 
An apyrexial period of eighteen days followed, when a true 
relapse, lasting a f(n'tnight, set in. Nearly two months later 
the ])atient again became feverish, and suffered from 
catarrhal jaundice. He made a good recovery. There were 
never serious intestinal symptoms. 

The second case was one of protracted course. There were 
epistaxis and intestinal luemorrhage. Convalescence was 
complicated by " typhoid s})ine." An a^-ray examination 
by Dr. W. (x. Harvey showed osteo-periostitis of the left 
side of tile third lumbar vertebra, spreading downwards to 
the fourth lumbar vertebra. [His papcM* will be found in 
Vol. cxxxv., |)age 110.] 

Dr. Drury said that the first case illustrated the ten- 
dency which there is in light cases of enteric to relapse. 
The lightness of the cases was shown by the fact that there 



Section of Medicine. 67 

was never any haemorrhage, which suggested that the ulcera- 
tion was not very deep. He did not suggest that heavy cases 
did not relapse, but he considered it more likely to occur in 
the mild cases. 

Professor McWeeney, referring to the first case, asked if 
the Widal reaction was done on more than one occasion; 
as there were three or four distinct relapses it would have 
been interesting to see if there were any fluctuations in the 
agglutinating power of the serum. He agreed that the 
attacks of jaundice were due to infection of the bile passages 
with Bacillus typhosus. 

Dr. Finny discussed the question of relapse and how 
relapses came about. He said that some soldiers who had 
been inoculated against typhoid had, shortly after inocula- 
tion, been exposed to infection and had contracted very 
severe typhoid. The more recently inoculated cases, in fact, 
seemed to suffer most. He drew a parallel between this and 
relapses. 

Tests far Liver Function. 
Dr. Nesbitt gave an account of four tests for liver function 
which he stated were now in very general use at some of the 
Continental clinics, and which he considered, from his own 
experience, would be found of service in the diagnosis of 
obscure liver disturbancs. 

Two of them depend on the fact that although consider- 
able tolerance of glucose may exist with even advanced 
disease of the liver, two other simple sugars — viz., laevulose 
and galactose — are excreted in the urine in considerable 
quantity after their administration by the mouth where dis- 
turbance of liver function exists. 

In the laevulose test 100 grm. of this sugar are given in the 
morning. Any trace of sugar in the urine indicates liver dis- 
order, but the test will not differentiate the nature. 

A serious objection is that the size of the dose is most ob- 
jectionable, being frequently followed by nausea, vomiting, 
and diarrhoea,, and the further fact that alx)ut 10 per cent, of 
normal cases show some sugar in the urine renders the test 
unreliable. 

The use of galactose in 40 grm. dose forms a much better 
test. Normal cases excrete sugar for one, or at most two, 
hours subsequently. Cases with general cell, as apart from 
local lesions, in the liver eliminate sugar for five, six, or more 



68 Royal Academy of Medicine in Ireland. 

hours in considerable quantity. The test is, therefore, posi- 
tive in — e.g., cirrhosis of all varieties, toxic forms of icterus, 
and parenchymatous degeneration — but negative in local 
lesions, such as tumours, and in two more or less general 
conditions — viz., chronic passive congestion and amyloid 
disease. This test is easily apphed, and will be found 
reliable. A further test, depending on quite a different 
function of the liver, is the use of amino-acids. 10 grm. of 
glycocoll are given, and the amino-acid in the urine is esti- 
mated by a modification of Heniique's method. No increase 
over the usual small traces is found where the liver is 
healthy, but disease of this organ causes the appearance of 
substantial amounts, even up to 5 grm. The test is rather 
more troublesome to carry out, but in practice has l)een 
found extremely accurate. 

The most simple, novel, and reliable of these tests is, 
however, the " aldehyde reaction." Two drops of Ehrlich's 
aldehyde solution (a 2 per cent, solution of dimethyl-para- 
amino-benzaldehyde in 50 per cent. HCl) are added to 5 c.c. 
of urine. A deep rose-red colour indicates excess of urobilin- 
ogen, and, therefore, insufficiency of the liver, which is allow- 
ing urobilinogen (formed in the intestines from bilirubin) to 
pass through into the systemic circulation. Normal cases 
show only the faintest trace of pink, constituting a negative 
reaction . 

This test has been found very reliable, and is given by any 
condition of the liver which will derange even a snudl nund)er 
of cells, but is most strongly positive in such conditions as 
chronic congestion, cirrhosis, tumours, degenerations of 
various forms, syphilis, and amyloid disease. Further, the 
reaction will be obtained frequently before physical signs of 
any kind have appeared. Its advantages in cases of this kind 
will readily suggest themselves. 

These tests will doubtless prove of great value to the differ- 
ential diagnosis of obscure conditions, where there may or 
may not be reason to suspect the liver, but on account of its 
extreme simplicity, (piickness, and apparent reliability, the 
aldehyde reaction is quite worth a ])lace in all routine ex- 
amination of the urine. 

TiiK CiiAiKMAN thanked Dr. Nesbitt for his paper, and said 
that anything that helped to the understanding of the 
chemical com})osition of the body and its physiological pro- 
cesses was worthy of the best att<'ntion of the Academy. 



Section of Medicine. 69 

Dr. Smith congratulated Dr. Nesbitt on the trouble he had 
taken in bringing forw^ard the results of his investigations. 
He considered that caution should be exercised in drawing 
any conclusions from risky tests. It would be difficult to 
exempt any organ in the abdomen — the pancreas for in- 
stance — from having shared in the chemical changes. Every 
one knew that attempts had been made to demonstrate, from 
experiments on the urine, the existence of pancreatic disease. 
He, therefore, took exception to the title of the paper, and 
asked how it could be known that it was the function of the 
liver and not of the pancreas. He referred to the expense 
of the experiments, and considered that this would prohibit 
their use to any large extent. He expressed the hope that 
sooner or later the organic chemists would elucidate the 
nomenclature of sugars which was now in such a hopeless 
state. He was not convinced that the aldehyde test was 
very important. 

Professor McWeeney felt that Dr. Nesbitt was going on 
the right lines. Attacks of the liver are found very difficult 
to explain, and in order to arrive at a better understanding 
as to what is going on it would seem desirable to test how 
the liver performs its functions. With regard to the testing 
the capacity of the liver to deal with sugars, he remem- 
bered the development of this question since Straus brought 
it forward in 1897, and, so far as he recollected, the best 
reason for using laevulose as a test of the adequacy of the 
liver is that laevulose is capable of being used by the liver 
alone, whereas galactose is capable of being used by the 
muscles also. The chief reason for using galactose was that 
the dose was considerably smaller. He submitted that in a 
severe case of liver inadequacy the sugar appeared earlier in 
the urine than it did if the liver was not so much out of 
order. The time of collection of the urine after the adminis- 
tration of the test was, therefore, of importance. 

Dr. Nesbitt, in replying, said he could not state the re- 
lationship between the liver function and the pancreas, but 
if it could be shown that these tests were positive in a 
number of cases, and it could be demonstrated that in these 
cases the liver was diseased, something was gained. He sub- 
mitted that these tests would show whether the liver was 
normal or not, 



SANITARY AND METEOROLOGICAL NOTES. 



Vital Statistics 
For jour weeks ending Saturday, May 17, 1913. 

IRELAND. 
The average annual death-rate represented by the deaths — 
exclusive of deaths of persons admitted into public institutions 
from without the respective districts — registered in the week 
ended May 17, 1913, in the Dublin Registration Area and 
the twenty-six principal provincial Urban Districts of Ireland 
was 18.1 ])er 1,000 of their aggregate population, which for the 
purposes of these returns is estimated at 1,199,180. The 
deaths registered in each of the four weeks of the period 
ending on 8aturda3% May 17, and during the whole of 
that period in certain of the districts, alphabetically arranged, 
correspond to the following annual rates per 1,000 : — 



County Boroughs, &c. 




Week ending 




1 

Average 
Rate 
for 4 
weeks 


April 
26 


May 
3 


May 

10 


May 
17 


27 Town Districts 


21.3 


18.5 


19.3 


18.1 


19.3 


Dublin Reg. Area 


24.5 


16.8 


20.4 


17.9 


19 9 


Dublin City 


2G.9 


16.6 


23.0 


17.4 


21.2 


Belfast 


20.4 


18.7 


17.1 


18.2 


18.6 


Cork 


23.8 


26.5 


23.8 


21.1 


23.8 


Londonderry 


17.8 


16.5 


5.1 


14.0 


13.4 

1 


Limerick 


16.2 


14.9 


24.4 


9.5 


16.3 1 

1 


Waterford 


17.1 


17.1 


20.9 


20.9 


19.0 , 

1 



The deaths (excluding those of persons admitted into public 
institutions from without the respective districts) from certain 
ei)idemic diseases regihterod in the 27 districts during the week 
ended Saturday, May 17, 1913, were equal to an annual 
rate of 1.4 per 1.000 Among the 138 deaths from all causes 



Sanitary and Meteorological Notes. 71 

for Belfast are -one from measles, one from enteric fever, 
4 from scarlet fever, 3 from diarrhoeal diseases, and one from 
diphtheria. One of the 31 deaths from all causes for Cork 
is from measles. One death from enteric fever is included in 
the 7 deaths from all causes for Limerick. One of the 11 
deaths for Waterf ord is from whooping-cough. Of the 4 deaths 
from all causes for Lis burn one is from measles. Among the 
9 deaths from all causes for Newry is one from measles. Five 
deaths from measles are among the 13 deaths from all causes for 
Wexford, and the 4 deaths from all causes for Kilkenny include 
one from enteric fever. 

DUBLIN REGISTRATION AREA. 

The Dublin Registration Area consists of the City of Dublin, 
as extended by the Dublin Corporation Act, 1900, together 
with the Urban Districts of Rathmines, Pembroke, Blackrock 
and Kingstown. The population of this area is 403,000 ; 
that of the City being 308,187, Rathmines 38,769, Pembroke 
29,942, Blackrock 9,161, and Kingstown 16,941. 

In the Dublin Registration Area the births registered 
during the week ended May 17 amounted to 200 — 111 boys 
and 89 girls — and the deaths to 151 — 81 males and 70 
females. 

DEATHS. 

The registered deaths, omitting the deaths (numbering 13) 
of persons admitted into public institutions from locahties 
outside the Area, represent an annual rate of mortality of 
17.9 per 1,000 of the population. During the twenty weeks 
ending with Saturday, May 17, the death-rate averaged 
22.4, and was 2.2 below the mean rate for the corresponding 
portions of the 10 years 1903-1912. 

The total deaths registered, numbering 151, represent an 
annual rate of 19.5 per 1,000. The annual rate for the past 
twenty weeks was 23.9 per 1,000, and the average annual rate 
for the corresponding periods of the past ten years was 25.8 
per 1,000 of the mean population for all deaths registered. 

The total deaths from all causes included 1 from diphtheria, 
1 from measles, 2 from influenza, 3 from whooping-cough, 
and 5 deaths of children under two years of age from diarrhoea 
and enteritis. 

In each of the three preceding weeks, deaths from diphtheria 



72 Sanitary and Meteorological Notes, 

were one, 2, and ; deaths from influenza were 7, 2, and 2 ; 
deaths from measles were 0, 0, and ; deaths from whooping- 
cough were 2, one, and one ; and deaths of chikken under two 
years of age from diarrhoea and enteritis were 5, 3, and 3, 
respectiv^ely. 

There were 33 deaths from tuberculous disease. This 
number includes 23 deaths from pulmonary tuberculosis, 3 
from tul^ercular meningitis, 3 from abdominal tuberculosis, 
one from tuberculosis of a joint, and 3 deaths from disseminated 
tulxirculosis. In each of the three preceding weeks deaths 
from tuberculous disease numbered 42, 29, and 34. 

Of 12 deaths from pneumonia, broncho-pneumonia caused 
6 deaths, lobar pneumonia one death, and pneumonia {t\ye 
not distinguished) caused 5 deaths. 

Organic diseases of the heart caused the deaths of 12 persons, 
and 10 deaths from bronchitis were recorded. 

Six deaths were caused by cancer. 

The deaths of 2 infants under one year of age were caused 
by convulsions, that of one from a congenital malformation, 
those of 5 infants by congenital debility, and those of 3 through 
premature birth. 

There were 3 accidental deaths, of which 2 were by vehicles 
and horses. 

In 2 instances the cause of death was " uncertified," there 
having been no medical att/cndant during the last illness. 
These cases comprise the deaths of 2 infants under one year of 
age. 

Thirty-seven of the persons whose deaths were registered 
during the week ended May 17, were under 5 years of ago 
(25 being infants under one year, of whom were under one 
month old), and 34 wvw aged 65 years and upwards, including 
28 ]X)rsons aged 70 and upwards. Among the latter were 16 
aged 75 years and upwards, of whom one (a female) was stated 
to have l)eon aged 94 years. 

STATE OF INFECTIOUS DISEASE IN THE DUBLIN 
REGISTIIATION AREA AND IN BELFAST. 

The usual returns of the number of cases of infectious 
diseases notified under the " Infectious Diseases (Notification) 
Act, 1889," and the " Tuberculosis IVevention (Ireland) Act, 
1008," as set forth in the following table, have been furnishecj 



Sanitary and Meteorological Notes. 



73 



by Sir Charles A. Cameron, C.B., M.D., Medical Superintendent 
Officer of Health for the City of Dublin ; by Mr. Fawcett, 
Executive Sanitary Officer for Rathmines and Rathgar Urban 
District ; by Mr. Manly, Executive Sanitary Officer for 
Pembroke Urban District ; by Mr. Heron, Executive Sanitary 
Officer for Blackrock Urban District ; by the Executive 
Sanitary Officer for Kingstown Urban District ; and by 
Dr. Bailie, Medical Superintendent Officer of Health for the 
City of Belfast. 

AiiiiK SHOWING THii; NuMBEU OF Cases OP INFECTIOUS DISEASES notified in the Dublin 
Registration Area (viz. — the City of Dublin and the Urban Districts of Kathmines 
and llathgar, Pembroke, Blackrock, and Kingstown), and in the City of Belfast, 
(luring the week ended May 17, 1913, and during each of the preceding three 
weeks. An asterisk (*) denotes that the disease in question is not notifiable in the 
District. 









1 — 
























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Oily of Diihlin J 


May 3 
May 10 


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May 3 


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Urban 


May 10 


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Disliici 


May 17 


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Puinlti'oke 
Urban I 
District 


April 26 
May .3 
Mav 10 
May 17 


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17 


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Urban { 
DiHl.riut 1 


April 26 
May 51 
May 10 
May 17 


* 
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Kin^^Hlowii 1 
Urban { 
DiHlrict 


April 26 
May 3 
May 10 
May 17 


* 
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1 


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1 
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April 26 


• 




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_ 


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22 




70 


Cilyof Helfaxt | 


May 3 
Mav 10 


• 
• 




46 

57 


- 


- 


8 
5 


- 


1 


3 


8 
9 


- 




• 
• 


14 

8 




86 
75 


^ 


May 17 


• 




37 


- 


- 


4 


- 


- 


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4 


1 




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4 




r.l 



a Continued Fever. 

Cases of Infectious Diseases under Treatment in Dublin 

Hospitals. 
During the week ended May 17, 1913, 9 cases of measles 
were admitted to hospital, 11 were discharged, and 20 cases 



74 Sanitary and Meteorological Notes. 

remained under treatment at the close of the week. In the 
three preceding weeks such cases were 16, 15, and 22 respec- 
tively. 

Twelve cases of scarlet fever were admitted to hospital, 21 
were discharged, and 90 cases remained under treatment at 
the close of the week. This number is exclusive of 19 con- 
valescent patients who remained under treatment at Beneavin, 
Glasnevin, the Convalescent Homo of Cork Street Fever 
Hospital, Du])lin. At the close of the three preceding weeks 
the cases in hospital were 87, 88, and 99 res|)ectively. 

Eight cases of diphtheria were admitted to hospital, 7 
were discharged, and there was one death. The cases in 
hospital, which at the close of the three ])receding weeks 
numbered 00, 00, and 58 resjxjctively, wei-e 58 at the close 
of the week. 

One case of enteric fever was admitted to hospital, 4 were 
discharged, and 19 cases remained under treatment in hospital 
at the close of the week, the respective numl)ers in hospital 
at the close of the three preceding weeks l)eing 27, 24, and 22. 

One case of typhus was discharged from hospital during 
the week, and 10 cases remained under treatment at the close 
of the week. 

In addition to the above-named diseases, 8 cases of 
]ineumonia were admitted to hos])ital. 9 were discharged, 
there were 2 deaths, and 18 cases remained under ti-eatment 
at the end of the week. 

ENGLAND AND SCOTLAND. 

The mortality in the week ended Saturday, May 17, in 
90 large English towns (including Ijondon, in which the rat<^ 
was 12.0) was equal to an average annual death-rat« of 12.8 
per 1,000 ]iersons living. The average rate for 16 principal 
towns of Scotland was 10.4 ])or 1,000, the rate for Glasgow 
being 17.4, and that for Edin))urgh l.S.2. 

INFECTIOUS DISEASE IN EDINBURGH. 

The Registrar-General lias Ix^en favoui-ed by A. Maxwell 
Williamson, M.D., B.Sc, Medical Ofticer of Health for Edin- 
burgh, with a copy of his Return of Infectious Diseases 
notitiod during the week eiuled May 17. From this report 
it appears. that of a total of 45 ca.ses notified, 21 were of 
phthisis, 12 of scarlet fever, 7 of diphtheria, one of erysii^elas. 



Sanitary and Meteorological Notes. 75 

and 4 of enteric fever. Among the 351 cases of infectious 
diseases in hospital at the close of the week were 100 cases of 
scarlet fever, 111 of phthisis, 49 of measles, 42 of whooping- 
cough, 25 of diphtheria, 2 of erysipelas, 8 of chicken-pox, and 
6 of enteric fever. 



Meteorology. 
Abstract oj Observations made in the City of Dublin, Lat. 53° 20' 

iV., Long. 6° 15' W., for the Month of May, 1913. 
Mean Height of Barometer, - - - 29.859 inches. 

Maximal Height of Barometer (14th, at 9 p.m.), 30.332 
Minimal Height of Barometer (8th, at 1 p.m.), 29.063 „ 
Mean Dry-bulb Temperature, - - - 51.5°. 

Mean Wet-Bulb Temjierature,- - - 48.2°. 

Mean Dew-point Temperature, - - 44.8°. 

Mean Elastic Force (Tension) of Aqueous Vapour, .303 inch. 
Mean Humidity, - - 78.9 per cent. 

Highest Temperature in Shade (on 24th), - 67.2°. 
Lowest Temperature in Shade (on 4th and 7th), 38.2°. 
Lowest Temperature on Grass (Radiation) (7th), 34.9°. 
Mean Amount of Cloud, - - - 58.9 per cent. 

Rainfall (on 17 days) - - - 2.802 inches. 

Greatest Daily Rainfall (on 5th), - - .668 inch. 

Greneral Directions of Wind, - - - W., S.W. 

Remarks. 
The early part of May was unsettled, cold and rainy or 
showery. In the week ended Saturday, the 10th, the sky was 
much clouded, rain fell frequently, thunder and hail showers 
being reported from time to time in many districts. On the 
11th the thermometer ran up to 63.1° in Dublin, but the next 
day was dreary and wet, with easterly winds and the ther- 
mometer ranging only from 48.2° to 51.3°. After this the 
weather improved, remaining chiefly fine until the 21st, on 
which day hail fell heavily in Dublin, and thunder and lightning 
occurred in several places. On the 24th a spell of hot weather 
set in over the south of Ireland, and even in Dublin the ther- 
mometer rose to 67.2° in the screen — the highest reading for 
the month. At Greenwich the thermometer rose in the shade 
to 75° on the day named, 78° being reached at Camden Square, 
London, N.W. The readings at these stations during the 



76 Sanitary and Meteorological Notes. 

following days were unusually high for May — namely, 
Greenwich— 81°, 84°, 84°, 81°, 81°, 80° ; Camden Square— 
82°, 84°, 84°, 82°, 83°, 80°. On Saturday, the 31st, a brisk 
dip in temperature was observed in the London area, for the 
maximum was only 63° at Greenwich and 66° at Camden 
Square. Du])lin almost escaped the electrical disturbances 
of the month, but in the south of England there were severe 
storms on the 27th, and in the course of the night of the 29th. 

In Du])lin the arithmetical moan tomix)rature (52.3°) was 
0.1° above the av^erage (52.2°). The mean dry-bulb readings 
at 9 a.m. and 9 p.m. were 51.5° In the forty -eight years ending 
with 1913, May was coldest in 1869 (M. T. = 48.2°), and 
warmest in 1893 (M. T. = 56.7°). In 1911 the M. T. was 
55.3°, and in 1912, 53.5°. 

The moan height of the barometer was 29.859 inches or 
0.130 inch below the corrected avrrage value for May — namely, 
29.989 inches. The mercury rose to 30.332 inches at 9 p.m. 
of the 14th, and fell to 29.063 inches at 1 p.m. of the 8th. The 
observed range of atmospheric pressure was, therefore, 1.269 
inches. 

The mean temperature deduced from daily readings of the 
dry-bulb thermometer at 9 a.m. and 9 p.m. was 51.5°, or 5.0° 
above the value for April, 1913 — 46.5°. Using the formula 
Mean Temp. = 3rin+ {Max. — Min.) x .47, the value is 52.0°, 
or 0.2° above the average mean temj^x^rature for May, calculated 
in the same way, in the thirty-five j'ears, 1871-1905, inclusive, 
(51.8°). The arithmetical mean of the maximal and minima] 
readings was 52.3°, compared with a thirty-five years' average of 
52.2°. On the 24th the thornKunoter in the screen rose to 
67.2°— wind, W ; on the 4th the tom]X)raturo fell to 38.2°— 
wind, N.N.W. The same reading was recorded on the 7th, 
wind, S.S.E. The minimum on the grass was 34.9° on the 
7th. 

The rainfall amounted to 2.802 inches, distributed over 17 
dayn. The average rainfall for May in the thirty-five years, 
1871-1905, inclusive, was 1.970 inches, and the average number 
of rain-days was 15. The rainfall therefore was considerably 
a])Ove the average, while the rain-days were 2 in excess. In 
1886 the rainfall in ^Fay was very largo — 5.472 inches on 21 
da3's ; in 1869, also, 5.414 inches fell on 19 days. On the other 
hand, in 1895, only .177 inch was measiu'cd on but 3 days. 



Sanitary and Meteorological Notes. 77 

In 1896 the fall was only .190 inch on 7 days. In 1911, 1.286 
inches fell on 10 days ; in 1912, 1.042 inches on 19 days. 

A lunar corona appeared on the 11th. High winds were 
noted on 6 days, including a gale on the 30th. Hail fell on the 
21st. Thunder was heard on the 1st. 

The mean minimal temperature on the grass was 43.4°, 
compared with 44.5° in 1912, 46.2° in 1911, 42.0° in 1910, 
41.9° in 1909, 45.2° in 1908, 41.6° in 1907, 41.9° in 1906, 
42.5° in 1905, 42.6° in 1904, 44.3° in 1903, 40.3° in 1902, 
41.7° in 1901, and 37.6° in 1894. The maximum fell short 
of 50° on the 6th (46.2°). The absolute maximum was 67.2° 
on the 24th. 

The rainfall in Dublin during the five months ended May 31st 
amounted to 13.899 inches on 91 days, compared with 11.161 
inches on 87 days in 1912, 5.986 inches on 69 days in 1911, 
12.421 inches on 92 days in 1910, 10.098 inches on 75 days in 
1909, 10.078 inches on 95 days in 1908, 9.499 inches on 81 days 
in 1907, 11.592 inches on 97 days in 1906, 9.026 inches on 81 
days in 1905, 11.741 inches on 92 days in 1904, 12.560 inches 
on 95 days in 1903, 9.973 inches on 81 days in 1902, 7.724 
inches on 67 days in 1901, 5.971 inches on 70 days in 1896, 
and a thirty-five years' average of 10,040 inches on 81 days. 



At the Normal Climatological Station in Trinity College, 
Dublin, the observer, Mr. C D. Clark, returns the arithmetical 
mean temperature as 51.8°, the mean dry-bulb reading at 9 a.m. 
and 9 p.m. being 52.1°. Rain fell on 13 days to the amount of 
2.71 inches, .69 inch being measured on the 5th. The number 
of hours of bright sunshine registered by the Campbell-Stokes 
sunshine recorder was 159.2, giving a daily average of 5.1 hours. 
The corresponding figures for May, 1904, were 192.5 hours and 
6.2 hours ; for 1905, 215.7 hours and 7.0 hours ; for 1906, 
132.5 hours and 4.3 hours ; for 1907, 173.0 hours and 5.6 hours ; 
for 1908, 193.9 hours and 6.3 hours ; for 1909, 231.5 hours 
and 7.5 hours ; for 1910, 175.5 hours and 5.7 hours ; for 1911, 
214.0 hours and 6.9 hours, and for 1912, 157.8 hours and 5.1 
hours respectively. The mean earth-temperature at 9 a.m. 
was 52.3° at a depth of one foot below the surface, 49.7° at 
4 feet. The corresponding values for 1912 were 54.5° and 
51.7° ; for 1911, 54.6° and 51.0° ; for 1910, 54.7° and 49.3°, 
and for 1909, 52.3° and 50.0°. The lowest temperature on 



78 Sanitary and Meteorological Notes. 

the grass (terrestrial radiation) was 20.0'' on the 7th. The 
highest temperature in the shade was 68° on the 24th ; the 
lowest was 36.0^ on the 7th. 



Captain Edward Taylor, D.L., returns the rainfall at 
Ardgiilan, Balbriggan, Co. Dublin, as having been 3.04 inches 
on 18 days ; the largest fall in one day was .88 inch on the 5th. 
The rainfall was 1.10 inches above the average, the rain -days 
were 5 in excess. Since January 1, 14.13 inches of rain have 
fallen at that station on 88 days, this measurement l)eing 3.00 
inches above the average and the rain-days l^eing 9 in excess. 
The shade temperature ranged from 67.9° on the 24th to 
35.3*^ on the 5th. 

Mr. T. Bateman returns the rainfall at The Green, Malahide, 
Co. Dublin, at 3.065 inches on 13 days. The greatest rainfall 
in 24 hours was .77 inch on the 5th. The extremes of tem- 
perature in the shade were — highest, 71° on the 25th ; lowest, 
33° on the 4th. The mean temi:>eraturo was 50.3°. 

At the Ordnance Survey Office, Phoonix Park, Dublin, rain 
fell on 16 days to the amount of 3.005 inches, the largest 
measurement in 24 hours being .770 inch on the 5th. The 
total amount of sunshine was 150.0 hours, the most in one day 
being 12.7 hours on the 18th. 

Dr. C. Joynt, F.R.C.P.I., returns the rainfall at 21 I^eeson 
Park, Dublin, at 2.765 inches on 16 days, .625 inch being 
measured on the 5th. 

At Cheeverstown Convalescent Home for Little Children 
of the Poor, Clondalkin, Co. Dublin, Miss C. Violet Kirkpatrick 
recorded a rainfall of 4.13 inches on 17 days, the maximal fall 
in 24 hours l)cing .90 inch on the 8th. 

Dr. Arthur S. Goff returns the rainfall at Belfort House, 
Dundrum, Co. Dublin, at 3.49 inches on 14 days. The greatest 
daily measurement was .65 inch on the 7th. The tem]X'raturc 
in the shade ranged from 70° on the 24th to 38° on the 4th 
and 7th. The moan tem]x>rature of the month was 53.0^, 
compared with 54.8° in 1912, 55.6° in 1911, 52.4° in 1910, 
53.6° in 1909, 56.2° in 1908, 51.1° in 1907, 51.8° in 1906, 54.6° 
in 1905, 53.3° in 1904, 53.1° i!i 1903, 50.5° in 1902, and 52.6° 
in 1901. Hail fell on the 6th. 

At Manor Mill Lodge, Dundrum, Co. Dublin, Mr. George B. 
Edmondson measured 3.42 inches of rain on 14 days, the 



Sanitary and Meteorological Notes. 79 

greatest fall in 24 hours being .72 inch on the 12th. The mean 
temperature was 52.1°, the extremes being — highest, 70° on 
the 24th ; lowest, 38° on the 4th. 

At the Sanatorium of the Dublin Joint Hospital Board, 
Crooksling, Co. Dublin, Dr. A. J. Blake, the Resident Medical 
Superintendent, reports a rainfall of 4.10 inches on 18 days. 
The largest meaurement in 24 hours was 1.08 inches on the 7th. 

Mr. W. M'Cabe, the observer for the Right Hon. L. A. 
Waldron, reports that the rainfall at Marino, Killiney, Co. 
Dublin, was 2.46 inches on 14 days, .54 inch being measured 
on the 5th. The average rainfall in May at Cloneevin, Killiney, 
in the 24 years, 1885-1908, inclusive, was 2.136 inches on 
13.8 days. 

At Coolagad, Greystones, Co. Wicklow, the rainfall measured 
by Dr. J. H. Armstrong was 3.64 inches on 17 days, .96 inch 
falling between the hours of 6 45 p.m. of the 5th and 9 a.m. 
of the 6th. The total fall since January 1st, 1913, equals 
21.68 inches on 95 days. Thunder was heard on the 1st, 
21st and 31st. 

Mrs. Sydney O'Sullivan measured 3.29 inches of rain on 
16 days at Auburn, Greystones, Co. Wicklow. The heaviest 
fall in 24 hours was .93 inch on the 5th. Distant thunder was 
heard on the 28th. Hail fell on the 31st. 

Dr. Charles D. Hanan, M.B., reports that the rainfall at the 
Royal National Hospital for Consumption, Newcastle, Co. 
Wicklow, was 4.70 inches on 16 days, the greatest fall in 24 
hours being 1.15 inches on the 5th. The screened ther- 
mometers ranged from 36° on the 7th to 67° on the 24th. The 
mean temperature was 49.4°, the mean maximum being 
55.6°, and the mean minimum 43.9°. 

The Rev. Arthur Wilson, M.A., writing from Dunmanway 
Rectory, Co. Cork, states that 5.55 inches of rain fell there on 
22 days, 1.34 inches being measured on the 7th. The rainfall 
was 1.97 inches over the average (3.58 inches). At Dun- 
manway other heavy falls were .75 inch on the 8th and .55 inch 
on the 11th. The first 11 days were very unsettled and cold, 
during which 4.36 inches fell. The rest of the month was fine 
and warm, with the exception of the 29th and 30th, which 
were wet. It was very warm on the 26th, 27th and 31st, and 
warm also from 12th to the 16th. The rainfall for the 5 
completed months of 1913 was 35.16 inches or 11.73 inches 
more than the average (23.43 inches) for the last eight years. 



PERISCOPE. 

"the law relating to public health in IRELAND." 

Under this title Messrs. E. Ponsonby, Ltd., 116 Grafton 
Street, Dublin, have just published the seeond edition of 
Dr. George T. B. Yanston's well-known Code of Public 
Health, which for more than twenty years has l)een a 
standard work on the subject in both le^^al and medical 
circles. The author is singularly well equipped for the task 
he has undertaken. A sometime Scholar of the House and 
a double Senior Moderator, a Master of Arts, and ]\)ctor of 
Laws of the University of ])ublin, one of His Majesty's 
Counsel and Legal Adviser to the Local Government Board 
of Ireland, Dr. Vanston has been enabled to produce a work 
which is a credit alike to himself, his Alma Mater, and 
the great profession which he adorns. We hope to review 
the book (which runs to over 1,400 royal octavo pages) in 
the August number of this journal. 

LITERARY NOTES. 

Messrs. Smith, Elder c'C Co. ])ublish(.Hl on June 'JO a work 
by Dr. W. McC. Wanklyn — who was formerly Medical 
Superintendent of the Small-pox Receiving Stations and 
River Ambulance Service of the Metropolitan Asylums 
Board, and is now an Assistant Medical Officer of the 
London County Council " — entitled " How to Diagnose 
Small-pox." The work is based on an experience of small- 
pox extending over twenty years, and including the revision 
of the diagnosis of upwards of 10,000 cases. It is intended 
for the busy practitioner and those who are not well versed 
in this disease. It is written in a clear and easy style, and 
deals with the subject in a practical numner. The work 
should be of special assistance in removing the doul)ts and 
ditliculties which surround this thorny subject. 

Mr. H. K. Lewis informs us that Mr. Louis R. J^awling's 
popular " Landmarks and Surface markings of the Human 
Body " has been adopted as the toxt-book at the Mc(iill 
University, Montreal ; Queen's University, Kingston ; 
Toronto University, Toronto ; and the Western University, 
London, Ont. 



THE DUBLIN JOURNAL 

OP 

MEDICAL SCIENCE. 



AUGUST 1, 1913. 

PART I. 
ORIGINAL COMMUNICATIONS. 



Art. IV. — Clinical Report of the Rotujida Hospital for 
One Year, November 1st, 1911, to October Slst, 1912. a 
By Henry Jellett, M.D. (Dubl. Univ.), F. E.G. P. I., 
Master; and David G. Madill, M.B. (Dubl. Univ.), 
and K. Marshall Allan, M.B. (Edin. Univ.), Assis- 
tant Masters. 

( Continued from page 19. ) 

Gynecological Report. 

During the year, 587 patients were admitted to the 
Gynaecological Department — a slightly smaller number 
than those admitted in the preceding year. There were 
479 operations performed, and the total mortality was 
nine — i.e., 1.53 per cent. Of the nine deaths one 
occurred the day after admission of a patient who was 
sent into the Hospital with an incarcerated myoma, which 
had been causing retention of urine for a consider- 
able time. The inside of the bladder was gangrenous, 
the urine black and foul smelling, and the patient was 

* Read in the Section of Obstetrics of the Royal Academy of Medicine 
in Ireland on Friday, April 18, 1913. [For the discussion on this Report 
see page 58 of the July number of this Journal,] 

VOL. CXXXVI,— NO. 500, THIRD SERIES. F 



82 Clinical Report of the Rotunda Hospital. 

in a condition of general poisoning. One death occurred 
of a patient operated on for papilloma of the ovary, owing 
to recurrence of the disease. One death was of a patient 
suffering from carcinoma of the pylorus with a large 
abdominal tumour, in whose case operation had to be aban- 
doned. One death was in a case of sarcoma of the uterus, 
in which an extensive resection of the small intestine had 
to be carried out. One death occurred immediately after 
operation for what subsequently proved to be chorion- 
epithelioma involving the pelvis. One death occurred from 
heart failure a couple of days before the patient was to leave 
hospital after an operation for uterine prolapse, in which the 
interposition operation was abandoned on account of ab- 
nonnal adhesions between the bladder and the uterus, and 
in which colpo-perinoeorrhaphy alone was done. One death 
was from acute general peritonitis after an operation for 
tuberculous appendages. One death was of a patient who 
was admitted seven months pregnant, with high tempera- 
ture and rapid pulse, who became jaundiced with total 
suppression of urine. Her case is referred to later. 

The number of major operations has been considerable. 
Hysterectomy for malignant disease is almost the only one 
in which the figures are lower than for the previous year. 
Wertheim's operation was performed only five times, 
while eight cases of cancer were sent out without 
operation. This does not mean that I operated only on 
early cases of uterine cancer. I have operated on all cases 
which 1 thought attorded any prospect of relief, but most 
of those we saw during the past year have been charac- 
terised by their advanced nature, and in those in which 
operation was not performed the disease was so extensive 
as entirely to prevent any operative measures. On the 
other hand, the number of operations for mvomata is con- 
siderable. There were fifteen hysterectomies, all of 
which were supra-vaginal, and twenty-four myomecto- 
mies. It is noteworthy in what a large proportion of 
cases it was found possible to save the uterus. All these 
cases — both hysterectomy and myomectomy — recovered. 



By Dr. Henry Jellett, Master. 83 

Twenty-five operations were performed for prolapse. 
In the treatment of this condition I have followed the same 
lines as previously — that is to say, I have tried to dis- 
cover the nature of the lesions present, and then to deal 
with each. Wertheim's interposition operation was done 
in eighteen cases. My own operation for shortening of the 
utero-sacral ligaments was done in thirteen cases, in six of 
which the interposition operation was also performed. In 
one case I did a reversed Wertheim operation, bringing 
down the body of the uterus posteriorly between the 
vaginal mucous membrane and the rectum. I did this 
because there was a very large rectocele, and there were 
no muscles in the pelvic floor that could be brought 
together to re-form the perineum. Consequently I saw no 
other way of curing the rectocele. The operation appeared 
to be successful in so far as the keeping up of the rectum 
was concerned, but I was not greatly pleased with the 
result otherwise. I think it is calculated to cause too 
abnormal a position of the uterus. I have made several 
efforts to see the patient now that some time has elapsed 
since the operation, but I have not been able to do so, 
so that I can give no opinion as to its ultimate results. 
Prolapse of the cervical stump after a hysterectomy is a 
complication which is very difficult to treat. One such 
case came under treatment, in which supra-vaginal hys- 
terectomy had been done some years before, and, as the 
woman at the time suffered from prolapse, the operator 
had fixed the upper portion of the stump to the abdominal 
wall, doing, in fact, a ventral cervical fixation. Under 
the strain of the prolapsing vagina, however, the stump 
elongated, until eventually, although it remained fixed 
above, it projected almost through the vulva below. In 
this case I operated as follows : — I first freed the stump 
from the abdominal wall through an anterior colpotomy 
opening, and then carried out an interposition operation, 
exactly as if the stump was the body of the uterus. This, 
however, gave no support to the upper portion of the 
stump, as all ligaments were gone, and there was no 



84 Clinical Report of the Rotunda Hospital. 

possibility of obtaining siipi^rt from them. The patient 
also had a ventral hernia, and so, at the second stage of 
the operation I cured this hernia, and at the same 
time I made an opening into the posterior vaginal fornix 
from above, and pulled np into the abdomen the vaginal 
portion of the cervix. I excised the mucous membrane 
of the cervical canal, and then tried to fasten the stump to 
the fascia lying over the sacral vertebrae, as is sometimes 
done in cases of rectal prolapse. Unfortunately, how- 
ever, the stump was not long enough to reach so high, and 
so I found the remains of the round ligaments and sutured 
them firmly to it. At the first operation I also did as 
extensive a perinaeorrhaphy as possible. The immediate 
results of the operation were satisfactory, but I have not 
seen the patient since, so cannot state what its later results 
have been. 

I wish now to refer more particularly to four cases of 
special interest that occurred during the year. 

Case I. — M. G., aged thirty-three, was admitted to the 
Maternity Wards on March 24th. She was in her fourth 
pregnancy, and at about the seventh month. She gave a 
history of vomiting for the past three days, with severe pain 
in the right side for the past week. On admission, her tem- 
])crature was normal, but her pulse was 140. She was very 
constipated, and complained of pain in the region of the 
appendix. As it was thought that she was probably suffer- 
ing from some trouble in the appendix, she was transferred 
to the Gynaecological Wards. The urine contained albumen, 
graiuilar casts, and red blood corpuscles. Action of the 
bowels was obtained by means of eneniata and purgatives. 
The next day her temperature rose to 101° F., while her pulse 
dropped to 120. There was a definite area of tenderness and 
fulness to be made out on the right side of the abdomen. 
Mr. Heuston kindly saw the case with me, and made a i)ro- 
visional diagnosis of an appendicular abscess. He accord- 
ingly opened the abdomen the same evening on account of 
the rising temperature. There was considerable difficulty 
in finding the appendix owing to the disphioement of the 
caecum by the pregnant uterus, and. when it was foimd, 
there was no abscess near it. The appendix was nonual in 



By Dr. Henry Jellett, Master. 86 

length and thickness, and was sHghtly kinked. It was re- 
moved in the ordinary manner. The patient vomited some- 
what after the anaesthetic, but the vomiting ceased the 
following morning. The next day calomel was given in grain 
doses, and the bowels moved slightly three times. The next 
morning the patient was jaundiced, the colour being especi- 
ally noticeable in the conjunctivae, and after mid-day there 
was almost total suppression of urine. At the same time 
her temperature became sub-normal, while the pulse was 
120, and the respirations 36. Later in the evening the pulse 
became very rapid and weak. Sub-mammary injections of 
saline solution were given, and diuretics by the mouth. The 
patient passed only an ounce and a half of urine during the 
night. She became very restless, and towards morning 
became comatose, and died at 8 a.m. 

The post 7nortevi examination revealed an abscess in the 
right kidney, and another of smaller size in the left kidney. 
The infecting organism was the Staphylococcus aureus. 

This case is particularly interesting on account of the 
impossibility of making an exact diagnosis during life. 
There was nothing definitely suggesting such a condition 
as abscess of the kidneys. Any special symptoms pointed 
to the appendix, or possibly to a septic peritonitis, and 
yet, at the operation, there was no evidence of trouble in 
the one or of the presence of the other. 

Case II. — Chorion- epithelioma with Extensive Involvement 
of the Pelvic Cavity. — C. McC, aged thirty-five, was ad- 
mitted to the Hospital on the 22nd of August. She stated 
that she had been married for four years, and had had three 
children at full term, the last pregnancy being a year ago. 
She complained of swelling of, and severe pain in, the 
abdomen. The latter began about three weeks ago, and 
about the same time she first noticed the swelling. Men- 
struation was irregular. When it occurred it lasted for six 
days, and was heavy in amount, with some pain. The last 
regular menstruation was six weeks ago, and since then she 
had had some blood-stained discharge. On examination, a 
tumour was found lying behind the uterus. It filled 
Douglas' pouch, and extended some way above the brim of 
the pelvis, and was soft in consistency. A few days later 



86 Clinical Report of the Rotunda Hospital. 

the abdomen was opened. The omentum was found to cover 
a dark tumour, resembHng blood-clot, about the size of an 
ostrich egg. The tumour contained dark, bloody fluid. It 
was exceedingly friable, and was situated behind the 
uterus, extending somewhat above the promontory of the 
sacrum. It was adherent to the uterus, intestines, and retro- 
peritoneal tissue. It extended round the right ureter and 
right uterine artery, which appeared as if they had been 
dissected out by it. The intestine was nearly perforated at 
one spot. The right tube and ovary were involved in the 
tumour. I thought that I was dealing with an old pelvic 
haematocele, which was partly intra- and partly extra-peri- 
toneal and in that belief I tried to remove the mass. As I 
have mentioned, it was very friable, and it bled freely where- 
ever it was separated. I removed as much of it as I could, 
and then, failing to check the haemorrhage in other ways, I 
tried to plug Douglas' pouch tightly with iodoform gauze. 
The bleeding, however, continued, and the patient died a 
few minutes after the operation was over. I regret to say 
that even during the operation I had no suspicion of the 
kind of case with which I was dealing, and thought all along 
that it was one of pelvic haematocele. Consequently, I did 
not ask for a post-mortem examination, and it was only some 
days later, when I received the report of the pieces of tumour 
that I had removed, that I learnt the nature of the case. I 
especially regret the omission of the post-viortcm examina- 
tion, as I am consequently unable to state what was the 
condition of the uterus. Dr. Rowlette's report of the frag- 
ments removed is as follows: — 

" The fragments consisted of clot mixed with friable tissue, 
and, under the microscope, masses of syncytial tissue were 
seen, some of which were very degenerate." 

It is interesting to note that tliere were no pulmonary 
complications present in this case, although it was apparently 
of some standing. 

Cases III. and IV. — Two Casca of Ruptured Uterus. — 
Two patients, both of whom were suffering on admission 
from ru|)ture of the uterus, were sent into Hospital by out- 
side practitioners in October. At the time I was laid up, and 
off duty, and they were l)oth seen and operated upon by my 
assistant. Dr. Madill 



By Dr. Henry Jellett, Master. 87 

The first case — J. W., aged thirty-four — was in her sixth 
pregnancy. It was stated that the uterus had ruptured 
about seven hours after labour began. On admission it was 
found that the child had escaped into the abdominal cavity 
with the exception of the head, which was still in the uterus. 
Dr. Madill opened the abdomen in the middle line. He 
removed the foetus and placenta, and then performed a 
supra-vaginal hysterectomy. In spite of the serious con- 
dition in which the patient was on admission she rallied well 
from the operation, and was discharged cured a month later. 

The second case — M. D., aged thirty- two — was admitted 
to the Hospital a few days later. It was evident from her 
history that she had been for several days in labour, and 
she was in a. much more serious condition on admission 
than was the first patient. She was stated to have had pain 
for a fortnight prior to admission, during which time she 
had had almost no sleep. On the morning just prior to 
her being sent to Hospital the forceps was applied three 
times, but failed to effect delivery. On examination of the 
abdomen the foetus was found to be in the abdominal cavity, 
while, through the vagina, the head could be felt presenting. 
It was large, and its bones overlapping. Subsequently it 
proved to be hydrocephalic. The condition of the patient 
was so very bad that both Dr. Madill and Dr. Purefoy, who 
also kindly saw the case, hesitated to operate, and waited for 
a little in the hope that the patient's condition might slightly 
improve. Later in the day — as a last chance — the abdomen 
was opened. A good deal of free blood was found in the 
peritoneal cavity, and the foetus and the placenta were both 
outside the uterus. They were removed, and a supra- 
vaginal hysterectomy performed with as little delay as possible. 
The patient, however, died just as the operation was complete. 

Dr. Madill has published the notes of these two cases, 
and they will be found in the ' ' Transactions ' ' of the 
Royal Academy of Medicine in Ireland. 

Three or four years ago I showed at the Obstetrical 
Section of the Academy a patient on w^hom I had per- 
formed a plastic operation for the cure of pendulous 
abdomen, the result of over-stretching of the fascia and 
separation of the recti muscles during pregnancy. I 
operated on this patient by a method of my own, and sub- 



88 Clinical Report of the Rotunda Hospital. 

seqiiently she became pregnant and went to full term, and 
was confined at the Rotunda Hospital without any over- 
stretching or yielding of the abdominal wall. 

During the past year I have operated on four more 
cases, making a total in all of some six or seven, and so I 
think it is worth referring to the operation in this Report. 
Although I evolved its steps for myself, I have since found 
that it must be considered as based on Blake's modification 
of Mayo's operation for umbilical hernia. T am not aware 
however, that any one has adopted a similar procedure for 
the cure of pendulous abdomen. T hope at a later time to 
describe the operation more fully in a special paper. Here, 
I will merely say that its steps are as follows : — 

First, the excision of an oval piece of skin extending 
from a little below the ensiform cartilage to a little above 
the symphysis. The width of the piece removed depends 
on the amount of redundant skin. 

Secondly, a vertical incision through the whole length 
of the exposed fascia into the peritoneal cavity. 

Thirdly, the suture of the edge of the conjoined fascia 
and peritoneum on the left side to the peritoneum at the 
opposite side, outside the belly of the rectus muscle in 
such a manner that the left fascia lies under the right 
muscle. 

Fourthly, the opening of the entire length of the sheath 
of the rectus muscle on the left side. This opening is made 
through the anterior layer. 

Fifthly, the opening of the entire length of the sheath 
of the rectus muscle on the right side. This opening is 
made through the posterior layer. 

Sixthly, the suture of the bellies of th(» recti muscles 
thus exposed to one another. This suture also includes 
the anterior edges of the opening in their respective 
sheaths. 

Sevevthhj, the suture of the edge of the fascia on the 
right side to the fascia on the left side outside the left 
rectus muscle in such a way that the right fascia covers 
over the left muscle. 



By Dr. Henry Jellett, Master. 



89 



Lastly, the closure of the incision in the skin. 

I have had uniformly successful results from this pro- 
cedure, and as pendulous abdomen with marked protrusion 
of the intestines and general lowering of intra-abdominal 
tension is a very serious cause of ill-health in women I 
think that it is one that is worthy of attention. 



Statistics of the Gynecological Department. 

Table No. I. — Nnmher of Admissions and of Operations. 



Number of Admissions 
„ Operations - 



587 
479 



Tablio No. II. — Nature < 


%nd Number of Operations. 


Vulva and Perineum — 




Uterus— cow. 


Removal of polypus 


I 


Vaginal shortening of utero- 


Extirpation of vulva' for 




sacral ligaments - - 13 


carcinoma 


1 


Vaginal fixation round 


Removal of Bartholin's cyst 


6 


ligaments - - 1 


Perinseorrhaphy — 




Interposition of uterus - 18 


Complete 


12 


Reversed interposition of 


Incomplete 


80 


uterus - - - 1 
Ventral suspension — 


Urethra — 




Alone - - - 17 


Excision of caruncle 


3 


Combined with other 

operations - - 98 


Vaotna 




Extra-peritoneal shortening 


Anterior Colporrhaphy 
Posterior colpotomj^ 
Excision of vaorinal c\''st - 


1 

6 

1 


round ligaments - - 85 
Intra-peritoneal shortening 
round ligaments - - 1 


Vesico-vaginal fistula 
Recto- vaginal fistula 


4 
2 


Gilliam's operation - - 4 
Anchoring cervical stump to 

round ligaments - - . 1 
M3^omectomy — 


Rectum — 




Abdominal - - 24 


Excision of haemorrhoids - 


2 


Vaginal - - - 1 
Hysterectomy — 


Cervix — 




Abdominal — 


Trachelorrhaphy 


14 


Supra-vaginal - - 24 


Amputation 


97 


Complete - - 2 


Posterior division - 


5 


Wertheim - - 5 
Vaginal - - - 1 


Uterus — 






Curettage — 




Tubes and Ovaries — 


Alone 


98 


Ovariotomy - - 23 


Combined with other 




Resection of ovary with 


operations - * - 


170 


other operations - - 30 


Removal of polypus (benign) 


8 


Salpingostomj'- - - 9 



90 Clinical Report of the Rotunda Hospital. 

Tablk No. II. — coTitintied. 



Tubes and Ovauiks — con. 




Miscellaneous — 




Resection of tube with other 




Appendicectomy, associated 




operations 


4 


with other operations 


8 


Salpingectomy — 








Single 


27 


Hemiotoni}' — 




Double 


2 


Umbilical 


2 


Salpingo-oophorectomy 




Ventral - 


1 


(alone) — 




Plastic operation for pendu- 




Single - 


1 


lous abdomen 


4 


Double 


2 


Resection of intestine 


2 


Salpingo-oophorectomy, with 




Mastitis 


2 


other operations — 




Scraping abdominal sinus - 


2 


Single - 


1 






Double (omitting 




Mortality 


9 


hysterectomies) 


4 


Percentage - - 1 


.53 


Tubal pregnancy 


5 


Average - - 1 in 65 


.22 


Removal parovarian cyst - 


3 







Table No. III. — Nature and Nnmher of Cusea Treated ivitliout 

Operation. 



No treatment indicated 


. 


32 


Vaginitis 


4 


Refused treatment • 


- 


30 


Vulvitis 


- 1 


Pregnancy - 


- 


15 


Pelvic cellulitis 


1 


Operation contra-indicated by 
general health 

Cystitis 


7 
3 


Atrophic uterus 

Inoperable malignant 
ease 


1 

dis- 
. 8 


Displacement treated 


by 




Rectal carcinoma 


1 


pessary 




4 






Ascites 




1 


ToUl 


. 108 



TnR SrANi).\RD OF Morbidity. 

The^ followin*^^ is the definition of morbidity as laid down 
by a Special Committee of the British Medical Associa- 
tion : — " A tem|)(M-ature is to be regarded as morbid which 
reaches 100° F. on any two occasions between the begin- 
ning of the second and the end of the ei^^hth day. All 



By Dr. Henry Jellett, Master. 91 

deaths are to be included as morbid, irrespective of tem- 
perature ; and , as some maternity hospitals do not admit 
abortions, these, for the sake of uniformity, are eliminated 
from the morbid statistics. The temperature is to be 
taken in the mouth twice daily, as close as possible to 
the hours of 8 a.m. and 5 p.m." 

The Insurance Act, 1911. 

Tn my last Keport I took the opportunity of bringing 
before you the probable consequences of the Insurance 
Act, so far as maternity hospitals were concerned, and I 
tried to show you how illogical were the rules drawn up 
to govern the Maternity Benefit. Since that time a Joint 
Committee of the three Dublin Maternity Hospitals has 
been appointed for, I believe, the first time, and, thanks 
to the work that has been done by the Committee, as well 
as to the support given to the demands of Maternity 
Hospitals, both here and elsewhere, by the General 
Medical Council, the objectionable rules issued by the 
Commissioners have been altered. It is now possible for 
a woman to receive her maternity benefit who is attended 
in her home by the recognised students or pupil midwives 
of the Hospital, while, in the case of a woman confined 
in the Hospital, the benefit may be paid either to her 
dependents or to herself as soon as she has left the 
Hospital. I trust that the success that has attended the 
appointment of this Joint Committee of the Dublin 
Maternity Hospitals will lead to its continuance, as I 
believe that such a committee can do much to promote 
our common interests. If it had been in existence some 
years ago I do not think that our duly qualified midwives 
would now have to go to England for examination by the 
Central Midwives Board. 

Conclusion. 

In conclusion, I have cordially to thank my Assistants 
and the nursing staff of the Hospital for the care and 
attention they have devoted to it during the past year, and 



^2 Idiopathic Epilepsy in Children. 

the Lady Superintendent particularly for the manner in 
which she has adapted the work of the nursing staff to the 
altered conditions which have resulted from the erection 
of the new Labour Wards. 



Art. V. — The Recognition and Treatment of True 
Idiopathic Epilepsy in Children.^ By James NofiL 
Greene Nolan, M.D. Univ. Dubl. ; B.A. T.C.D. ; 
Member Medico-Psychological Association ; Assistant 
Medical Officer, Hellingly Hospital, East Sussex 
County Asylum. 

In making these suggestions as regards diagnosis and 
treatment of epilepsy in children, I wish to confine myself 
as far as possible to those cases of true idiopathic epilepsy, 
of which Aldren Turner gives the following : — 

Definition. — " Epilepsy is a chronic, progressive 
disease, characterised by the periodic occurrence of 
seizures in which loss of consciousness is an essential 
feature, commonly, but not invariably, associated with 
convulsions, and frequently accompanied by psychical 
phenomena. It generaliy occur?^ in persons with an here- 
ditary neuropathic history. It runs its course uninterrup- 
tedly, or with remissions, for a number of years ; and ter- 
minates either in a cure or in the establishment of the 
confirmed disease." 

How(wer, the subject would be very incomplete without 
cit leasl, mentioning and classifying the various nervous 
diseases to which children are subject in which seizures 
may occur, often indistinguishable from forms of true 
epilepsy. These cases of secondary epilepsy are not in 
general nearly so tractable, with certain definite excep- 
tions, as will be noted. In this class, too, must be men- 
tioned those cases occurring from traumata — i.e., cases of 
true Jacksonian e])ilepsy. 

Epilepsy occurs more frequently in males than females, 

• A Thesis read for the Degree of Doctor of Medicine in the University 
of Dublin, June 1913. 



By Dr. J. N. G. Nolan. 93 

and this is noticeable from the first year onwards. One 
child out of every 500 is subject to the disease. The 
diseases originate more frequently in the first year of life 
than in any other. Then the fourth, seventh, and ninth 
years show a greater number than the intermediate years, 
and there is nearly as great an initial incidence in the 
fourteenth and fifteenth years with the onset of puberty 
as there is in the first year. 

It has been conclusively proved that a neuropathic in- 
heritance is the chief causative factor in the disease, and 1 
have rarely found a case in which there was not a neurotic 
blemish on the parental tree. One authority gives the 
following table : — 

Epilepsy 

Insanity 

Alcoholism - 

Other nervous disorders 

No known heredity - 



More common exciting causes 
tioned : — 

A. — Reflex Influences. — Diseases of the nose — rhinitis, 
adenoids; diseases of the eyes — strabismus, myopia; 
diseases of the ear — mid-ear disease, polypus; diseases of 
the teeth — caries, pyorrhoea-alveolaris ; disease of the 
throat — tonsillitis ; disease of the stomach — gastritis ; 
diseases of the intestines — constipation, parasites ; diseases 
of the genitals — phimosis, pruritus. 

B. — Psychical Causes — Fear, emotional excitement, 
shock, grief, overwork, prolonged anxiety. 

C. — Infective Diseases — More frequently scarlet fever, 
but measles, influenza, diphtheria, pertussis have also 
been observed to bring to light the latent disease. 

It should be noted that a temporary arrest of the 
seizures occasionally occurs in consequence of an attack of 
pyrexia. Also, the onset of the catamenia is frequently the 
exciting cause of the first seizure in a neurotic girl. As far 



37.2 


per 


cent. 


5.4 




>) 


3.1 




>) 


5.3 




5 > 


49.0 




> > 


LOO.O 




are 


the 


undermen- 



^ Idiopathic Epilepsy in Children. 

as can be ascertained there are no definite conclusions to 
be drawn between tiie state of the maternal health dnrincr 
pregnancy or an alcoholic condition per se existin-. in 
either parent durinf; conception, or in the mother durincr 
intra-uterine life, and the incidence of epilepsy occurring 
in the child. ^ 

As regards secondary epilepsy, the convulsions are 
not always accompanied by a loss of consciousness, which 
IS invariably present for a greater or lesser time in the 
Idiopathic variety. 1 mention below the more common 
conditions in which these secondary attacks occur :— 

1. Congenital Cerebral Diplegia. 

2. Acquired Cerebral Paralysis— 

(1.) Infantile hemiplegia and di])legia. 

(2.) Atrophic sclerosis and cystic formation. 

3. Intra-cranial Tumours. 

4. Vascular Lesions — 

(1.) Thrombosis. 
(2.) Haemorrhage. 
(3.) Embolism. 

5. Encephalitis. 

G. Hydrocephalus — 
(1.) Congenital. 
(2.) Primary. 
(3.) Secondary. 

7. Cerebrospinal Syphilitic Lesions— 

(1.) Meningitis. 

(2.) Vascular lesions— especially thrombosis. 

(3.) Gummata. 

(4.) Diffuse specific lesions. 

8. Juvenile General Paralysis. 

9. Traumata. 

Practically all cases of secondary epilepsy may be re- 
garded as incurable, save those in which congenital syphilis 
has been the predominant existing factor. These cases, if 
they are to have a fair chance of a recovery, must be recog- 
nised early, and here the Wassermann reaction proves of § 
the greatest assistance. Taking only the imbecile children I 



By Dr. J. N. G. Nolan. 95 

under fifteen years of age in my care at present, the 
Wassermann reaction was + in 8.3 per cent, in those who 
suffered from convulsive attacks, whereas it was + in only 
2.7 per cent, in those who did not, and it is interesting to 
note that no physical stigmata of congenital lues could be 
detected in any of these children. 

Other hopeful patients to deal with are those who have 
recently suffered some injury which is directly causing their 
attacks. These recent traumatic cases give a fair percent- 
age of recovery if seen early when operative measures 
can be undertaken. The success of the operation depends 
on the absence of post-operative adhesions or scar tissue 
formation beyond a minimum amount, and even then good 
results are not always assured. However, once the con- 
vulsive habit has been established there is a tendency to its 
perpetuation in the form of recurring epileptic seizures, so 
that the convulsions introduced by the above-mentioned 
disorders (and by uryemia and eclampsia in adults) may be 
the forerunners of genuine epileptic seizures which persist 
after the exciting cause has been successfully treated or 
surgically removed. The prognosis, therefore, is invariably 
bad, for the subject is always handicapped by a poorly de- 
veloped nervous system, and the mental condition may 
range from that of slight backwardness to one of total 
idiocy. The treatment, therefore, is directed towards re- 
moving the existing cause and controlling the convulsive 
attacks. These may range in form from the severe major 
fit to a scarcely noticeable minor attack, or, indeed, may 
be replaced by one of the various psychical equivalents, 
though the latter condition is not readily recognisable in 
children. 

Diagnosis. — It is not difficult to recognise the majority 
of these secondary cases. The symptoms of the causative 
disease are generally sufficiently obvious to prevent a mis- 
take being made. Some doubt may arise in the cases due 
to specific disease, and, as already pointed out, the aid of 
the Wassermann reaction is required. It is important to 
remember that the symptoms to which the parents draw 



^^ Idiopathic Epilepsy in Children. 

one's attention are those of the seizure, and a careful ex- 
amination of the child must be made in any doubtful cases. 
Treatment. — The general treatment of the causative 
disease must be undertaken thoroughly, and of great 
importance is the building up of the patient's general 
strength. 

These points will be dealt with more fully later on, and 
it is sufficient to say here that, having rigorously adopted 
general measures which always necessitate home care by 
suitable nurses, or in schools intended solely for defective 
children, one can hopefully attempt to check the convul- 
sions. A nutritious purin-free diet enables one to do this 
with the aid of much smaller doses of the bromides. The 
addition of borax is, I have found, very efficacious in these 
cases. The dosage may be increased until control is estab- 
lished, but it is unnecessary to exhibit more than 60 grs. 
of the combined salts per diem. Larger doses only cause a 
worse mental state due to the condition of bromism being 
established. Gellineau's treatment proves of great service 
in these refractory cases, and by the use of dragees there 
is very little difficulty in administering the drug. 

The general educational treatment is the same as that 
advocated for the idiopathic cases. But these children are 
usually more backward, and are rarely able to take their 
[)lace among their fellow members in general society. 

T come now to the recognition and treatment of the idio- 
pathic disease in the young, and, first, 1 should like to 
draw attention to the neuropathic symptoms which mani- 
fest themselves in the mentally unstaple. Long before any 
convulsion occurs a child may be noticed to exhibit very 
indicative neuroses, and if treatment be at once under- 
taken the convulsive ajttacks may be permanently warded 
off. Infantile convulsions are of serious import when 
they occur in the neuropathic child. Kcpially important 
from the medical |)()int of view are such disorders of 
childhood as night-terrors, head-banging, teeth-grind- 
ing, nocturnal incontinence, sleeplessness, outbursts of 
temper, choreiform movements, the habit spasms, and 



I 



By Dr. J. N. G. Nolan. 97 

often some such definite objective phenomena as abnormal 
timidity, shyness, and self -consciousness. In addition, 
it may be noted that these nervous symptoms have their 
physical counterpart, and the child rarely looks healthy, 
or as well developed as it should for its age. Eye defects 
are frequently present. 

Should the case come under notice later, when the con- 
vulsive attacks have made their appearance, more drastic 
treatment has to be adopted. The question of psychical 
equivalents occurring in these young children is too 
vague, and of too doubtful import, to require discussion, 
for one is apt to be misled by the spitefulness and bad 
temper which frequently is noticeable in some children, 
more especially in those who have been " spoilt," and 
who lacked parental control, but who have shown no 
other objective symptoms, and these children, as a rule, 
will not acquire this disorder. 

The elements of an attack are twofold : — (A.) A con- 
vulsive, (B) psychical. 

Under the convulsive element we note :^ 
(1.) Aura. 

(2.) A complete attack in which there is a loss of con- 
sciousness, with a convulsive seizure (haut-mal). 
(3.) An incomplete attack in which there is only loss 

of consciousness (petit-mal). 
(4.) SequelcC — (^-g-, post-epileptic automatism. Coma. 
B. — Under the psychical element there are to be noted— 
(1.) The diagnostic epileptic character and tempera- 
ment. 
(2.) Definite paroxysmal psychoses which precede or 

succeed the convulsive phase. 
(3.) Psychoses which replace entirely the convulsive 

phenomena — i.e. , equivalents. 
(4.) The permanent inter-paroxysmal mental stale re- 
sulting from the convidsive seizures. 
It won hi be too long a matter to discuss the various 
combinations of these elements which may arise, for 
some cases merely exhibit an aura followed by an equiva- 

a 



98 Idiopathic Epilepsy i)i Children. 

lent. Others have a complete attack with no preceding 
aura or any sequela. Equivalents are as likely to be 
followed by serious sequela? as is an incomplete attack. 
Bearing this in mind, and aided by an unbiassed family 
history, it is not dilticult to arrive at a diagnosis. 

The differential diagnosis has to be made between 
hysteria, Gower's vagal attacks, febrile migraine, aural 
vertigo, heart disease, and, as we have tried to point out 
above, the seizures resulting from organic cerebral lesions. 

Prognosis. — Hippocrates says : — " If it attacks little 
children the greater number die ... if youths, re- 
covery may take place. There is danger of its becoming 
habitual, and even increasing if not suitably treated." 

This may be regarded as a somewhat hopeful view in 
the light of later day research. 

The following table represents the present-time pro- 
spects more accurately. It has been compiled from the 
records of the Queen's Square Hospital. 

Age at outset. Arrests. Improved. Confirmed. Cases. 



o/ o/ 

/o /o 



o/ 

Under 10 - 19.8 18.0 G2.0 111 

From 11 to 15 20.0 35.9 43.8 89 

,, IG to 20 - 34.3 29. G 35.9 64 

Treatment. — 1. Prophylaxis in a cliild who has ex- 
hibited the' jU'odromata wc have mentioned above should 
be undertaken at once. The management of the child 
should be based upon general hygienic and dietetic lines, 
and for its successful issue requires the alliance of the 
parent, teacher, and physician. » Regulated periods of 
exercise and instruction must alternate with regular 
periods of rest and repose. Corporal punishment must be 
absolutely prohibited. All over-exertion and strain, 
whether mental or j^hysical, must be assiduously guarded 
against, and here great tact on the physician's part 
is required. The usual stimulating dietary of tea and 

■ It maybe stated here that those children require constant observation 
day and night to prevent any untimely mishap occurring. 



By Dr. J. N. G. Nolan. 99 

meat had better be abolished, and milk and cereals sub- 
stituted. Drug treatment had better be avoided at this 
stage, save the administration of general tonics and neces- 
sary aperients. 

The treatment of epilepsy at the onset of the disease 
may be : — (1.) Medicinal; (2) dietetic; (3) a combination 
of both the above, with general hygienic treatment. It 
need hardly be said that the last is the ideal course to 
adopt. A carefully-regulated life with a purin-free diet 
and a small daily dose of bromides is the treatment j^ar 
excelleyice. The latter do not require to be given in great 
quantities or at intervals during the day. The smallest 
dose which appears to exert a favourable influence over 
the fits should be taken as the maximum, and this never 
should exceed 60 grs. The effect is intensified by the full 
quantity being given at one time. The best time is at night 
or before rising, depending on whether the patient is 
subject to diurnal or nocturnal attacks. Plenty of water 
should be given with the dose, and sufficient laxative to 
ensure a daily evacuation of the bowels. The best adjuvant 
is the syrup of Virginian prune. 

Strychnine, borax, belladonna, zinc salts, opium, and 
innumerable other drugs have all been tried with varying 
success in individual cases ; probably the bromides which 
have been given w^ere the chief factor in obtaining a cure. 
Flechsig's treatment, in our hands, has yielded no success, 
and it appears fraught with considerable danger, more 
especially in children. Organotherapy and serotherapy 
have not as yet produced a cure, and the latter appears 
to be a very irrational form of treatment. 

As regards actual treatment during an attack there is 
nothing new to be said. It should be noted "that attacks 
preceded by a prolonged aura can be warded oft' by a 
method which each patient discovers for himself, and 
which an observant nurse can apply when an attack seems 
imminent. 

As regards the condition of "status," hypodermic in- 
jection of the bromides, aided by " lavage of the colon," 



100 Idiopathic Epilepsy in Children. 

and chloral administered rectal ly in ^rs. 30 doses wiill 
prove sufficient in milder cases. In the more severe 
attacks the convulsions must be controlled by chloroform, 
or death from exhaustion will ensue. 

The diet should be carefully regulated, and on the same 
lines as we have i)reviously laid down. Sodium chloride 
should find no place in the cuisine of a " fitty " child. 
Kegularity and moderation, in all things, and abstinence 
from the various stimulating condiments, so frequently 
used nowadays, should be insisted ui)on. 

Surgical treatment is absolutely useless «ave for remov- 
ing some pre-existing exciting cause ; circumcision when 
indicated will prove as efficacious as excision of the cervical 
sympathetic ganglia. 

Before an " arrest " can be claimed, freedom from an 
attack for five years ought to be taken as a standard. 
During this time the medicinal course must be systemati- 
cally adhered to, being gradually diminished, but never 
abolished. 

General Education. — Some children show no menial 
defect, others exhibit a considerable degree of dementia. 
Shuttleworth, from his observations in the London 
School Board, compiled the following table from 470 
cases : — 

17 per cent, show^ed no mental improvement. 

27.5 percent, showed some mental improvement. 

iO [)er cent, showed considerable menial improvemenl. 

15.5 per cent, were incapable of being educated. 

However, by reason of their malady, these children 
ought not to go to general schools. Their education is 
fraught with difficulty, bnl it should proceed on general 
lines, with due regard to the child's future. 

Manual and industrial work ought to figure largely in 
the curriculum. The Lloyd system is the best that has 
been devised for these backward children. Such educa- 
tion is, therefore, best obtained in special homes and 
schools under medical supervision, and unless all facilities 
are available at home tlu' child's future prospects are 



By Dr. J. N. G. Nolan. 101 

materially benefited if removal to a special school be 
insisted upon. 

Exercise should be a sine qua non; tennis, football, 
Swedish drill, &c., are admirable, and if massage can be 
given afterwards all the better, as the circulation is 
sluggish and the general nutrition poor in many of these 
cases. 

Such, in the main, is the treatment employed for some 
time past at the Hellingly Mental Hospital. 

Unfortunately, early cases are the exception, as certifi- 
cation is the last resort of the unhappy parent. 

The scope for useful work will undoubtedly be much 
wider when the new^ Mental Deficiency Bill comes into 
being. 

Even w^ith these unsatisfactory cases we get gratifying 
results, and quite 80 per cent, of our defective epileptics 
are usefully employed in the various industrial shops ; and 
the younger children all benefit by their school training. 

I am indebted to Dr. Taylor, K.M.S., for affording me 
every encouragement, and providing me with all facilities 
for the treatment of these children. Also to Dr. W. Kees 
Thomas, my colleague, for carrying out the clinical blood- 
tests and for the use of much valuable information which 
he had acquired wdien in charge of the hospital. 

In conclusion, I wish to point out that much may be 
done to alleviate the future lot of a confirmed case by an 
early practical education and judicious medication. 

Many cases will be improved, and some will enjoy a 
complete arrest of their distressing malady if treatment 
on the lines we have indicated be thoroughly carried out. 

The lot of a demented convulsive is not a happy one, 
either to himself or his friends, and the greatest care 
should be taken that the bromide state be not super- 
imposed upon an already unstable mental fabric. Any 
improvement that may be effected is a gain to the patient, 
even if only temporary, and everything should be tried for 
a considerable period before abandoning the case to the 
ranks of the insane. 



102 The Treatment of Dysentery. 

Art. VI. — The Treatment of Dysentery hy Injeetions 
of Emetine Hydroehloride.^ By James H. C. 
Thompson, M.D. Univ. Dubl. 

INTRODUCTION. 

Next to malaria, dysentery is the most widespread and 
imjx^rtant disease with which we have to deal in 
troj)ical countries. The prevalence of the disease, and its 
tendency to dan^i^eroiis sequehT, make it of the utmost 
imf)ortance that we should have some reliable and effec- 
tive treatment for it. 

The treatment of dysentery by the ipecacuanlia root 
dates back to the time when the root was brou^xht from 
Brazil to Europe by Piso, and was nsed by Helvetius in 
the treatment of Louis XTV. Tt was used subsequently 
by many An^^lo-Indian physicians, but it was in 1858 that 
¥j. R. Docker, A. M.S., introduced the use of lar^^e doses 
(GO ^a's. two or three times a day) of the powdered root in 
the treatment of severe dysentery in Mauritius with j]jreat 
success, reducinfT the death-rate there from 10 to 18 per 
cent, to 2 ]wv cent. These excellent results stimulated 
other ))hysicians to the further use of the dru^. However, 
some years later, the use of ipecacuanha for dysentery went 
out of fashion, its place beinj^ taken by the salines and 
ammonium chloride in hepatitis. 

Ipecacuanha has, however, re^jfained its favour in the 
last few years, owinf]^ to its advocacy by Sir Patrick 
Manson, and now its place is doubly assured in the prac- 
titioner's armamentarium by Professor Tjeonard Po«^^er's 
introduction of the treatment of dysentery of soluble salts 
of emetine — one of the active principles of ipecacuanha. 

This treatment consists of the hypodermic injection of 
small doses of emetine hydrochloride* in watery solutions. 
These injections do not cause nausea or vomitin^^, the 
dru^ is quickly and readily absorbed, even in apparently 
hopeless cases, and the* exact dosage of the active prin- 
ciple is insured. 

• A Thesis submitted for tlie Degree of Doctor of Medicine in the 
University of Dublin, June, 1913. 



By Dr. James H. C. Thompson. 103 

For the past seven years 1 have been medical officer to 
a large group of tea estates in Cachar, on the north-east 
frontier of India. There we have a working native popu- 
lation of 50,000, and also about 80 Europeans. 

Malaria, dysentery, cholera, &c., are endemic, and at 
certain seasons of the year they become epidemic. 

In some places as much as 25 per cent, of the total 
sick-list is due to dysentery. 

I have had ample opportunities for observing and treat- 
ing such cases. In this thesis, therefore, I propose to give 
an account of the work done on this subject, and the 
result of my own experience in some cases. 

The incidence of dysentery may be said to be a result 
of the operation of two factors — the local and personal. 
The local factor being wherever the general hygienic con- 
ditions are bad, wherever the soil is fouled with excreta, 
and especially where the water-supply is polluted. The 
personal factor is the weakened natural resistance of the 
bowel due to chill, bad food, intemperance, &c. Here 
the specific micro-organism finds the ground, as it were, 
prepared for it. 

Three main types of dysentery, correlated to three types 
of parasites, are now^ fairly well made out. These are : — 
Bacterial, protozoal, and verminous, all of which types 
we get in Cachar, arid also sometimes a mixed infection. 

It is, however, of the protozoal type, amoebic dysen- 
tery, that we get by far the greatest number of cases, and 
it is with this type that we are now dealing. 

It may be accepted as fairly certain that " amoebic 
dysentery " is caused by the Entamoeba histolytica, as 
shown by Schaudinn, also by his experiment of feeding 
cats on the dried dysenteric stools containing the encap- 
sulated spores of the Entamoeba histolytica, and by the 
further strong argument of the intimate connection which 
exists betw^een dysentery and the presence of amoebop in 
nearly all liver abscesses. 

Amoebic dysentery is usually insidious in its onset. 
The patient feels shivery and out of sorts; he generally 
starts with griping and diarrhoea and copious watery 



104 The Treatment of Dysentery. 

stools. Soon, however, the stools become smaller, less 
fcTculent, more mucous, and streaked with blood, and fre- 
quently there is tenesmus, and often tenderness over the 
left iliac fossa. The temperature is seldom raised, but the 
pulse-rate is increased. These cases usually continue for 
about five to ten days, and then gradually the symptoms 
clear up, but there is a strong tendency to recurrence of 
the attack on the slightest dietary indiscretion, and some- 
times the attack recurs without any obvious cause. One 
frequently meets cases of natives who have suffered from 
chronic dysentery of this type for years or months, and 
are reduced ]iractically to walking skeletons. 

In the case of Europeans, liver abscess is the most 
serious sequela to guard against. 

In the bacillary dysentery (or epidemic type) the onset 
is more sudden, and generally there is a sharp rise of tem- 
perature to 102° or 103°. There is not so much tendency 
to relapse, or formation of liver abscess. 

Shiga, who has described the Bacillus dysenterica , 
claims to have produced a serum, by immunising animals, 
with which he has treated the disease with considerable 
success in Japan. 

The treatment hitherto in vogue, while including a large 
section of the PharmacojiaMa, has been along two or three 
main lines, viz. : — Ipecacuanha, salines, or castor oil. My 
treatment usually was to start off with 3vi of castor oil and 
a few minims of tinct. opii ; after that had produced its 
effect I ordered rn,xx tinct. opii inSssof water, to be fol- 
lowed fifteen minutes later by gr. 30 of pulv. ipecac, in 
emulsion. (No food having been taken for some time pre- 
viously.) This was repeated every four hours. Diet re- 
stricted to soup, milk, or albumen water, and the patient 
rigorously confined to bed. If, after twelve doses, there 
was no improvement, I then ordered the saline treat- 
ment — 

H Sodii sulphatis, 5i ; 

Acidi sulphurici dil., rt\x ; 
Aqua\ ad 5ss. 

Such a dose every 2 hours. 



By Dr. James H. C. Thompson. 105 

This was given till blood and mucus had disappeared 
from the stool. 

In many cases the ipecacuanha caused nausea and 
vomiting, and we could not get the patients to take it. 
Indeed, the treatment of dysenteric patients, especially 
coolies, was attended with much difficulty, as they natur- 
ally resented medicine w^hich they considered only made 
them feel w^orse ! 

Keratin-coated pills did not give much better results. 

This was my routine treatment, and that of my col- 
leagues in other districts. Of course, in certain cases we 
adopted different methods, but we were without any cer- 
tain and reliable treatment, and sometimes much valuable 
time was lost in unavoidable experiment in trying to find 
out a suitable drug. 

In 1911, Vedder found that emetine — the principal 
alkaloid of ipecacuanha — had the power in high dilution 
of destroying amoeba? in broth cultures. 

Although it was not certain that this w^as the patho- 
genic amoeba, Kogers, of Calcutta (who has also intro- 
duced the hypertonic saline treatment for cholera), tested 
the effect of a solution of emetine hydrochloride on Amoeba 
histolytica in dysenteric stools. He found that on placing 
a piece of mucus containing numerous active amoeba^ in a 
normal saline solution, a 1 in 10,000 of this salt, the 
pathogenic organisms were immediately killed, and mate- 
rially altered in microscopical appearance, while after a 
few minutes they are rendered inactive, and apparently 
killed by a solution as w^eak as 1 in 100,000. 

Kogers, therefore, decided to try the effect of this 
emetine in cases of amoebic dysentery, and he obtained 
strikingly good results, which he published in the Dritish 
Medical Journal, June 22nd, 1912. They were all cases 
in which the patients could not tolerate ipecacuanha by 
the mouth, and one of the cases was acute hepatitis. 

Case I. — I first tried this treatment on a Hindu, male, 
aged forty-two, with a history of acute dysentery of about 



106 The Treatment of Dysentery. 

eight days' duration, fifteen to twenty stools daily, contain- 
ing mucus and pure blood ; pain and tenderness in both iliac 
fossai. The Dr. Babu had given him ipecacuanha mixture, 
but he had vomited it each time. I injected J gr! emetine 
hydrochloride in the morning, and another J gr. in the even- 
ing. On the same night he passed four stools, blood nearly 
stopped, mucus less, and pain very much relieved. Next 
day he got ^ gr. emetine and passed two stools, faeculent, 
small quantity of mucus, pain quite gone. Patient dis- 
charged third day. 

Case II. — A coolie, male, aged twenty. Acute dysentery, 
intolerance of ipecacuanha by the mouth. I injected :} gr. 
(Muetine. No nausea or vomiting; gave him another ^ gr. 
eight hours after. Symptoms all relieved. Two more injec- 
tions cured him. 

Case III. — An old coolie, male, aged seventy, had been 
suffering for years from chronic dysentery. About eiglit to 
twelve stools daily. Thickening and tenderness of the bowel. 
He was reduced almost to a skeleton, and unable to get 
about. I injected ^ gr. twice daily for about a week. Stools 
were reduced to one or two a day, healthy, and patient was 
feeling and looking very much better. Unfortunately, he got 
})n(Mmionia and died. However, there is no doubt he was 
malving a wonderful recovery under the emetine treatment, 
after years of chronic dysentery and various treatments. 

Case IV. — A coolie woman, aged twenty-seven. Eight 
months pregnant, suffering from acute dysentery. Injected 
^ gr. emetine twice daily; cured in two days. Had a iiormal 
delivery at full time. This case illustrates the fact that this 
treatment is applicable to pregnant women, and is a most 
important point in dealing with Indian women. 

Case V. — European child, male, aged two and a half. 
Had an attack of measles about one month previously, now 
developed symptoms of acute dysentery. Blood-stained 
mucous stools. Severe tenc^smus, pain and tendiM'uess in 
both iliac fossa?. Small doses of ipecacuanha caused vomit- 
ing. We then injected j^ gr. emetine three times the first 
day; next day the sym|)toms were relieved, except the child 
cried a good deal. We injected ^ gr., after which the stools 
Were free fr<^m blood, and contained onlv n trace of mucus. 



By Dr. James H. C. Thompson. 107 

He developed meningitis, and died forty-eight hours later. 
In the bungalow where this child died, his father, mother, 
aunt, and my colleague (who had stayed there during the 
child's illness) all contracted dysentery, but each was given 
a 1 gr. injection, which promptly cut short the attack. We 
traced the source of the infection in this case to the 
bungalow water supply, which had been fouled by a coolie 
suffering from dysentery. 

Case VI. — A villager brought a child, female, aged four, 
to my bungalow suffering from chronic dysentery of six 
months' standing. The stools consisted chiefly of glairy 
mucus slightly blood-stained. The child was emaciated 
and very weak. I gave the child one J gr. tablet of emetine 
by the mouth, and gave three more tablets to the mother, 
with instructions to give one to the child every morning, 
and to come back on the fourth day. The result surpassed 
my expectations. The child was brought back to me, look- 
ing better and brighter. Stools were almost normal, no 
pain in abdomen, and there had been no tendency to vomit. 
A month after, there was a slight relapse, but a further 
course of four tablets cured her, and since then she has 
been in good health 

Case VII. — A Swede, male, aged forty-seven, came under 
my care in April, 1912. He had an interesting surgical history, 
having been operated on for appendicitis and peritonitis 
five years ago. Previous to that he had severe lead poison- 
ing, and had double cataract operation performed. There 
was also a history of an attack of dysentery about eight 
years ago. He complained of general malaise, loss of 
appetite, loss of weight, a slight pain over the liver and 
behind the right shoulder. He had a dry, hacking cough. 
He looked haggard, and his complexion was a dirty muddy 
grey. Temperature from 99.5° in the morning to 101. 2° in 
the evening. Pulse 90 to 110. Eespirations 22. Bowels 
regular. He did not perspire at night. On examination, 
his cardiac, pulmonary, and urinary systems were found 
sound. The liver was very slightly enlarged downward, 
and there was slight tenderness on deep pressure. I gave 
him two injections of quinine bihydrochloride, 15 grs. in each, 
in order to eliminate any question of malaria. I then 
put him on 10 gr. doses of pulv. ipecacuanhae four times 



108 The Treatment of Dysentery- 

daily, and 2 grs. of calomel at night. Light diet and rest. 
After ten days, as he did not improve, I sent him to a 
hospital in Calcutta. His liver was cr-rayed, and showed 
dark patches over it. He was kept in hospital for three 
weeks, and given large doses of ipecacuanha and low diet. 
He lost 281bs. in hospital, but the fever quite left. He was 
then sent to a seaside resort, where one day, after being 
there about a week, he said " he felt sick and vomited up a 
lot of stuf? like blackberry jelly, and felt much better after 
it." After returning to Calcutta, his liver was cc-rayed 
again, and appeared quite normal. He came back to 
Cachar in June, 1912, and said he felt much better, but did 
not have any appetite or energy. He could not put on any 
of the weight he had lost. About last October he began to 
have an " uneasy feeling over his liver." He perspired at 
night, and was easily fatigued. He looked ill, haggard; 
comj)loxion yellowish green; temperatiu'c 99°; pulse 110; 
respirations 20. No cough. I injected him with I gr. 
emetine every day for a week. All liis symptoms dis- 
appeared, appetite returned, got a clear, healthy com- 
plexion; pulse and temperature normal. Sleeps well, and 
has put on weight steadily. He has had no relapse to 
present time. 

T consider tliiil this was clearly a case of amoebic 
hei)atitis, and j^ossibly what he vomited at the seaside may 
have been a liver abscess, which, fortunately for him, 
discharged into the stomach. The fact that he had 
dy>;entery eight years ago, and that the liver symptoms 
cleared up rapidly under the emetine treatment, appears to 
show that the origin of the trouble was amcebic. 

I used to give small doses wIumi T first tried emetine — 
J-gr. doses — but now T never use less than J-gr. doses for 
achilts, and sometimes when I get early cases I inject 1 gr., 
which T find jiracticnlly aborts the disease. I have never 
found any ill elTect following an injection. 

Strict aseptic precautions are taken, and I always boil 
syringe and needle, and use boiled water for making the 
solution. 

In mixed dvsenterv infection — i.e., amcebic and bacil- 



By Dr. James H. C. Thompson. 109 

lary — I find that injections of emetine, and 5ss doses of the 
acid sodium sulphate mixture by the mouth is the most 
satisfactory method, strict attention always being paid to 
diet and rest. 

These, then, are a few of about 150 cases which I have 
treated with this emetine hydrochloride. In some of the 
cases the treatment had no effect whatever, and those, 
according to Kogers, are of bacillary origin. So, there- 
fore, not only does emetine cure the amoebic variety 
(which constitutes about 85 per cent, of the dysentery in 
my district), but it serves for a differential diagnosis for 
bacillary dysentery, and thus enables it to be quickly 
treated along the proper lines. 

In conclusion, I think that we have in the treatment of 
dysentery by injections of emetine hydrochloride, a power- 
ful, reliable, and scientific method, the value of which it 
would be difficult to over-estimate. 



THE USE OF SUMBUL. 

A DRUG which is not very often prescribed nowadays in England 
is suEobul root, of which the tincture is officinal (? official) in the 
" British Pharmacopoeia." Its chief action, according to Hale- 
White, is as a carminative; and, as it also contains valerianic 
acid, it has been used a good deal for neurasthenia and 
functional nervous disorders. Sumbul is contained in one, if 
not more, of the secret quack medicines which are under in- 
quisition at the hands of a Parliamentary Commission. It was 
formerly a favourite for combination with bromides, though 
one eminent authority in London who thus prescribed it 
avowed openly that he did so merely because it very effec- 
tively covered the nasty taste of bromide salts. Dr. IMaclit 
has been investigating sumbul clinically at the Johns 
Hopkins Hospital, and he has come to the conclusion that 
it is quite useless for any and every kind of functional 
nervous disorder. In a small percentage of cases some tem- 
porary improvement followed its exhibition ; but there was 
no lasting benefit. — TJic Hospital, June 21, 1913. 



PART II. 
REVlliWS AND BIIUJOGRAPIIICAL NOTICES, 



The Ldw Relatincj to Public Health in Ireland. By 
George T. Ix Vanston, M.A., LL.D. (sometime 
Scholar and Double Sen. Mod., Trin. Coll., Dublin); 
one of liis Majesty's Counsel; J.e^al Adviser to the 
Local Government Board for Ireland; editor of " The 
Tjaw Kelating to Local Government in Ireland," " The 
Law of Municipal Boroughs in Ireland," &c. Second 
Edition. Dublin : E. Ponsonby, Ltd. 19i:i Roval 
8vo. Pp. xcv + 1333. 

Oi'K issue for June contained a short notice of the pub- 
lication of the new e<lition of Vanston "s " IHiblic Health." 
The first edition of this valuable work was published in 
181)-2. At that time the principal Act had been in full 
working order for several years, and the want was felt of 
an authoritative book on the subject. In the interval of 
fourteen years various amending Acts had been passed, 
and all of these were rej)roduced together with the Act of 
1878 and the statutes incorporated with it in the first 
" Vanston." The book was at once recognised as the 
standard authority on the subject of public health in this 
country — the Irish " Tjundey " or " Glen," or, perhaps, 
we should describe it better as the " Lundey a)i(l Glen " 
of Ireland, occupying as it does the same place with regard 
to Irish |)ractice that these two well-known books hold 
jointly with regard to the English practice. 

A nmch-needed supplement was |)r()duced in 18*.)7, and 
brought the work thoroughly uj)-to-date. Since tlien, 
h(nvever. many new statutes relative to Medical Juris- 
prudence have been passed, new rules and regulations 
have been made, there have been legal decisions almost 
innumerable. More lliaii twelve hundred of them, we are 



Vanston — Public Health in Ireland. HI 

told, have been noted in the edition under review over 
and above those contained in the earher edition and sup- 
plement, each of which has determined or explained some 
doubtful point in the legal construction of a word or a 
sentence — a matter of as equally vital importance to the 
medical practitioner as to the lawyer. A new edition was, 
therefore, urgently required, and Dr. Vanston has skil- 
fully supplie'd the demand. 

The order and arrangement of the earlier work have 
been preserved. In the first part we have the Act of 1878 
and the various amending Public Health Acts, so-called, 
wliich have been passed between that date and the present 
time. These include the important Acts of 1890 and 1896 
and the Public Health Acts Amendment Act, 1907, of 
which Parts III. (Sanitary Provisions) and Part IV. (In- 
fectious Diseases) are of such great importance to medical 
men. The statutes, twelve in number, which are included 
in this part are set out in full, omitting only those sections 
which have been since repealed and those which do not 
in any way apply to Ireland. Each clause is carefully 
annotated, and numerous cross-references are given. In 
all, no less than 427 pages are devoted to the Public 
Health Acts, w^hich constitute Part I. of the work. 

Part II. is devoted to those statutes which are incor- 
porated wholly or in part with the Public Health Acts or 
which otherwise affect sanitary authorities. The seventy- 
eight statutes comprised are arranged in chronological 
order, and occupy four hundred and ninety-three pages. 
They deal with many and varied subjects, with Companies 
Clauses Consolidation Acts, with the Pollution of Rivers, 
the Sale of Food and Drugs, and Electric Lighting, with 
the Housing of the Working Classes, and the Notification 
of Infectious Diseases, with Factory Acts and Gasworks. 
The Shops Acts of 1912 and 1913 and the Tuberculosis 
Prevention (Ireland) Acts of 1913, which in part repealed 
the Act of 1908, have been included in the text by the 
insertion of an extra sheet. We are glad to see that the 
author has reproduced those sections of the National In- 
surance Act which deai with the administration of sana- 



112 Reviews and Bibliographical Notices. 

torium benefit and inquiries into the causes of excessive 
sickness. 

Looking at it from a medical point of view, we regret 
that it was not [)ossible to inchide the Infectious Disease 
Notification and IVevention Acts and the Tuberculosis 
Prevention (Ireland) Acts in that part of the work which 
is devoted more exclusively to the subject of Public 
Health, hut we quite see that this would ultimately tend 
to confusion rather than to elucidation, for, if medical 
men were allowed to include those statutes which appeal 
chiefly to them, public authorities would also desire to 
include the statutes dealing with their duty in the matter 
of |)ublic health, while the legal mind would at once fly 
to the Public Authorities Protection Act or to the Lands 
Clauses Acts and the Trustee Act, and demand that they 
should certainly be included in Part I. As a medium 
course we would suggest that the statutes in Part 11. 
should be grouped in sections instead of being placed in 
chronological order. Section I. containing those concern- 
ing the duties of medical practitioners and sanitary 
officers, Section 1 1. consisting of those statutes which ap[)ly 
more particularly to public bcnlies, and Section III. com- 
|)rising all the statutes which are not included in either 
Section I. or Section 11. , but? which nevertheless are in- 
corporated in the Public Health Acts or which otherwise 
affect sanitary authorities. 

The third part of the volume is reserved for Hides and 
Regulations of the liord Ijieutenant and Privy Council, and 
for Orders of the Local (lovernment Board and the Board 
of Trade made pursuant to and by virtue of the various 
statutes contained in Parts I. and 1 1. The Local Govern- 
ment Board's Model Bylaws are set out in A|)pendix A. 
Appendix 1) contains Instructions as to Provisional Orders 
under the Public Health Acts and loans under the Hous- 
ing of the NN'orking Classes (Ireland) Act, 1908, while 
Appendix C refers to the repayment of loans by local 
authorities. There is a good index, which covers no less 
than (Mghty-three [)age8. 

The length of time required to prepare so comprehensive 



Keibel — Mall — Maniml of Human Embryology. 113 

a volume for the press has left its mark in the long list of 
addenda and corrigenda which follows the tables of con- 
tents, of statutes, and of cases, in the forefront of the 
book. The majority of the alterations are references to 
recent case law, many of the cases mentioned being re- 
ported in the current volumes (1913) of the law reports. 

There are wonderfully few misprints in the text through- 
out the fourteen hundred odd pages, and most of them 
have been detected by the author. One of a couple of 
unimportant misprints which we noticed was in the list 
of addenda at page xcii. The test for determining whether 
a supply of water is for domestic or trade purposes is stated 
to have been laid down by the House of Lords in 1812 — a 
date when people knew little, and cared less, about any- 
thing relating to hygiene. 

The book is well printed and neatly bound — a credit 
alike to the University Press, Dublin, and to the pub- 
lishers, Messrs. E. Ponsonby, Ltd. 

A. E. M. 



Manual of Human Embryology. Edited by Franz 
Keibel, Professor in the University of Freiburg in 
Baden ; and Franklin P. Mall, Professor of Anatomy 
in Johns Hopkins University, Baltimore, U.S.A. In 
tw^o volumes. Vol. II., with 658 Illustrations. Phila- 
delphia and London : J. B. Lippincott Company. 
1912. Pp. 1032. 

We do not hesitate to say that the publication of the 
second volume of Keibel and Mall's Human Embryology 
completes the most important and comprehensive work 
upon the development of man which has appeared in any 
country up to the present time. Most heartily we con- 
gratulate the editors upon the completion of their task. 

By publishing the work simultaneously in English and 
German they have placed readers of these languages under 
a deep debt of gratitude. Volume II. contains seven 
chapters which deal with (1) the development of the ner- 
vous system ; (2) the development of the chromaffin 
organs and of the suprarenal bodies ; (3) the development 

H 



114 Reviews and Bibliographical Notices. 

of the sense or^^ans ; (4) the development of the digestive 
tract and the organs of respiration ; (5) the development 
of the blood, the vascular system and the spleen; (6) the 
development of the urino-genital organs ; and (7) the 
interdependence of the various developmental ])rocesses. 
In each of these chapters we find collected into a con- 
secutive history a vast amount of information, derived in 
part from the investigations by the authors themselves, 
and in [)art from the researches of others published in the 
scientific periodicals of all countries. Very much of the 
information given is made accessible now for the first 
time to readers of English, and there can be no doubt 
that as a result of the work not only will a great stimulus 
be given to further investigation and research in eml)ry- 
ology, but much light will be thrown upon many problems 
connected with the i)hysiology and pathology of obscure 
conditions which affect the human subject. 

The work is profusely illustrated, and contains most 
valuable lists of the papers dealing with the various sub- 
jects under discussion. We are told that the idea of this 
manual of human embryology originated with the late 
Professor His. Workers in every country have reason to 
rejoice that his project has been so successfully completed 
by the distinguished editors and their collaborators. 



Diseases of Children by Various Authors. Edited l)y 
Archibald (^ARROD, D.M., M.A., F.R.C.P., F.R.S. ; 
Fre:derick E. Batten, M.D., M.A., F.R.C.P. ; and 
HiKiH THrRSFiHLD, D.M., M.A., F.R.C.P. London : 
Edward Arnold. 1913. Royal 8vo. Pp. xv + 1184. 

This work forms a very valuable addition to the literature 
on children's diseases. It takes the form of a System of 
Medicine, the different chapters being written by different 
authors. By this means the editors have been able to 
combine in one volume the most recent investigations by 
specialists in each different subject. Of course every book 
brought out in this way has some drawbacks, such as over- 
lapping of subjects, lack of uniformity of style, &c., but 
the advantages in the present instance certainly out- 



Bury — Clinical Medicine. ■ 115 

weigh any of these disadvantages, and the editors are 
most heartily to be congratulated on their production. It 
would be invidious to quote from one chapter to the ex- 
clusion of another, but it may be mentioned that, as well 
as the ordinary systemic classification, infectious diseases, 
and so forth, we find interesting chapters, such as 
"Heredity," by Gossage ; " GEdema," by G. F. Still, 
that add interest and variety to the whole. In fact, it is a 
book to which one may turn for refreshment when we are 
wearied wdth the form of the ordinary text-book. In 
addition to this, the book forms a valuable exposition of 
the views of what can now be considered as a well-defined 
school — that of the London Pa3diatrists. And here again 
the editors are to be congratulated on having secured the 
services of men w^hose names carry conviction with them. 
The book is well brought out and illustrated, and, in 
spite of its 1184 pages, is not too unwieldy. 



Clinical Medicine. A Manual for the Use of Students 
and Junior Practitioners. By Judson S. Bury, M.D. 
(Lond.), F.K.C.P., B.Sc.,^ Vict. Third Edition. 
Edited by Judson S. Bury and Albert Kamsbottom, 
M.D., M.E.C.P. London: Charles Griffin & Co, 
191-2. Koyal 8vo. Pp. xxi + 530. 

The third edition of this now fairly well-known work does 
not differ materially from its predecessors. In addition, 
however, to general revision in accordance with the ad- 
vance of its subject, a new chapter has been supplied by 
Dr. Barclay, of the Manchester Royal Infirmary, en- 
titled " Examination of the Deeper Structures by means 
of the Rontgen Rays." This will be found a most inter- 
esting and useful account of a method which is attaining 
greater prominence daily in the province of diagnosis. 
The article is quite free from the technicalities which fre- 
quently obscure this topic for the non-specialist, and it is 
somew^hat surprising to find the number of conditions 
w^hich may be " illuminated " by the use of the rays. 
For the benefit of those unacquainted with the previous 



116 Reviews and Bibliographical Notices. 

editions of the book, we may say that the title is some- 
what misleading — the contents are not to any substantial 
extent a descri[)tion of medical diseases, but of the 
methods, both clinical and laboratory, used in their 
diagnosis. Recognising this as the scope of the work, we 
must admit that the object has been well carried out. 
The various [)rocedures are clearly and simply put, are 
sufficiently comprehensive, and only well-tried methods 
and established facts are included. Illustrations are pro- 
fuse, and though not quite such artistic and finished 
pictures as those which adorn most modern text-books, 
t4iey are not a whit less instructive thereby. The blood- 
plates, however, lack realism. Probably in no depart- 
ment of Medicine at present is the competition of books 
keener than in this subject of clinica)! diagnosis — we must 
confess that we can see very little difference between 
many of them — and we often wish that their respective 
authors could collaborate to produce one book combining 
the merits of all without the present widespread over- 
lapping. 



Tuberculin in Diagnosis and Treatment. By Loris 
Hamman, Associate in Medicine in the Johns Hopkins 
University and to the Johns Hopkins Hospital ; and 
Samuel Wolman, Instructor in Medicine in the Johns 
Hopkins University. New York and London : D. 
Appleton & Co. 19UJ. Cr. 8vo. Up. xiv + 881. 

Tins book is a most valuable addition to the literature 
dealing with the diagnostic and therapeutic uses of tuber- 
culin. It is written in a thoroughly scientific spirit, but 
we fear that it is a little too elaborate to prove really 
useful to any except those who are extensively engaged 
in the treatment of tubercular patients. The general 
practitioner who may number amongst his ])atients a few 
tubercular cases who may be suitable for tuberculin treat- 
ment requires a more concise handbook as his guide. 
Possibly the authors would be of ojiinion that the general 
Tjractitioner has hardly the time or opportunity to study 



Hamman — WOLMAN — TuhercuUn in Treatment. 117 

the subject sufficiently to make himself a safe and reliable 
administrator of tuberculin; but, even if we agree with 
such a possible view, the fact remains that there are 
many patients who can be treated only by the local prac- 
titioner, and we fear that, as already stated, a man in 
general practice will find this book too minute and 
elaborate to be mastered. 

Having expressed this opinion, we hasten to add that 
the book is most interesting, and is written by men who 
are obviously masters of the subject. It is divided into 
three main sections, of which the first deals with the 
scientific principles underlying the diagnostic and thera- 
peutic uses of tuberculin, the second with the use of tuber- 
culin in diagnosis, and the third with the use of tuberculin 
in treatment. 

Under the second section aid the diagnostic tuberculin 
tests are discussed at length, and their value is appraised. 
How well the authors have preserved their balance 
in relation to these tests is shown by their reiterated 
assertion that the tuberculin tests never in themselves 
establish a diagnosis. A positive result undoubtedly 
indicates that infection at some time or other has 
occurred, but it by no means proves that the reacting 
individual is at the time suffering from active tuber- 
cular disease. Nowadays, when it is the fashion 
amongst a certain class of doctors to label every indi- 
vidual w^ho gives a positive skin reaction as actively 
tubercular, and later to claim his cure (from a disease 
from which he has never suffered) as evidence of the value 
of some special line o£ treatment, it is refreshing to read 
the views of candid scientific inquirers who are seeking 
truth and not kudos or fees. As therapeutists, the writers 
take an intermediate position between those who advocate 
the production of a strong reaction and those who think 
that even the slightest reaction is to be avoided. We 
cannot here discuss their views in detail, but agree with 
them that the circumstances of each individual case must 
be considered, and that while general rules are useful, 
such rules should unhesitatingly be abandoned if the wel- 



118 Reviews and Bibliographical Notices. 

fare of the patient so demand. The more experience one 
has the more one is likely to know the rule laid down by 
other workers and the less is one likely to follow any of 
them slavishly. 

We once again commend this hook to all sanatorium 
w^orkers and to those engaged in tuberculin dispensary 
work. 



hivalld (uid Convalescent Cookery. T^y Mafy E. Birt. 
Second Edition. Bristol : John Wright t^ Sons, Ltd. 
1913. Pp. 32. 

This is a small booklet containing many excellent 
receipts suitable for the sick room. They are mostly those 
to b(^ found in ordinary cookery books, but are worded in 
a clear and vivid way, which, together with the con- 
venience of having all in one small book, gives a reason 
for the book's existence. It may be remarked that the 
omission of albumen water should be corrected before 
another edition is published. 

A Course in Normal Histology. By Rudolf Krausr 
(Berlin). Translated by V. .1. R. Schm.\hl, M.D. 
(New York). London : Rebman. lAd. In two parts. 
Part I., pp. vii and 86. 

The first part of this work forms an excellent compen- 
dium of useful information in microscopic technicpie. It 
is not com])l(>te, but it has admirable features. It begins 
with a g(M)d account of the theory of the microscope and 
how it should be used. Then it proceeds to explain the 
methods of preservation of tissues and the ])reparation of 
sections. The advantages and disadvantages of the 
various j^rocedures are well told, and where advice is 
given it is reliable. One misses, however, any reference to 
the picro-corrosive fixing fluid of G. Mann, which is much 
used in Great Britain. In the matter of section cutting 
stress is laid, and rightly so, upon the method of freezing 
bv means of solid carbon dioxide^ and on the necessity of 



Lyth — Influence of Thermal Environment. 119 

every student being able to prepare a useful microscopic 
specimen early in his clinical career. 

Stains and their uses are, on the whole, well treated. 
More might have been said on the methods of staining 
film preparations, but for reference to the composition of 
most of the weld-known staining mixtures the article on 
this subject is very serviceable. Practical directions are 
also given for injecting and mounting preparations. The 
first part ends with a section on the drawing and measur- 
ing of microscopic objects. The importance of drawing 
as a means of acquiring histological knowledge is fully 
impressed upon the student, and no more useful precept 
could be inculcated. 

The book is of convenient size, well illustrated, and 
fililed with practical information. 

The second part, which has not yet appeared, contains 
the descriptive account of the histology of the tissues and 
organs. 



Influence of Thermal Environment on the Circulation 
and the Body Heat. By E. R. Lyth, M.B., &c. 
London : John Bale, Sons & Danielsson, Ltd. Pp. iv 

and 72. 

This small book contains the results of a series of studies 
chiefly on the effects of temperature on the circulation. 
They have been carried out with great trouble and care, 
and include records of pulse-rate, of blood-pressure, and 
of temperature. The blood-pressure was recorded by 
means of Oliver's haemodynamometer. Two sets of blood- 
pressure measurements are given, which the author 
terms "vascular pressure," shown by the greatest ex- 
cursion of the index, and " systolic impulse pressure," 
which obliterates the movement altogether. These cor- 
respond to what are usually called ''diastolic" and 
"systolic" pressures. The temperature was taken in 
the rectum and on the skin of the inguinal region of the 
abdomen by means of specially-constructed thermo- 
meters. 



120 Reviews and Bibliographical Notices. 

A large number of the observations were made with 
the subject in bed, and inchide the effects of increasing 
the covering (hot condition) and of reducing or removing 
the covering (cold condition). In the former the pulse 
and temperature rise, the blood-pressure falls; in the 
latter the pulse and skin temperature fall, while blood- 
pressure and rectal temperature rise. 

The significance of these circulatory changes is then 
discussed, the author deducing that the blood-pressure 
changes are not of cardiac but, on the contrary, of peri- 
]Dheral origin. 

Cold, however, does not always reduce the pulse-rate, and 
the o])posite effect is shown to occur under different con- 
ditions, such as the influence of a cold wind, a cold bath, 
and ])articularly by a stream of cold water if the tempera- 
ture is not too close to that of the skin. These conditions 
influence not only the pressure and speed of the current, 
but ail so the distribution of the blood. 

There are useful data in the book contained in a large 
number of tables. These are for the most part reduced to 
the graphic form in charts, of which there are altogether 
fifteen. The author is of the opinion that the evolution 
of heat in the contraction of the heart is a material factor 
in the production of body heat. 



Handbook of the Historical Medical Museum. Organised 
by Henry S. Wellcome in connection with the Seven- 
teenth International Congress of Medicine, London, 
1913. 8vo. Pp. 140. 11 Plates and 5 Plans. 
For many years the study of medical history met. with 
liltle encouragement in the British Isles, and those few 
who devoted time to the elucidation of its problems were 
lookcHl on more as harmless faddisls than as contributors 
to serious knowledge. Such views have, however, we 
hope, passed away for ever, and w(^ are gradually coming 
to recognise not only the interest but the importance of 
the study of the History of Medicine in the elucidation of 
man's evolution. Already a Section for this study has 



Pollock — Harrison — Venereal Diseases. 121 

been added to the Royal Society of Medicine, and this 
year, for the first time, a Section of Medical History has 
been inchided in the programme of the International 
Congress. Mr. Wellcome has taken the opportunity of 
the Congress to open his long-promised Medical Museum, 
and the Congress has been fortunate in securing it as an 
adjunct to the meetings. The book before us is intended 
merely as a guide to the treasures exhibited, and not as a 
descriptive catalogue ; but it contains sufficient to make 
us look forward with pleasure to a visit to the Museum, 
and to express the sincere hope that a complete catalogue 
will be published later on. 



A Manual of Venereal Diseases. Introduction by Sir 
Alfred Keogh, K.C.B. ; late Director-General of the 
Army Medical Service. History, Statistics, Invaliding, 
&c., Brevet-Colonel C. H. Melville, R.A.M.C, late 
Professor of Hygiene, Royal Army Medical College*. 
Clinical Pathology and Bacteriology, Brevet-Colonel 
Sir William Leishman, K.H.P., F.R.S., R.A.M.C, 
Professor of Pathology, Royal Army Medical College. 
Clinical Course and Treatment, Major C. E. Pollock, 
R.A.M.C. Second Edition, revised and largely re- 
written, with new matter by Major L. W. Harrison, 
R.A.M.C, Clinical Pathologist, Military Hospital, 
Rochester Row. Oxford Medical Publications. 
London : Henry Frowde and Hodder & Stoughton. 
1913. Demy 8vo. Pp. xvi -h 318. 

The second edition of Pollock & Harrison's " Manual of 
Venereal Diseases " is practically a new book. Since the 
first edition of what we then described as "a little 
volume " was reviewed in the number of this Journal for 
January, 1908 (Vol. CXXV., page 36), the study of 
the venereal affections has attracted more attention than 
ever before, our knowledge of them has much increased, 
and their treatment has advanced by leaps and bounds. 
All this has been recognised by the authors of this 



122 Revieivs and Bibliographical Notices. 

handsome volume of more than 300 demy octavo pages, 
and the result is a thoroughly practical and, on the whole, 
eminently scientific treatise. The title-page has been 
transcribed in full at the head of this review in order that 
our readers may see for themselves how wide is the scope 
of the subject-matter of the book, and by what com]x4ent 
pens it has been contributed. 

In the light of modern investigations Major L. W. 
Harrison has practically re- written the chapters TI. to 
v., inclusive, on the pathology of syphilis. To 
show how thoroughly up-to-date the letterpress is it 
is only necessary to refer to page 31, at which allu- 
sion is made to Noguchi's successful experiments in re- 
lation to the artificial cultivation of the Spirochcpte 
pallida, or Treponema pallidum as Schaudinn named 
the organism. It was so recently as 1911 that H. 
Noguchi succeeded in obtaining pure cultures with which 
he produced typical syphilitic lesions in rabbits. At 
page 33, a footnote draws attention to a still more recent 
paper by Noguchi, entitled " A method for cultivating T. 
pallidum in fluid media." This ])aper was jMiblished in 
the Journal of Experimental Medicine for 191'2 (Vol. 
XVI.). 

As was to be expected also, the first of the chapters 
on treatment (Chapter VII.) is entirely given up to a very 
full and able account of salvarsan and neo-salvarsan from 
Major Harrison's pen. It is illustrated by two coloured 
plates. Of these, the first shows an extra-genital chancre 
of the thumb and a maculo-papular eruption on the tnmk. 
The colour photogra]ih was taken immediately before an 
intra-muscular injection of salvarsan (0.6 grm.) at the 
Military Hospital, Rochester Row. Another colour 
photograph of the same case was taken ten days after- 
wards. It shows the chancre almost healed, while only 
stains of the rash remain. 

Major Harrison points out that the effect of salvarsan 
on the T. pallidum and on the Wassermann reaction is 
not less striking, and constitutes one of the main supports 
of its specific action. He states (hat the Wassermann re- 



Pollock — Harrison — Venereal Diseases. 123 

action varies in the length of time which elapses before it 
becomes negative. Further, he admits that the effects of 
the remedy on parasyphilitic lesions is uncertain. We 
are inclined, perhaps from a too limited experience, to go 
further and suggest that it is practically nil. We doubt 
that salvarsan or neo-salvarsan can exercise any curative 
pov^er once organic changes have taken place in the 
central nervous system. Here is what Major Harrison 
says on the subject : — " In some cases of tabes it has 
caused the sexual power to return and the Argyll-Eobert- 
son 2:)upil to disappear, and has effected considerable im- 
provement in co-ordination ; in others it has proved dis- 
appointing, and has sometimes even aggravated the sym- 
ptoms. In most cases of general paralysis it has proved 
disappointing." He adds : — " Most of the impressions 
regarding the effect of salvarsan on parasyphilis have been 
gathered, however, from results obtained when not so 
much was known regarding the best methods of giving the 
remedy, and better results are now^ being reported under 
improved methods " (page 174). 

One of the most interesting chapters in the book is the 
thirteenth, on the treatment of gonorrhoea. The author is 
again Major Harrison, who deals with the question under 
four headings : — (1) The general management of the 
case ; (2) drugs ; (3) methods of urethral medication ; and 
(4) vaccine and serum therapy. 

The methods of urethral medication may be roughly 
classified as (1) small syringe, (2) large syringe, (3) irri- 
gation, (4) jellies, &c., (5) by the application of heat, 
(6) by means of instruments, (7) ionisation — the last with 
zinc in chronic cases being distinctly encouraging. 

But the treatment by the local application of heat 
strikes us as being the most novel and instructive. Major 
Harrison observes that ' ' the theoretical foundation of this 
is the destructive effect of comparatively low temperatures 
on the gonococcus, which dies in six hours at 104° F., 
and at higher temperatures in a considerably shorter 
time." (Page 248.) He adds :— " Kyaw (1912) reported 
considerable success with diathermv, but the necessary 



124 Reviews and Bibliographical Notices. 

apparatus is too costly to permit of the general application 
of this form of treatment." Diirin^ a recent visit to 
Harro^^ate we had an opportunity of seeing the diathermy 
api^aratus at work. In order to get over the difficulty of 
expense, Major (1. J. Houghton, one of the staft" of the 
Military Hospital, Rochester Row, London, has recently 
used with success in gonorrhoea the hot-water bougie in- 
vented by Dr. Valentine, of Silchar, India. This in- 
genious instrument, and the method of employing it, are 
fully described by Major Harrison, who also has used an 
electrically-heated bougie devised for the treatment of 
stricture by ])r. Ph. Kobelt. 

Enough has been stated to show the high character of 
the work before us. It is a matter for regret that in so 
scientific a treatise the practically useless and even mis- 
leading " Table of Values in Diagnosis " should still find 
a place on pages 156 and 157. 



Essentials of Medicine : a Text-hook of Medicine for 

Students heginyiing a Medical Course, for Nurses, and 

for all others interested in the Care of the Sick. By 

Charles I^hillips Emerson, M.D. ; late Resident 

l^hysician, the Johns Hopkins Hospital, and Associate 

in Medicine, the Johns Hopkins Hospital. Second 

Edition, revised. Philadelphia and London : J. B. 

Lippincott Company. 1911. Demy 8vo. Pp. xi + 

401. 

It is hard to realise that this book is by the same author 

as the excellent " Clinical Diagnosis," which also lies 

before us. The preface tells us that it is intended for 

junior students of medicine and for nurses, but there is also 

the suggestion that "the book may be attractive to the 

general reader." The second of these purposes is, in our 

opinion, the only one which deserves to be fulfilled, 

though practically all reference to the subject of nursing 

is omitted. There is, however, a good summary of 

dLseases of all kinds comprised under the term " medical " 

written in non-technical style, which would, no doubt, be 



Emerson — Clinical Diagnosis. 125 

of interest and profit to an intelligent nurse could she be 
induced to read it. As regards the other objects we do not 
agree. The "writing of semi-technical books for the en- 
lightenment of lay readers is not encouraged by the leaders 
of medical thought in this country, for the very good 
reason that more harm than good may be done thereby. 
The paper cover enclosing the book is, however, of interest 
in this connection. We find there three advertisements of 
works by medical men, entitled: — "Why Worry?" 
" Those Nerves," and " Self-help for Nervous Women." 
Further comment is needless ! It should be stated that 
the author in his preface disclaims its use as a " family 
physician." We hope that his advice will be followed. 

The value of the book to the medical student is doubtful. 
His time is fully taken up during the first years with sub- 
jects in which examinations must be passed to the satis- 
faction of examiners, who are often not greatly interested 
in the clinical aspect or bearing of their work. The 
average student will not find time for reading books which 
will not help him much in the particular course on which 
he is engaged. Later on, when he sees a case in hospital, 
he should be encouraged to read up as much as he can 
about it, not merely to recollect its simplest features. 
There is already too much tendency to rely on a work con- 
sisting of "Essentials" or "Elements," and if for no 
other reason the training is bad. 



Clinical Diagnosis. By Charles Phillips Emerson, 
A.B. , M.D. Third Edition. Philadelphia and London : 
J. B. Lippincott Company. 1911. 8vo. Pp. xxix -f 
724. 
An excellent testimonial to the value of this work consists 
in the mere fact that the third edition has appeared in the 
space of five years. But, as the author points out, a book 
of this nature must be kept up-to-date, as far as is con- 
sistent with the inclusion only of " subjects the value of 
which is reasonably certain ... and methods which 
have been well tested." 



126 Reviews and Bibliographical Notices. 

Needless to say, many changes have been effected, and 
the appearance of the book considerably altered. We 
venture to say that little of importance has been omitted 
concerning the particular topics dealt with ; in fact, we 
may go farther and aj)ply the word " comprehensive " to 
the description of the six subjects which occupy a bulky 
volume of over seven hundred pages. These subjects are 
in order : the sputum, urine, stomach and intestinal con- 
tents, the blood and various body fluids. 

Though the number of text-books dealing with the 
same question in diagnosis is enormous, and many of them 
are so excellent that they have become our constant 
assistants, we have not met one before which restricts its 
scope and magnifies its field to the same extent as that 
before us. To whatever subject we turned for informa- 
tion, we found in full all that we already knew, and, it 
must be confessed, much of which we were hitherto 
ignoiaid. Though all the sections are so good, we are 
most pleased with that on the blood, which, in addition 
to being the largest, is ])robably of most interest at the 
present time. Not only the various pathological changes 
in the blood itself, but also those in the bone-marrow 
are dealt with, while exhaustive descriptions of the 
Wassermann reaction and the opsonic index are in- 
cluded. The illustrations in general are numerous and 
(excellent, but the coIouhmI l)lo()d |)lates are particularly 
(>nVclive — indeed, more like what is expected in an atlas 
of haniatology than in a text-book. 

The subject of Junctional diagnosis, which is attracting 
nnich ;il((Mili()n on llic ContincMii, is not neglected, an 
interesting account being given of the various methods 
of examining for renal funclion, though the author re- 
• rrcts that Ihe amount of work done in this held has been 
rather unlruitfnl. We are sorry, nevertheless, that the 
plan of \hv work does not include the methods of testing 
function in ollu>r organs, some of which are of consider- 
able interest and proved value. 

The book, on the whol(\ gives one an unusual feeling 
of satisfaction, [)robably due to its completeness of detail 



Abler— Malig7iant Growths of the Lungs. 127 

in all the subjects attempted. The index is good, and 
will prove of much assistance in the work of reference, 
which is, after all, the main function of such a book. 



Primary Malignant Growths of the Lungs and Bronchi. 
By J. Adler, M.D. New York and London : Long- 
mans, Green & Co. 1912. Demy 8vo. Pp. xii + 3-25. 

Our first thought on taking up a volume with this title is 
anticipated by the author in his opening sentence : — " Is 
it worth while to write a monograph on the subject of 
primary malignant tumours of the lung? " But when we 
consider the scanty and scattered information on the sub- 
ject already in existence we are compelled to admit that it 
is certainly " w^orth while," provided any one can be 
found with sufficient energy and perseverance to under- 
take the task. Professor Adler has done so with a 
thoroughness that deserves tlie gratitude and approbation 
of the profession, and has compiled what we believe will 
prove to be a classic on the subject. He combats the 
general idea that primary malignant neoplasms of the 
lungs are among the rarest forms of disease, and shows 
that in recent years more and more cases are being re- 
ported — not, he believes, from any increase in the inci- 
dence but rather from more careful post-mortem examina- 
tion, both naked eye and microscopic. 

The book proper is in two sections — pathological and 
clinical — but the greater part of the work consists of 
elaborate tables giving the recorded facts of a large number 
of undoubted cases collected from various sources. We 
fear that these tables will hardly meet with an apprecia- 
tion proportionate to the labour which their com|)ilation 
must have entailed, as, with the exception of the statis- 
tician, we doubt whether many will have the enthusiasm 
to carry them through such formidable lists. 

In the pathological section there is not much addition to 
our knowledge concerning the appearance and nature of 
these growths, but the descriptions are very clear and con- 
cise, and we would like to give special praise to the really 



128 Reviews and Bibliographical Notices. 

beautiful reproductions of micro-photographs of the 
various conditions referred to. They are collected together 
at the end of the book. 

The two chapters dealing with signs and symptoms will, 
no doubt, prove of most general interest. The clinical 
symptoms of pain, cough, sputum, res[)iratory difficulty, 
irregular fever, and cachexia are those on which most 
stress is again laid. With the exception of the importance 
of the use of x'-rays, and possibly of the bronchoscope, 
there is no attempt to point out a " royal road " to dia- 
gnosis, and (lerhardt's advice is quoted — " Always to sus- 
pect tumour in persons of advanced age where tuberculosis 
is not likely and cannot be found by ordinary examination, 
where there is" cough with bloody exi)ectoration." Perusal 
of the literary portion of the book will occupy only a few 
hours, and we cordially reconnnend it to those who may 
chance to meet a case presenting the old description of 
" anomalous signs and symptoms." 



Clinical Klcvtrocardiugraphij. By Thomas Lewis, M.J)., 
D.Sc, F.R.C.P. ; Assistant Physician and Lecturer 
on Cardiac Pathology, University College Hos[)ital ; 
London : Shaw & Sons. 1913. Demy 8vo. Pp. viii -i- 
V20. 

This book is a companion volume to the author's pre- 
vious work entitled " Clinical l)is(M*ders of the Heart 
Beat." After careful perusal of it one is forced to the 
conclusion that the only satisfactory method of gaining a 
knowledge of electrocardiography consists in obtaining 
an electrocardiograph and working wi(h it oneself; or, 
perha|)s, even better still, in attending a clinique, where 
the electrocardiograph is in use, and obtaining a course of 
lecture demonstrations on the methods of using the in- 
strument, and on the interpretations of the resulting 
cardiograms. Once one has had this experience we have 
no doubt tliat the present volume would seem as an in- 
valuable guide to further study, but without such experi- 
Q^^,Q — and the reviewer frankly admits that he has never 



Chundra — Laws of Sexual Philosophy. 129 

used an electrocardiograph — it is practically im]_x)ssible to 
obtain a comprehensive or clear knowledge of the subject 
from reading. 

As far as we can judge, the writer has stated his 
facts clearly and fairly, but the recital is withal some- 
what dry, and it is hard to agree that in many cases 
the examination is not superfluous. Possibly this method 
of examination has an important future before it, but in 
spite of the honest conviction of the writer of this book 
we find it hard to believe that the present practical value 
resulting from it is sufficient to induce one to devote too 
much time to acquiring a mastery of its technique. To 
specialists the volume will, no doubt, largely appeal. We 
again state that we believe the book to be an excellent 
summary and judicial statement of all that is known on 
the subject of electrocardiography. 



Laws of Sexual Philosophy . An Exposition of Eastern 
and Western Sexual Science from Medical, Moral, and 
Social point of view. (Designed for the Students of 
Gynaecology and Obstetrics.) By J. L. Chundra, 
L.M.S. (Calcutta University); Kustomjee Scholar, 
Emeritus Professor of Medicine and Clinical Medicine, 
College of Physicians and Surgeons of Calcutta and 
India respectively ; Consulting Physician to Calcutta 
Free Hospital, and Victoria Kefuge Hospital, &c., &c. 
Calcutta. 1913. Pp. v + 208. 
The contemplation of the title-page and frontispiece of 
this interestingly curious — and decidedly Oriental — 
volume, and a glance at its unfamiliarly-phrased contents, 
bring prominently into the field of our mental vision 
suggestions of the rapidly progressive narrowing of the 
girdle of our planetary globe, and the increasing closeness 
(we avoid the term intimacy, very consciously, but with- 
out prejudice) of contact between the mechanical West 
and the mystical East. And the interest of such reflec- 
tions is emphasised in the present case by the fact that 
we have never forgotten the importance of the concen- 

I 



130 Reviews and Bibliographical Notices. 

trated truth : Ex Oriente lux. Of course, since the date 
of the estabhshment of the claim of the West to the 
" loot " of the East, the wisdom of the philosophy of the 
latter has often been emphatically, and e\en brutally, 
depreciated. Still there remain some thinking people who 
(l(j not exclusively appreciate the spiritual inspiration 
afforded by the bike, or the motor, or even that furnished 
by the 'plane ; and who would fain look forward to a 
''revival" of the modes of thought, and wireless waves 
of the propagation of the same, which [U'oduced, in their 
respective periods, the most impressive and commanding 
personalities known to history ; and which have left in 
their res[)ective wakes the most imposing extant monu- 
ments of thought and of achievement, of artistic insi)ira- 
tion and of instructive i)ractical wisdom — deservedly so 
named. 

It is one of the characteristics of the phase of Western 
materialism which is specially represented in its modern- 
istic theory and juactice of the healing art : that the 
emotional aspect of sexual rolationshi]) is kept as com- 
pletely as possible out of sight ; and when forced forwards 
from the background to which it has been so very arti- 
ficially — and tyrannically — relegated, the revealed facts 
and data, thus unexpectedly exposed, are at once sub- 
jected to attempts (decidedly vain efforts !) at weight and 
measurement a])proximating to the unsympathetic rigidity 
of the ap[)>licati()n of the metric system. But such 
foot-standard has not been successfully made to fit ; and 
most assuredly it never shall. The sexual instinct, or 
a|)petite — commentators and doctrinaires may apply what 
terms they choose — was given to insure the preservation 
of the species, as surely — and to seeing eyes as obviously — 
as was the appetite for food with a view to ]ireservation 
of the life of the individual. As the former has been 
evermore associated with the most lofty emotions of which 
humanity has i)n)ved itself callable, and has had its 
attraction emphasised by the fact of being baited with the 
highest attainal)le source and degree of physical pleasure, 
there is every reason why it should be exalted in the con- 
templation of every true citizen of the world's coming 



Chundra — Laws of Sexual Philosophy. 131 

democracy, instead of being thought of as a manifestation 
of the moral uncleanness of humanity. We have no doubt 
whatever that the very unhealthy secretiveness, and per- 
sistent avoidance of the application of the most elementary 
hygienic practice, maintained through the long series of 
centuries with regard to the sexual organs — and especially 
those of the female — should be credited with the primor- 
dial genesis and subsequent ravages of the pathological 
processes which are now being wholly credited to the 
account of the much-libelled coccus and spirochcete. 
Anyway, the fact is now before us, that the other western 
nations are rapidly advancing in this domain of enlighten- 
ment ; while Great Britain is, as usual, hobbling up 
clumsily in the rear — while ready to claim a lion's share 
of credit if the conditions of future environment prove 
favourable. This fact could not fail to reveal itself to any 
observer dowered by Nature with the gift of seeing, who 
had an opportunity of glancing over the exhibits of the 
great Aufstellung held in Dresden two years ago ; of which 
the sexual library and museum of venereal pathology 
collectively made one of the most distinctive, as w^ell as 
instructive, of outstanding features. 

But the Oriental still occupies a view-point very far 
removed, indeed, from that hitherto occupied by the 
average citizen of our Occidental communities. In con- 
sonance with this circumstantial fact is our author's 
choice of title. Philosophy, rather than Physiology- 
Gum-Pathology , is connotative of the attitude duly appro- 
priate to those — even still very much mystical — regions, 
many of the constituent communities of which waged fana- 
tical warfare during untold centuries for the maintenance 
of the superiority of the respective claims to adoration of 
the Yoni and the Lingain. And the whole treatment of 
the — literally vital and vitalising — subject maintains its 
appropriate diametrical remoteness. Nevertheless, as re- 
gards the actual scientific (and even philosophic) nature 
of the bulk of the contents of this volume, we do not here 
feel called upon to bow with enforced himility. The writer 
has given us a good many items of the sacred Wisdom of 



132 Reviews and Bibliographical Notices. 

the East, in illustration of the problems of one of the most 
assiduously cultivated departments thereof ; but we con- 
fess that we would have been more effectively impressed 
if he had conveyed them in carefully phrased and 
grammatical English. At her Western debut, the 
Oriental Minerva of sexual Wisdom might well have 
been presented in a well-fitting and gracefully-flowing 
costume — even improved, with characteristic tropical pro- 
fuseness of decoration by a richly cndiroidered train of 
illustrative comment and quotation. Of the latter there 
is a great deal — but chiefly derived from Western sources. 
The frontispiece — a Murillo-like crescent embracing in 
its concavity a voluptuously graceful presentation (hardly 
less so for being somewhat modernistic and Frenchified) 
of the Queen of Heaven and of Night ; with some appro- 
priately illustrative stars in the background, and ushered 
in with an appropriate motto of metrical dedication : — 

Oh Thou! Mother of Procreation, 

The mystery of the Universe regulation 

Unknown and Unknowable revealation : [sic !] 

Thou'rt the main Spring of Creation, 

I dedicate this to thee, with reverence and admiration. 

Holding, as the author confessedly does, that "to 
clearly diagnose is to destroy," the language of mysticism 
and alphabet of moral hieroglyphics must necessarily 
figure largely in the structure and decoration of a doctrinal 
edifice of his construction which was destined to compre- 
hend and illustrate one of the most j)rofound subjects of 
human thought — as well as one of the broadest of human 
interests. The writer, as he is prone to embroider and 
adorn his matter with suitable gems of history and of 
dogma, might pardonably, we think, have pointed out this 
connection : that the Crescent Moon had been the pagan 
Byzantine symbol centuries before the introduction of 
Christianity ; that its retention in relative prominence was 
permitted, or winked at, by Constant ine the Great and his 
advisers (for the political leverage afforded by its hypnotic 
influence) after the victorious elevation of the Divine 
Lab a r urn : and that its presence above the glittering dome 



Chundra — Laws of Sexual Philosophy. 133 

of St. Sophia was tolerated by the triumphant Turks on 
entering into possession — always more liberally disposed 
towards the ceremonial observances and practices of their 
contemporaries than ever were their Christian neighbours, 
pace the cumulative testimony of hosts of Western his- 
torians to the contrary! (This fact, which must interest 
inquiring readers at the present epoch-making juncture of 
the solutioyi of Turkish dominance in South-eastern 
Europe, permanently undermines, of course, the popular 
fallacious tradition of the source of the antagonism of 
*' The Crescent and the Cross " ; and of the Moham- 
medan origin of the former, and its adoption as their 
religious symbol by the leaders of Islam.) 

The Oriental's exalted conception of the importance and 
dignity of the sexual functions, and their organs, is mani- 
fested in every line, as well as paragraph, of the present 
volume. The author quotes approvingly the aphorism of 
the famous (Western) Fernel : totus homo semen est. He 
affirms that ' ' Woman is the keystone in the eugenic 
arch. Her quality determines the character and strength 
of our human superstruction. (Here, of course, the 
eugenists must have their say — probably, one of ap- 
proval?) A specimen of *' Author s remark " is : " Men- 
struation is Nature's wash day — the poorest blood in the 
circulation is thrown out, for menstrual blood possesses 
none of the vital properties peculiar to that which escapes 
when haemorrhage occurs " — a statement of alleged fact 
which seems to suggest that his physiology is hardly up- 
to-date, as standardised from the Western view-point. 
He emphasises the fact that the sexual " appears to be 
the most sociable and lest selfish of all instincts. It is a 
much more noble, because less purely selfish instinct than 
hunger or thirst." The enunciation of the prospective 
reward of its realisation may be ail-too veracious in its 
practical philosophy, but it cannot be described as ex- 
hilarating to coming candidates to read (with heavy 
" underscoring ") that; " It is an universal law : — n had 
husband is cursed with a good wife and conversely a good 
husband with an ill-tempered wife.'' (We are not quite 



134 Reviews and Bihlioqraphical Notices. 

sure whether the eiigenists have taken account of the 
workin«^ of this su^^^estively " maqnetic " law of po-lar 
contrasts.) We learn that : " the fjenesaic act, accom- 
plished normally and completely, leaves at its close a con- 
dition of well-being . . . from the most troubled 
disposition of mind a tendency to gaiety and warmth of 
heart." The equilibrium of this statement might, per- 
haps, l)e improved by one of the immortal Stagirite : — 
" Omnc animal post coitum, cjallo excepto, triste est/' 
The various devices for " ]irevention " are catalogued, 
from the methods of Onan down to those of the New 
^()lk Perfectionists. Many of the curious manifestations 
ul ancient and mediaeval views of menstrual uncleanness 
are referred to. Probably the most absurd of all is one that 
is not menti(jned here. Matthiolus, the famous commen- 
tator of Dioscorides, and Father of Modern Therapeutics, 
tells us that Iloman ])atrician ladies originally introduced 
la])-dogs, and his testimony regarding the practical object 
of the original personal culture of those dainty favourites 
is thus produced by Ulysses Aldrovandus, the Father of 
Modern Natural History : — " Cum ipse noverit mulieres, 
qu;v non alia de causa catellos ^lelitesios domi alebant, 
qiiam lit, dum mensibus lal)()rar(»nt , ea excrementa 
ringerent qu.ne concreta pudendis partibus inho^rebant, quos 
canes ciinuilingos vocant , nee tamen, oh banc causam, 
aliquo rabiei periculo agitata^ sunt." Such was the 
function of the primordial lajvdog of the luxurious 
Uoman dama of the days of Shakes]M^are. And thus was 
the origin of the horrors of ]uj<1rophohia pojndarly 
accounted for in the same period. The idea of the im- 
purity of menstruation seems to have prevailed in every 
primitive community of human beings. Our author does 
not neglect the strange coincidence of the lunar time 
period. He might have addinl the Pythagorean item of 
median-al mysticism : that the same periodic number (of 
the lunar and meusfrual cycles) amounted to the sum of 
the digits, beginning with the " divine " unit, and ending 
with the sacred and symbolic seven (1+2 + B + 4 + 5H- 
-f 7 = 28) : the liitter representing the actual number of 



Chundra — Laws of Sexual Philosophy. 135 

the planets which presided over, and continuously regu- 
lated, all suhlunar phenomena and events (and of which 
the full Levantine importance is ever and anon making 
itself felt in the pages of Holy Writ). 

The classification here made of human types, male and 
female respectively, is still more Oriental in its remote- 
ness from the Western view-point and surface standard. 
The same remark applies to the author's observations and 
instructions regarding sexual intercourse. He recommends, 

generally speaking between the ages of twenty and 
thirty," that it be "repeated every other day." He 
mentions, of course, the limiting periods laid down by : 
Mohammed, once a week ; Zoroaster, nine days ; Solon and 
Socrates, ten days; Luther, twice a week. Lists of 
articles of diet, of drugs, and of hygienic practices w^hich 
promote sexual desire and sexual vigour, are here pro- 
vided. For instance : " The practice of rubbing ' sindur ' 
— red oxide of mercury — betw^een hair locks on the fore- 
head, amongst Hindu w^omen is highly scientific. It 
keeps the head warm and stimulates sexual desire." 

Our author treats marriage with the highest — even 
devotional — respect; referring to it as "a divme institu- 
Uon " (in face of the depressing law of pairing already 
quoted), and also states that : " True marriage is the 
happiest condition of an earthly existence, and is con- 
ducive to a long life and green old age." And, in con- 
nection with puerperal conditions of difficulty, we were 
deeply impressed by his reference to the reply of the 
almost superhuman Corsican, when asked by Dubois in 
the very difficult labour of Marie Louise : " Whether, if 
matters come to an extremity, he should save the mother 
or the child; Napoleon, notwithstanding his desire for 
the birth of an heir to his dynasty, replied — ' The 
mother, it is her right." We would specially com- 
mend to our British contemporaries — who have recently 
commenced the dnscovery of that extraordinary leader of 
men — a deliberate mental contrast of this reply to that of 
Henry VIH. of England, under circumstances of striking 
similarity ; bearing in mind at the same time that the 



136 Reviews and Bihliographical Notices. 

" bluff King Hal " was the most popular of all English 
monarchs, and the true founder of " modern " England. 
The author may, indeed, be pretty truthfully said to 
have touched every aspect of his subject ; although we 
cannot conscientiously compHment him on having 
" made up his brief," or mastered the fundamental data 
on which the whole structure depends for its ultimate 
stability. Still we believe that there is a kernel of sound 
practical ''philosophy '' in the statement that: "The 
married woman who tells her physician that she does not 
enjoy connubial bliss is the woman who lied to herself at 
the altar and swore to love, honour, and obey the man she 
thought she could ' put up with.' " He quotes, with 
apparent approval, Janke's " scientific " principle of 
" crossed inheritance " ; who thereon " advises women 
who long to have a boy to drink a glass of champagne 
before fulfilling their conjugal duties in order to gain 
sexual vigour." He seems, however, to contrast un- 
necessarily the Oriental view : " The Hindu philo- 
sophers, on the other hand, conclude that the parent 
possessing the greatest amount of vital force will confer 
the sex of the offspring." 

" Sexual inversion " receives full attention, as is in- 
evitable in an Oriental treatise, and with illustrative 
allusions to the homo-sexuality of Scx^rates, of Plato, of 
Michelangelo (et hoc genus omne) — depressing examples 
of the combination of the highest moral ideals, and 
artistic enthusiasm and capabilities, with life-practice of 
inexplicable as well as unspeakable vileness and per- 
versity. The volume, though very fidl, does not refer to 
the perversion of hetero-sexuality which was offered by 
Levantine tradition in explanation of the sweeping sen- 
tence of the universal deluge. The book of Genesis tells 
us that the sons of God came down unto the daughters of 
men ; the sequel is not revealed : the latter adopted the 
r6le of incubus instead of the natural one of succuhus. 
And an Oriental treatise would be made more instructive 
by inclusion of the curious fact of philosophic history, 
that : in the days when Alexandrian Sophists were the 



Grant — Hints for Regimental Medical Officers, 137 

guardians of the world's concentrated wisdom, one of 
their geometers — Euclid by name — undertook to deduce 
from the original (female) source of human life, the 
spatial laws which regulate the measurements of all 
forms of inanimate matter. Few geometers, and (if 
possible) still few^er gynoocologists, of the twentieth cen- 
tury, we venture to opine, have hitherto recognised in 
Euclid's first diagram a hieroglyph of the pudenda of the 
human female. But thus has Eastern " Philosophy " 
been evermore screened off from the gaze of the " pro- 
fane," for the more subtle enjoyment of its esoteric 
disciples and evangelists. 

K. 



Hints for Regimental Medical Officers of the Territorial 
Force. By Capt. M. F. Grant, R.A.M.C. London : 
Forster Groom & Co., Ltd. 1913. Pp. 40. 

The author of this little book is well qualified for the task 
which he has set out to accomplish. He has written this 
w^ork with a view to aiding those w^ho have passed through 
an initial course at the Territorial Force School of Instruc- 
tion, and directs fhe medical officer in the way he should 
set about doing his duty rather than what he should 
actually do. 

In the opening pages the author clearly lays down the 
relation of the Medical Officer to the Commanding Officer, 
and points out that aill orders to the men, except those of 
the Royal Army Medical Corps, must be made through 
that officer. He then sets out the various duties of a 
medical officer as regards sanitation, recruiting, and 
annual training, and gives useful hints as to suitable sub- 
jects for lectures, &c. Finally, he shows the personnel 
under the direct command of the medical officer, and the 
equipment at his disposal. 

Wherever possible, references are given to official pub- 
lications, and the pages are interleaved so that notes may 
be added as required. The book seems admirably >suited 
to the purpose for which it is published, 



PAirr III. 

MEDICAL MISCELLANY. 

Reports, Transactions, and Scientific Intellifjenec. 



ROYAL ACADEMY OF MEDICINE IN IllELAND. 



President— Walter G. Smith, M.D., F.R.C.P.I. 
General Secretary— J. A. Scott, M.D., K.H.C^S.T. 

SECTION OF SURGERY. 

IVosidont— R. D. Purefoy, M.IX, P. R. C.S.I. 
Sectional Srcivtary— C. A. Ball, M.D., F.R.(\S.I. 

Frkhnj, May 0, 1013. 

The PiiEsn)ENT in the Chair. 

Pole I/Kjatinii for II ypcrtJnjroidifim (with lantern slides). 
Mi{. \V. Pearson read a paper on the above, givinpf a rrsuwr 
ot the histological changes in the thyroid gland which 
acconi])any the clinical evidences of hyperthyroidism, and 
advocating surgical measures as the most rational treatment 
in the vast majority of cases. The anatomy of the vascular 
and lym])hatic circulations of the gland was then described 
in detail, special attention being directed to the distribution 
and anastomoses of the blood-vessels, and their relationships 
as well as those of the lymphatic vessels to the capsular in- 
vestment of the thyroid. A knowledge of these points is essen- 
tial if }Kjle ligation is to be effective. A di'scription of Mayo's 
ligation of the su})erior thyroid vessels and Jacobson's " polo 
ligation " was followed by an account of a severe acute case 
in which the bilateral pole ligation was performed with most 
satisfactory results, no other special treatment bciug ado}>ted. 

The paper concluded with some observations nii f.-chni(jue 
and aft('i*-li-eatment. 

Mr. \V. 1. HE CouRCY WiTEEi^ER congratulated Mr. 
Pearson on the way in which he had brought before them 
the lymphatic distribution of the thyroid gland. If the dis- 



Section of Surgery. 139 

tribution in the thyroid was as Mr. Pearson described, there 
could be little doubt of the efficacy of the operation of pole 
ligation. He recalled his experience of treatment in a case 
which was considered unsuitable for partial thyroidectomy 
which was followed by marked improvement of the con- 
dition. A point of interest was that in some cases of hyper- 
thyroidism many of the clinical symptoms are often absent 
or do not present themselves until the patient was very far 
gone. He affirmed that Coffer's blood count in such cases 
was useful for diagnostic purposes. Another point of in- 
terest was the wonderful improvement which followed par- 
tial thyroidectomy in exophthalmic cases. Since it had been 
pointed out that the wound should be treated as a suppu- 
rating one, and since drainage in conjunction with liberal 
uses of saline had been supplied, the mortality had become 
inappreciable. Once the bad symptoms had passed off the 
patient might be said to be well in from three to four days. 
He had experience of a case of this kind in his own practice. 
Dr. H. Stokes inquired if Mr. Pearson could give the mor- 
tality in those cases which were not treated. 

Mr. a. a. M'Connell inquired if there was any histo- 
logical difference in the gland after ligation. Kecent ex- 
perimental work, he thought, showed that in some cases in 
which the arteries were ligatured there was no histological 
difference, but where the veins had been ligatured there was 
marked histological difference. He suggested that it was 
possible that the ligature of the latter was a more important 
feature than the former. In cases where both were ligatured 
the histology was more distinct. 

Dr. Keegan inquired if the operation would be suitable for 
cases of large cystic conditions of the thyroid in young chil- 
dren where there was a good deal of hypertrophy of the 
thyroid with some dyspnoea. He would also like to know 
what points Mr. Pearson would lay stress on in the prepara- 
tion of a patient for the operation, and what anaesthetic he 
considered most suitable. 

Mr. Gunn said he had seen the patient referred to both 
before and after the operation, and he would like to add his 
testimony to the success of the operation. He did not con- 
sider that any surgeon would have attempted an operation 
for the removal of the gland from a patient in a similar con- 
dition. He agreed with Mr. Pearson with the exception of 



140 Royal Academy of Medicine in Ireland. 

one point — i.e., the suggestion that hgation of the pole 
might be done in early and mild cases. He considered that 
partial thyroidectomy was safe in such cases, and he would 
be inclined to keep the pole ligation for the bad cases. He 
mentioned that Mr. Pearson had used a local anaesthetic in 
one case, but this type of anaesthesia was not usual in these 
cases. 

The President said that these cases had a very great in- 
terest for any one concerned as he was with obstetrics. 
What the relation was between enlargement of the thyroid 
and arrested, diminished, or suppressed menstruation he 
had not a clear idea, but that there is a connection he was 
perfectly satisfied. It occasionally fell to his lot to prescribe 
for patients suffering from amenorrhoea, in whom perhaps 
there was not a considerable enlargement of the thyroid, 
and in a number of these cases that he could recall general 
treatment had resulted in a reduction of the thyroid and a 
return of the menstrual flow. He had seen some cases of 
very great enlargement of the gland in women comparatively 
young, and who had borne a comparatively large number of 
children at short intervals ; but whether these cases would 
have any connection with the condition of exophthalmic 
goitre he could not say. One of the worst cases of the kind 
that he could recall was that of a girl, aged nineteen, 
who struggled through typhoid fever, and a year afterwards, 
during which menstruation did not return, exophthalmos 
occurred. That patient was under observation and treat- 
ment for two or three months when the menstrual flow re- 
appeared with very marked improvement in her condition, 
but she was by no means cured. 

He remembered another case of exophthalmic goitre, 
attended with wasting and profuse perspiration at night, 
marked protrusion of the eye-balls, with scanty menstrua- 
tion. The patient was childless. She was not treated, and 
was lost sight of for about three years. When next seen the 
condition was much improved, although it was likely that 
she had not undergone any treatment. 

Mr. Pearson, replying, said there was no doubt that liga- 
tion was efficient in the great majority of cases. The mild 
cases would get quite well, although many relapse after a 
few years. In recommending the operation for mild cases 
he did not mean that every mild case should be operated on, 



Section of Surgery. 141 

but he suggested that every mild case that had been medi- 
cally treated for a definite length of time should be submitted 
to ligation, because it offered a better chance of getting well, 
and it was simpler and less radical than partial thyroidectomy. 
There were evidences of histological changes, and he men- 
tioned one case recorded by Murphy where, after the ligation 
operation on the two poles, the entire thyroid became a malig- 
nant mass, so that apparently there was a danger in rare 
cases of the change being too excessive. The blood count 
which Mr. Wheeler had found of value had been given up by 
the Mayo's. The question of drainage was, of course, impor- 
tant, but not in ligation operations. The important thing in 
this operation was to choose the right time, when the patient 
was not in a severe exacerbation. To avoid rough handling 
of the gland was also important. Massage and pulling of the 
gland about should also be avoided. Eough handling, he 
considered, had more to do with bad symptoms than in- 
efficient drainage. With the severe cases that have not been 
operated on the mortality was high. The greater mortality 
he attributed to what were looked upon as the terminal 
changes. He did not think ligation would be indicated in 
the cases mentioned by Dr. Keegan. As to preparation for 
the operation, he looked on absolute rest, diet, and drugs as 
important, and he considered £c-rays the most useful of all 
treatment. In his case rectal feeding, digitalis, and the 
application of ice-bags was the only treatment resorted to. 
He found that local anaesthesia worked very well, the only 
objection being that bleeding appeared to be greater than if 
general anaesthesia was used. He considered that it was in 
the severe cases that ligation was the most useful. 

The remarks regarding the relationship with amenorrhcea 
were most interesting, and he considered that the whole 
ductless systems of the body were closely correlated. The 
occurrence of a slight amount of goitre in young women was 
very common, but the condition usually subsided without 
treatment. Acute fever and general physical exhaustion he 
looked upon as forerunners of this condition. 

The President having to leave, Sir John Lentaigne took 
the Chair. 

Some Cases of Intestinal Stasi<s. 
Mr. W. I. DE CouRCY Wheeler read a paper on the variouu 



142 lioijal Academy of Medicine in Ireland. 

abdominal angulations and kinks associated with the term 
intestinal stasis. He based his conclusions on a study of 
twenty recent abdominal cases, and illustrated his remarks 
with lantern slides. 

Stress was laid on the association of various intra- 
abdominal lesions, and he condemned the practice of per- 
forming the operation of appendicectomy with great rapidity. 
If an appendix lent itself to rapid removal by its anatomical 
position and absence of gross pathological changes, either 
the operation was not justified, or, more likely, the sym- 
|)t<)ms were equally due to such conditions as Lane's ideal 
kink or Jackson's membrane. Mr. Wheeler was able to trace 
eJackson's membrane in direct and unbroken connnuni- 
cation with the right margin of the omentum, and he 
accepted the theory of Gray and Anderson that it was 
nothiiif]^ more than the lateral margin of the great omentum 
])ulled out during the descent of the ciecum. The congenital 
theory as to the formation of this and other bands and mem- 
branes forming kiulvs was satisfactory and comprehensible. 
Dilatation of the duodenum was often overlooked, and was 
due to develoj)mental adhesions at the duodeno-jejunal 
juncture or to a band stretching across the duodenum to the 
right of the superior mesenteric artery. 

Jackson's membrane, so far from hel])ing to fix the 
CHBcum, often caused a marked kink at the he])atic flexure, 
with prohii)se and dilatation of the caecum. Cases with 
slight or marked visceroptosis, with s])lashing caecum, and 
diffuse right-sided discomfort or pain, ahuost invariably had 
a well-developed Jackson's membrane. The membrane 
should be divided if causing exaggerated angulation of the 
lu'piitic iiexure. The cases with a little experience can be 
diagnosticated before operation. 

Left-sided pain was often due to an exaggerated kink of 
tile pelvic colon rendered worse in females by the impheation 
of the left ovary in the line of fusion between visceral (meso- 
colic) and parietal peritoneum which caused the kink. A 
plastic operation on tlie mesocolon relieved the kink, and 
often cured constipation in the most intractable cases. 

In enteroptosis cases the conditions described were most 
marked. (iastro-enterostomy, like appendicectomy, was 
often performed witliout having regard to developmental 
adhesions and obstructions of a congenital kind below the 



Section of Surgery. 143 

duodenum. It was a simple and rapid operation to perform, 
but was seldom indicated beyond cases of pyloric obstruc- 
tion. Until recently, gastro-enterostomy was too frequently 
performed, and the after-results were not as favourable as 
was generally supposed. 

Mr. Wheeler thought the whole subject-matter required 
riddling and discussion, but that certain points were defi- 
nitely settled, one of the most imi:)ortant being the definite 
presence of abnormal angulations and rotations of the gut, 
which, when relieved by operations, caused the disappear- 
ance of symptoms in a number of obscure abdominal cases. 
The relief of constipation by a plastic operation on a develop- 
mental kink was worthy of attention. 

X-<ray Diagnosis of Abnornialities of tJie Intestinal Tract. 

J)ii. Maurice Hayes read a paper illustrated with lantern 
slides. He stated that in all cases the data furnished by 
the x-ray examination should be carefully analysed in con- 
junction with the previous history and the subjective and 
objective symptoms of the patient. Radiography should be 
employed as an aid to, and not as a substitute for, the 
ordinary methods of diagnosis. 

To interpret accurately the different shadows cast by the 
intestines requires much practice and experience. The 
shadow of a loop of the bowel, when viewed obliquely, gives 
the idea of an existing kink, when in reality the curve may 
be the arc of a circle which may not be at all sufficient to 
delay the passage of the intestinal contents. 

In spasmodic strictures of the oesophagus the bismuth food 
may be seen to enter the stomach with a sudden rush when 
the spasm relaxes. 

In cicatricial stenosis the food passes in a thin stream, and 
peristaltic movements are violent. 

In malignant strictures the peristaltic movements in the 
neighbourhood of the growth are feeble. Reverse peristalsis 
is often present, and enlarged glands can be observed near 
the gullet in the posterior mediastinum. 

As the position of the umbilicus varies, a transverse line 
between the summits of the iliac crests would be the most 
accurate land-mark. In the erect position the greater curva- 
ture of what may be termed the ** normal " stomach reaches 
this line. Radiography is of doubtful value in determining 



144 Royal Academy of Medicine in Ireland. 

the presence or absence of gastric ulcers. A point of maxi- 
mum tenderness to pressure over a particular part of the 
stomach or duodenum is not strong presumptive evidence of 
an existing ulcer. Adhesions which fix the terminal part of 
the ileum to the right pelvic brim can be detected by x-ray 
examination, and the latter is the most valuable method of 
accurately determining the position of the large intestine. 
The duodenum is often seen to be nuich dilated — esi)ecially 
when there is obstruction to the free passage of food into the 
jejunum, or when there is delay in entering the caecum. 

Dr. Faknan said he had gone into the literature, and was 
not satisfied that the clinical symptoms attributed to these 
kinks were really due to them. It was well known that rest 
in bed did improve the condition. He was not satisfied that 
the performing of plastic operations and the removal of them 
will improve the condition, nor would the removal of the 
adhesions improve it. 

The Chairman (Sir John Lentaigne) said he took a deep 
interest in this subject, and his opinion largely coincided 
with Dr. Farnan's. He was not satisfied that the oi)inion 
put forward by Lane was proved. There were three 
main schools of mechanical theory of this affection — t.c, 
the English school, led by Lane, the Danish and the 
French. All the schools acknowledged that there were 
cases in which symptoms similar to those complained 
of in these instances are present without evidence of 
stasis, and that there may be some other cause. The Conti- 
nental school say that most of the trouble is due to putrefac- 
tive changes in the intestine and that the condition is due 
to intestinal toxaemia. That there was a good deal of truth 
in this there was not the slightest doubt in his mind. 



SECTION OF 0I3STET1UCS. 

President — Sir Andrew J. Hdrne, F.R.C.IM. 
Sectional Secretary— G. FitzGihbon, M.D., F.K.C.IM. 

Fridiuj, May 23, 11)13. 

The President in the Chair. 

Some Scquche of Labour. 
Dr. Bethel Solomons read a paper on the above, in which 



Section of Obstetrics. 145 

he submitted the results of examining 543 primiparae on the 
sixteenth day of the puerperium. 

The President said the paper opened up a new field for 
obstetricians to more or less insist on the thorough exami- 
nation of their patients before discharging them. He was 
astonished at the very high percentage — i.e., 48 — of lacera- 
tions of the cervix uteri which were found to have occurred 
in primiparae, but, of course, the lacerations varied from 
one-third of an inch to one inch. He considered that if that 
large number of lacerations of the cervix occurred one would 
expect severe post-partum haemorrhage, and it should cause 
the obstetrician to try and find the origin of the haemor- 
rhage, and he would deem it a duty to stitch the cervix 
immediately. 

He thought that most of the backward displacements he 
frequently found were congenital and unimportant, and no 
matter what treatment may be carried out, at the end of 
two months if the patient is again examined this displace- 
ment will be found to have recurred. He suggested that if 
the patient was examined two months after confinement it 
could be ascertained if there was any real displacement, and 
an opinion could then be formed as to the treatment neces- 
sary. He looked on it as a duty to suture a ruptured 
perineum at once. Catgut sutures very often become 
absorbed too soon, and in his practice he invariably used 
the ordinary silk- worm gut, and found it successful. He 
had not yet adopted " early rising," and from what he had 
heard he would be chary in doing so. 

Although Dr. Johnson put on forceps, force was not 
applied for some time afterwards. He suggested that the 
forceps was used merely as a dilator. 

Dr. Hastings Tweedy said that Dr. Solomon's statistics 
of lacerated cervices would come as a surprise to many. It 
had been asserted by an eminent Fellow of the Academy 
that such tears did not occur in normal delivery. This 
view was in the main true, but was subject to exceptions, 
for he (Dr. Tweedy) had reported tears after perfectly 
normal child-birth. 

Posture had no effect in bringing about a condition of 
retro-displacement, it owed its origin to the presence of a 
full bladder or to congenital defect in the majority <^f cases. 

K 



146 lioijal Academy of Medicine in Ireland 

An improperly applied binder was another direct cause, 
and one that was seldom appreciated. 

Before the application of a binder the uterus should be 
sharply antefiexed, and the third ])in should be placed 
so as to groove the binder above the uterus and fix the 
latter in a condition of anteflexion. 

Pulmonary embolus was a septic condition, and ditl not 
arise in consequence of getting the patient up too sooiT. It 
was, moreover, associated, in his experience, with a quick 
pulse. He had no faith in the power of calcium lactate to 
stay the progress of a septic clot. 

rROFESSOii Thompson said that he did not consider that 
calcium salts administered by the mouth or hypoder- 
mically had the effect of hastening coagulation. 

])r. Spencer Siieill said he had seen many backward 
disi)lacements of the uterus ])roduced by tight lacing of the 
corset before complete involution had taken place. The 
maximum coagulation resulted from calcium salts if ad- 
ministered at broken periods.^ 

Dr. Allen said he had never found calcium salts of 
much use in helping coagulation. He had found that in 
suturing the perineum catgut alone does not give as good 
results as silk-worm gut, or a combination of both. He 
inquired if the time at which the suturing is done has not 
an effect on the morbidity. While one did not like putting 
forceps on the undilated os he pointed out that Dr. 
Johnson stated that he had proved that he could do so 
without any evil effect. 

])r. Solomons, in replying, said that his experience of 
the calcium salts only extended to cases of threatened 
abortion, miscarriage, or premature labour, in which he had 
found them of very little influence. He was unable to say 
wliether perineums united better when stitched imme- 
diately or some hours after labour. He was convinced 
that when forceps was applied to the cervix which was 
not fully dilated a tear always resulted. He agreed that 
48 per cent, of tears in his series was greater than the 
ultimate results would have shown, but he had pointed out 
that the paper was based on examinations made sixteen 
days after confincnnc^nt, and he felt sure that a great 
number of tlie tears then apparent would afterwards heal. 
He considered that a capable nurse could apply a binder 



Section of Obstetrics. 147 

better than a doctor who gets so much less practice. 
He thought that although the constant dorsal decubitus 
was the most common cause of post-partum retroversion, 
he did not exclude insufficient emptying of the bladder and 
other conditions as possible predisponents. 



Breast-feeding of Infants. 

Dr. Ella G. H. Webb read a paper on this subject. 

Professor Thompson said the consideration of the 
physiological aspect of the question was difficult as so little 
was known about the physiological stimuli that promoted 
the secretion of milk. He referred to a paper by Dr. Janet 
Lane-Clayton, recently reviewed in the British Medical 
Journal, on *' The Investigation of the Question of Milk and 
Lactation." No one had yet succeeded in discovering a 
nerve, the cutting or excitation of which interfered in 
the slightest with the secretion of milk. The general 
opinion was that if the mother was getting sufficient ordi- 
nary food she produced as much milk as she would on any 
special food. He was not a very strong believer in the in- 
fluence of proteins in increasing the constituents of milk. 
The only constituent of milk that could with certainty be 
influenced by the diet was the fat. It was quite possible 
that milk as regards proteins might become undesirable 
from an alteration in the relative amount of caseinogen. 
The practical points brought out in the paper struck him 
as very useful. 

Dr. Hastings Tweedy said mothers and nurees were 
very fearful of starving the infant. He had observed that 
breast milk became (^s a rule) very scanty on about the 
sixth or seventh day, and it was at this time bottles were 
usually begun. The introduction of bottle-feeding forty- 
five years ago constituted the most disastrous experiment 
that the human race ever embarked on. Its condemnation 
did not entirely rest on the high rate of infantile mortality ; 
more serious still were the ill consequences in after-life in- 
flicted on the infant who worried through a succession of 
stomachic disorders, or other debihtating illnesses. He 
could declare, from observations made in his own practice, 
that bad teeth in the adult seldom occuiTed in those whose 
infancy and young childhood had been free from disease. 



148 Royal Academy of Medicine in Ireland. 

It is evident, too, that permanent defect cannot be limited 
to the teeth. Bones, muscles, brain, skin, &c., must also 
suffer. 

Children can deal with excess of some particular con- 
stituent in food; this is shown by the splendid results 
obtained in the whole-milk method of feeding. He did not 
think that infants should be placed on measured amounts 
of food. T^t them be given what they can digest, at 
intervals not shorter than three hours. 

If they throw up, regurgitate, or get diarrhoea, of the 
kind which immediately follows on ingestion of food, urgent 
indications are thereby afforded that a smaller quantity 
should be given. 

More infants were injured by excess than by depreciation. 

The President said it was the experience in mateniity 
hospitals that a very large majority of women do nurse, 
and he believed the mothers amongst the ])oor were able to 
nurse for a very long time. Food, undoubt^idly, did seem 
to militate against the secretion of milk or the reverse. He 
recalled his experience when wet nursing was in vogue — 
i.e., that over- feeding was one of the chief means of in- 
sufficiency of milk. He agreed with Dr. Webb with regard 
to the application of alcohol to the nipples in preparation 
for nursing, and also as regards the i)ulling out with the 
fingers instead of with a breast pump or other such instru- 
ment. 



THE BEDSIDE MANNER — LATEST. 

Doctor (callitKj at hospital, ten minutes after the dinner-hcll 
has gone, to " dress " his patient, in private ward). — " I 
say, that's a fine game at Lords. By Jove! I remember 
playing in a holiday match at Horsham. They had a couple 
of Sussex men bowling for them. Vine and Killick. I took 
the first over from Killick. First ball, dead on middle 
stump; second ball, dead on middle stump; third, dead on 
middle; fourth, glanced it to leg — four; fifth, cut it to 
boundary— four; sixth, glanced it to leg— four! Twelve in 
first over— not bad, what? St. Mary's men didn't bluff a 
catch the whole day and we won by two runs. Here, nurse, 
where's my overall and rubber gloves? Tiet's get to work, 
for goodness sake." —Punch, June 18, 1013. [But, dear 
Mr. Punch, is this fact or fancy, a joke or a libel? — 
" Mimule, tolle josos ! — Non est jocus esse Malignum." — 
Ed.] 



SANITARY AND METEOROLOGICAL NOTES. 

Vital Statistics 

For jour weeks ending Saturday, June 14, 1913. 

IRELAND. 

The average annual death-rate represented by the deaths — 
exclusive of deaths of persons admitted into public institutions 
from without the respective districts — ^registered in the week 
ended June 14, 1913, in the Dublin Registration Area and 
the twenty-six principal provincial Urban Districts of Ireland 
was 18.5 per 1,000 of their aggregate population, which for the 
purposes of these returns is estimated at 1,199,180. The 
deaths registered in each of the four weeks of the period 
ending on Saturday, June 14, and during the whole of 
that period in certain of the districts, alphabetically arranged, 
correspond to the following annual rates per 1,000 : — 



County Boroughs, &c. 




Week ending 




Average 
Kate 
for 4 
weeks 


May 
24 


May 
31 


June 

7 


June 
14 


27 Town Districts 


19.2 


16.6 


17.1 


18.5 


17.8 


Dublin Reg. Area 


21.5 


16.0 


15.9 


20.8 


18.5 


Dublin City 


21.7 


16.1 


16.9 


22.8 


19.4 


Belfast 


17.0 


16.7 


17.1 


17.5 


17.1 


Cork 


27.2 


17.0 


15.0 


17.0 


19.0 


Londonderry 


11.4 


11.4 


22.9 


15.3 


15.3 


Limerick 


21.7 


20.3 


16.2 


12.2 


17.6 


Waterford 


22.8 


15.2 


28.5 


19.0 


21.4 

1 



The deaths (excluding those of persons admitted into public 
institutions from without the respective districts) from certain 
epidemic diseases registered in the 27 districts during the week 
ended Saturday, June 14, 1913, were equal to an annual rate 
of 0.9 per 1,000. Among the 133 deaths from all causes for 
Belfast are one from measles, one from enteric fever, and 3 
from diarrhoea and enteritis of children under 2 years of age. 



150 Sanitary and Meteorological Notes. 

One of the 25 deaths from all causes for Cork is from scarlet- 
fever. One of the 10 deaths for Waterford is from whooping- 
cough, and of the 5 deaths from all causes for Newry one is 
from measles. Among the 12 deaths from all causes for 
Londonderry^ are 2 from diarrhoea and interitis of cliildren 
under 2 years of age. 

DUBLIN REGISTRATION AREA. 

The Dublin Registration Area consists of the City of Dublin, 
as extended by the Dublin Corporation Act, 1900, together 
with the Urban Districts of Rathmines, Pembroke, Blackrock 
and Kingstown. The population of this area is 403,000 ; 
that of the City being 308,187, Rathmines 38,769, Pembroke 
29,942, Blackrock 9,161, and Kingstown 16,941. 

In the Dublin Registration Area the births registered 
during the week ended June 14 amounted to 208 — 112 boys 
and 96 girls — and the deaths to 173 — 83 male^ and 90 
females. 

DEATHS. 

The registered deaths, omitting the deaths (numlx>rin,s; 12) 
of persons admitted into public institutions from localities 
outside tho ^Vi'ea, represent an annual rate of mortality of 
20.8 per 1,000 of the population. During the twenty-four 
weeks ending with Saturday, June 14, tho death-rate averaged 
21.8, and was 2.0 Ix^low thc^ mean rate for the corresponding 
portions of the 10 years 1903-1912. 

The total deaths registered, numbering 173, repi-esent an 
annual rate of 22.4 per 1,000. The annual rate for the past 
twenty-four weeks was 23.3 ]^r 1,000, and the average annual 
rate for the corresponding periods of the ])ast ten years was 
25.0 ]x>r 1,000 of the mean population for all deatlii> registered. 

The total deaths from all causes included 2 from scarlet 
fever (one l)cing that of a ]icrson admitted to hospital from a 
locality outside the Area), 2 from diphtheria, 4 from whoo]>ing- 
cough, and 2 deaths of cliildren under two years of age from 
diarrhwa and entcM'itis. 

In each of the three ))receding weeks, deaths from scarlet 
fever were 0, one, and ; deaths from di])htheria were one, 
0, and ono ; deaths from whooping-cough were 2, 0, and 3 ; 
and deaths of children under two years of ago from diarrhoea 
and enteritis wore 6, 2, and 3 rcs]X^ctivoly. 



Sanitary and Meteorological Notes. 151 

There were 40 deaths from tuberculous disease. This 
number inchides 29 deaths from pulmonary tuberculosis, 6 
from tubercular meningitis, and 5 deaths from other forms of 
the disease. In each of the three preceding weeks deaths 
from tuberculous disease numbered 30, 25, and 25. 

Of 13 deaths from pneumonia, broncho-pneumonia caused 
4 deaths, lobar pneumonia 3 deaths, and pneumonia (type 
not distinguished) caused 6 deaths. 

Organic diseases of the heart caused the deaths of 14 persons, 
and 13 deaths from bronchitis were recorded. 

Eleven deaths were caused by cancer. 

The deaths of 2 infants under one year of age were caused 
by convulsions, those of 2 from congenital malformations, 
those of 4 infants by congenital debility, and those of 8 through 
premature birth. 

There were 6 deaths by accident or negligence, 3 of these 
being by burns or scalds of children under 5 years, and there 
were 2 deaths by drowning. 

In 3 instances the cause of death was " uncertified," there 
having been no medical attendant during the last illness. 
These cases include the deaths of 2 infants under one year of 
age. 

Forty-one of the persons whose deaths were registered during 
the week ended June 14 were under 5 years of age (28 bemg 
infants under one year, of whom 10 were under one month old), 
and 35 were aged 65 years and upwards, including 22 persons 
aged 70 and upwards. . Among the latter were 13 aged 75 
years and upwards. 

STATE OF INFECTIOUS DISEASE IN THE DUBLIN 
REGISTRATION AREA AND IN BELFAST. 

The usual returns of the number of cases of infectious 
diseases notified under the " Infectious Diseases (Notification) 
Act, 1889," and the '' Tuberculosis Prevention (Ireland) Act, 
1908," as set forth in the following table, have been furnished 
by Sir Charles A. Cameron, C.B., M.D., Medical Superintendent 
Officer of Health for the City of Dublin ; by Mr. Fawcett, 
Executive Sanitary Officer for Rathmines and Rathgar Urban 
District ; by Mr. Manly, Executive Sanitary Officer for 
Pembroke Urban District ; by Mr. Heron, Executive Sanitary 
Officer for Blackrock Urban District ; by the Executive 



152 



Sanitary and Meteorological Notes. 



Sanitary Officer for Kingstown Urban District ; and by 
Dr. Bailie, Medical Superintendent Officer of Health for the 
City of Belfast. 

Tamle showing the Ndmbek of Cases of Infectious Diseases notified in the Dublii 
Registration Area (viz.— the City of DubUn and the Urban Districts of Kathmine 
and llathgar, Pembroke, Blackrock, and Kingstown), and in tbe City of Belfast 
during the week ended June 14, 1913, and during each of tlie preceding thre 
weeks. An asterisk (♦) denotes that the disease in question is not notifiable in th 
District. 



Cities and 
(JuHAN Districts 


Week 
entlinp; 


m 


ox 

•ee 


u 


S 


<- 
> 

c 
1 
"3 


e8 

■c 

« 

a 
c 


. 7 

03 

3 
O 

If 


"See 
X c 


> 

V 

= o 

V >. 


J 


o 
2 

3 


60 

S 

8 

its 
C 

'5. 

o 
o 




•2 

ll 


.S 

u 
< 


1 

o 


City of Dublin \ 

KalhiiiineH iiixl r 
Itatligav j 
Urban i 
District { 

Pembroke J 
DiHi.rict 

Blackrock [ 
Urban •' 
DiHtrict 

Kin^Mluwii 1 
Urban 
District 

Olty or Belfast 


May 24 
MaV ;il 
June 7 
.Tune 14 

May '24 
May M 
Juno 7 
June 14 

May 24 
May ;il 
.lune 7 
June 14 

May 24 
May .31 
June 7 
June 14 

May 24 
May :tl 
June 7 
Juno 14 

Mav 24 
May ;il 
June 7 
June 14 


7 
1 
2 
3 


- 


17 

14 

15 

4 

1 

1 

4 
2 
2 
2 

3 

1 

1 

yi 
■11 

26 
35 


1 
3 
4 

1 

1 1 


z 

_ 


3 
3 
8 
G 

3 
1 

1 
1 

1 
2 

1 

1 

1 

2 

5 
3 
(5 




2 

1 

.1 


7 
3 

r> 

3 

1 

1 
1 

7 
2 
2 
8 


3 

1 
1 
2 

1 

2 
2 
3 
8 


- 


1 

2 
2 
2 


* 
• 
* 
• 

• 
• 
« 
• 

• 1 

• i 


14 

14 

19 

6 

• 
« 
• 
• 

• 
• 
• 
• 

2 

11 

14 

11 

G 




47 

,18 
54 
2-' 

4 
2 

1 
:! 

13 
7 
6 

n 

4 

1 

1 
1 

3 

59 
04 
46 
58 



a Oontinucd Fever. 

Cases of Infectious Diseases under Treatment in Dubun 

Hospitals. 

During the week ended June 14, 1013, 2 cases of measles 
were adniitt-od to hos])ital, one was discliarged, and 11 cases 
romained nmhr treatment at the close of tlie week. In the 
three preceding weeks such cases wen^ 18, 17, and 10 resi)ec- 
tively. 

Nine oases of scarlet fever were admitted to hos])itaI. 1 1 
were discharcjed, there were 3 deaths, and 1)3 cases remained 
under treatment at the close of the week. This number is 



Sanitary and Meteorological Notes. 153 

exclusive of 17 convalescent patients who remained under 
treatment at Beneavin, Glasnevin, the Convalescent Home of 
Cork Street Fever Hospita'., Dublin. At the close of the three 
preceding weeks the cases in hospital were 80, 100, and 98 
respectively. 

Twelve cases of diphtheria were admitted to hospital, 
were discharged, and there were 3 deaths. The cases in 
hospital, which at the close of the tln-ee preceding ^veeks 
numbered 56, 56, and 4^^ res])ectively, were 42 at the close 
of the week. 

Four cases of enteric fever were admitted to hos]')ital, one was 
discharged, and 24 cases remained under treatment in hospital 
at the close of the week, the respective numbers in hospital 
at the close of the three preceding weeks being 19, 23, and 21. 

One case of typhus was admitted to hos]>ital during the 
week, one was discharged, and 8 cases remained under treat- 
ment at the close of the week. 

In addition to the above-named diseases, 7 cases of 
pneumonia were admitted to hospital, 12 were discharged, 
there were 2 deaths, and 15 cases remained under treatment 
at the end of the week. 

ENGLAND AND SCOTLAND. 
The mortality in the week ended Saturday, June 14, in 
96 large English toAvns (including London, in which the rate 
was 11.4) was equal to an average annual death-rate of 11.8 
per 1,000 persons living. The average rate for IG principal 
to^vns of Scotland was 14.2 per 1,000, the rate for Glasgow 
being 15.4, and that for Edinburgh 11.6. 

INFECTIOUS DISEASE IN EDINBURGH. 

The Registrar-General has been favoured by A. Maxwell 
Williamson, M.D., B.Sc, Medical Officer of Health for Edin- 
burgh, with a copy of his Return of Infectious Diseases 
notified during the week ended June 14. From this Report 
it appears that of a total of 31 cases notified, 14 were of 
phthisis, 11 of scarlet fever, 2 of diphtheria, and 4 of erysiiTclas. 
Among the 341 cases of infectious diseases in hospital at the 
close of the week were 110 cases of scarlet fever. 111 of phthisis, 
30 of whooping-cough, 46 of diphtheria, 6 of erj^sipelas, 3 of 
chicken-pox, and 4 of enteric fever. 



154 Sanitary and Meteorological Notes. 

Meteorology. 
Abstract of Observations made in the Citij of Dublin, Lat. 53° 20' 

N., Long. 6° 15' W., for the Month of June, 1913. 
Mean Height of Barometer, - - - 30.040 inches. 

Maximal Height of Barometer (28th, at 9 p.m.), 30.461 „ 
Minimal Height of Barometer (5th. at 4 p.m ), 20.601 
Mean Dry-bull) Temperature, - - - 56.6° 

Mean Wet-bulb Temperature, - - - 52.7° 

Mean Dew-point Temperature, - - 49.2° 

Mean Elastic Force (Tension) of Aqueous Vapour .354 inch. 
Mean Humidity, . . _ . 77,0 ]X5r cent. 

Highest Temperature in shade (on 17th), - 75.1° 
Lowest Temperature in Shade (on 12th), - 43.4° 

Lowest Temperature on Grass (Radiation) (12th) 41.1° 
Mean Amount of Cloud - - - 59.3 per cent. 

Rainfall (on 13 days) - - - - 1.198 inches. 

Greatest Daily Rainfall (on 19th) - - .251 inch. 

General Directions of Wind - - W., N.W., S.W. 

Remarks. 

A generally favourable month — the first half distinctly cool 
and changeable, \\ith brisk S.W. and afterwards N.W. winds, 
and frequent though not heavy rainfalls. On the 9th the wind 
rose to the force of a fresh gale from S.W. and W.S.W. Anti- 
cyclonic conditions prevailed from the 12th to the 16th in- 
clusive, and the weather was fine, dry, and warm. On the 
17th the thermometer rose in the shade to 75.1° in Du])lin, 
82° in St. James's Park, London, 85° at Camden Square, Lon- 
don, and 87° at the Royal Observatory, Greenwich. Two 
days later the maximum in Dublin was 61.7°. Local showers 
occurred in this city on the 23rd and 26th, thunder, lightning, 
and hail accompanying one such shower on the afternoon of 
the 23rd. The ('losing days of the month were beautifidly 
fine, warm, and bright, with light ])reezes at first from N.W., 
afterwards from N.E. During this a]X)ll of high summer the 
])arometer stood high and was steady. 

In Dul)Un the arithmetical mean tom^ierature (57.1°) was 
below the average (57.9°) by 0.8° ; the mean dry-bulb readings 
at 9 a.m. and 9 p.m. were 56.6°. In the forty-nine years end- 
ing with 1913, June was coldest in 1909 (M. T. = 54.8°), 1907 
(M. T. = 55.4°), 1882 (M. T. = 55.8°), and 1879 (" the cold 



Sanitary and Meteorological Notes. 155 

year ") (M. T. = 55.9°). It was warmest in 1887 (M. T. = 
62.3°), 1896 (M. T. = 61.4°), and 1899 (M. T. = 61.3°). June, 
1909, established a record for coldness. In 1912 the M. T. 
was 57.1°. 

The mean height of the barometer was 30.049 inches, or 
0.132 inch above the corrected average value for Jrme — 
namely, 29.917 inches. The mercury rose to 30.461 inches 
at 9 p.m. of the 28th, and fell to 29.601 inches at 4 i^.m. of the 
5th. The observed range of atmospheric pressure was, there- 
fore, .860 inch. 

The mean temperature deduced from daily readings of the 
dry-bulb thermometer at 9 a.m. and 9 p.m. was 56.6°, or 5.1° 
above the corresponding M. T. for May, 1913, Using the for- 
mula. Mean Temp. = Min.+ (Max. — Min.) x .465, the 
value was 56.6°, or O.S below the average mean temperature 
for June, calculated in the same way, in the thirty-five years, 
1871-1905, inclusive (57.4°). The arithmetical mean of the 
maximal and minimal readings was 57.1°, com^oared with a 
thirty-five years' average of 57.9°. On the 17th the ther- 
mometer in the screen rose to 75.1° — wind, N E. ; on the 12th 
the temperature fell to 43.4° — wind, N.N.W. The minimum 
on the grass was 41.1°, also on the 12th. 

The rainfall amounted to 1.198 inches on 13 days. The 
average rainfall for June in the thirty-five yearSj 1871-1905, 
inclusive, was 1.990 inches, and the average number of rain- 
days was 15. The rainfall, therefore, and the rain-days were 
below the average. In 1878 the rainfall in June was very 
large — 5.058 inches on 19 daj^s ; in 1879 also, 4.046 inches fell 
on 24 days. On the other hand, in 1889, only .100 inch was 
measured on 6 days. In 1887 the rainfall was only .252 inch, 
distributed over 5 days. June, 1910, established an undis- 
puted record for excessive rainfall in Dublin — the measure- 
ment being 6.211 inches on 19 days. In 1912, 2.595 inches 
fell on 23 days. 

High winds were noted on 7 days, reaching gale-force (8) 
on the 9th. 

The rainfall in Dublin during the six months ending June 
30th amounted to 15.097 inches on 104 days, compared with 
13.756 inches on 110 days in 1912, 7.729 inches on 80 days in 
1911, 18.632 inches on 111 days in 1910, 12.061 inches on 84 
days in 1909, 11.729 inches on 107 days in 1908, 12.336 inches 



156 Sanitary and Meteorological Notes. 

on 108 days in 1907, 12.641 inches on 100 days in 1006, only 
6.741 inches on 67 days in 1887, and a thirty-five years' 
average of 12.030 inches on 96 days. 



At the Normal Climatological Station in Trinity College. 
Dii])lin, the observer, IVIr. C. D. Clark, reports that the 
arithmetical mean temperature was 56.5°, the mean dry-biilb 
reading at 9 a.m. and 9 p.m. being 57.2°. The thermometer 
rose to 76° in the shade on the 17th, and fell to 42° on the 12th. 
The grass minimum was 37.0° on the 4th. Rain fell on 10 
days to the amount of 1.133 inches, .240 inch l)cing measured 
on the 19th. The numlx)r of hours of bright sunshine regis- 
tered by the Campbell-Stokes sunshine recorder was 173.5, 
giving a daily average of 5.8 hours. The corresponding figures 
for li)05 wore 217.6 hours and 7.3 houi-s ; 1906, 210.3 hours 
and 7.0 hours ; 1907, 129.4 hours and 4.3 hours ; 190S. 181.4 
hours and 6 hours ; 1909, 158.7 hours and 5.3 hours ; 1910, 139.0 
hours and 4.7 hours ; 1911, 190.9 hours and 6.4 hours ; and 
1912, 161.7 hours and 5.4 hours. The mean earth temjx^ra- 
ture read at 9 a.m. was 57.7° at a depth of 1 foot below the 
surface of the ground, 54.0° at a depth of 4 feet. 



At Ardgillan, Balbriggan, Co. Dublin, Captain Edward 
Taylor, D.L., measured 1.29 inches of rain on 15 days, the 
heaviest fall in 24 hours being .25 inch on the 9th. The rain- 
fall was 1.03 inches below the average of twenty years, while 
the rain-days were 2 in excess Temperature in the screen 
rose to 67.9° on the 28th and 29th. and fell to 40.0° on the 12th. 
Since January 1, 1913, the rainfall at Ardgillan amoimts to 
15.42 inches, or 2.87 inches more than the average, and the 
rain-days number 103, or 11 in excess. The extremes of rain- 
fall in June at Ardgillan in recent years have Ix^en — greatest, 
4.62 inches in 1910 ; least, 1.20 inches in 1904. 

Mr. T. Batcman reports that the rainfall at The Green, 
Malahide, was .945 inch on 13 (?) days. The heaviest fall in 
24 haurs was .26 inch on the 5th. The mean shade tem]iera- 
ture was 56.1°, the extremes being — highest, 72.5° on the 28th ; 
lowest, 39.0° on the 11th. 

Dr. C. Joynt returns the rainfall at 21 Leeson Park, Dublin, 
at 1.055 inches on 13 days, .225 inch having been recorded on 
the 19th. The half-vear's fall was 14.576 inches on 100 da vs. 



Sanitary and Meteorological Notes. 157 

At the Ordnance Survey Office, Phoenix Park, Dublin, rain 
fell on 14 clays to the total amount of 1.385 inches, .300 inch 
being registered on the 5th. The duration of bright sunshine 
was 180.4 hours, the largest daily duration being 13 hours on 
the 17th, and again on the 30th. 

At Cheeverstown, Clondalkin. Co. Dublin, Miss Violet C. 
Kirkpatrick recorded a rainfall of 2.04 inches on 13 days. The 
greatest falls in 24 hours at Cheeverstown were .43 inch on the 
19th and .40 inch on the 9th. 

At Manor Mill Lodge, Dundrum, Co. Dublin, Mr. George B. 
Edmondson registered a rainfall of 1.16 inches on 14 days. 
The greatest fall in 24 hours was .31 inch on the 19th. The 
mean temperature of the month was 57.5°, the extremes 
lx)ing — highest, 79° on the 17th ; lowest, 44° on the 12th. 
The half-year's rainfall was 18.52 inches on 104 days, com- 
pared with 8.20 inches on 85 days in the same period of 1911, 
and 16.51 inches on 114 days in 1912. 

At the Sanatorium of the Dublin Joint Hospital Board, 
Crooksling, Co. Dublin, Dr. A. J. Blake, Resident Medical 
Suj^ermtendent, recorded a rainfall of 1.79 inches on 11 days. 
The heaviest fall in 24 hours was .54 inch on the 9th. 

Mr. W. J. M'Cabe, on behalf of the Right Hon. L. Waldron, 
supplies the following record of the rainfall at Marino, Kil- 
liney : — Rain fell on 8 days to the amount of .76 inch, the 
maximal fall in 24 hours being .30 inch on the 19th. The 
average rainfall at Cloneevin, Killiney, in the 24 years, 1885- 
1908, was 1.771 inches on 13.2 days. 

Dr. J. H. Armstrong reports that at Coolagad, Greystoncs, 
Co. Wicklow, the rainfall was .96 inch on 14 days. The 
heaviest rainfall in 24 hours was .23 mch on the 9th. In 
June, 1912, the Coolagad rainfall was 4.92 inches on 23 days. 

At Auburn, Greystones, Co. Wicklow, Mrs. Sydney 
O'Sullivan measured .97 inch of rain on 14 days — .23 inch 
being recorded on the 9th. A slight thunder shower occurred 
on the 22nd. 

Dr. Charles D. Hanan, M.D., reports that at the Royal 
National Hospital for Consumption for Ireland, Newcastle, Co. 
Wicklow, rain fell on 12 days to the amount of 1.11 inches, the 
maximal fall in 24 hours being .29 inch on the 9th. The mean 
temperature for the month was 54.9°, the extremes being — 
highest, 70° on the 28th ; loAvest, 43° on the 1st and 3rd. The 



158 Sanitary and Meteorological Notes. 

mean maximum tom]X)raturo was Gl.O^ ; the mean minimum 
tem]X)raturc was 48.7°. 

The Kev. Arthur Wilson, M.A., reports a rainfall of 4.16 
inches on 15 days at the Rectory, Dunman\va3% Co. Cork. 
The rainfall was ,53 inch above the average for June. On 
the 22nd .70 uich was measured. The rainfall for the com- 
pleted six months of 1013 amounts to 39.32 inches on 123 days, 
the averages being 27.0() inches and 1 10 days. The lirst eleven 
days were very unsettled and cold for June, .00 inch of rain 
was measured on the 4th and .56 inch on the 6th. From the 
16th the weather was mostly dry, but rain fell on the nights 
of the 17th, 20th, and 22n(l to the amount of 1.40 inches. 
The rainfall of the last 8 days was only 0.10 inch. Thunder 
occurred duruig the night of the 20tli. While the month as 
a whole was cool, the 1st, 15th, 16th, 20th, and the last four 
days were very warm. 



AIMONTA WATEll IN W KST Al'KICA. 

As might have been expected, representatives oi tlie 
medical faculty practising in West Africa express very 
favourable views of the usefulness of Ai)enta Water in that 
country, especially as a preventive and cure of chronic 
constipation. Professor Dr. KiUz, Imperial Government 
riiysician, Cameroons, observes that he has always given 
the preference to it in the West African tropics on account 
of its many advantages. He points out that it is specially 
in hot clinuitcs that the European is predisposed to suffer 
from constipation, ])artly because ol tlie loss of lluid from 
the skin, ])artly by change of diet, and partly as a sequel to 
I he most ))revalent of tro])ical nudadies — viz., nudaria. 
The professor testifies that Apenta has jU'ovcd itself a mild 
but reliable aperient, free from unjjleasant after-effects, 
and one which patients take readily. Apenta has been 
ioinul to bear well I hi- heat of the tropics. 

Lrn:uARY notk. 
An important work on " Arterial Disease aiul Angina 
Pectoris," by Sir T. Cliiford Allbutt. M.D., F.R.S., is 
announced for publication in the aidunm by Messrs. 
Macmillan & Co., St. Martin's Street, London, W.C. 



PERISCOPE. 

THIRD INTERNATIONAL CONGRESS OF OCCUPATIONAL DISEASES. 

In 1906 the first ** Congresso internazionale per le malattie 
del lavoro," convened by a number of energetic Italian scien- 
tists, met at Milan. In 1910 the second Congress followed at 
Brussels, and was largely attended. The Permanent Inter- 
national Committee for the Study of Diseases of Occupa- 
tion (** La Commission permanente internazionale pour 
r^tude des maladies professionnelles ") resolved that the 
next Congress should be held in Vienna in September, 
1914, on strictly scientific lines. The Presidents will be 
Dr. Franz von Haberler, Chief of the Austrian Sanitary 
Department, and referee in sanitary matters to the Ministry 
of the Interior, and Dr. A. Schattenfroh, Professor of 
Hygiene and Director of the Institute of Hygiene in the 
University of Vienna. The General Secretary is Dr. 
Ludwig Teleky, Lecturer on Social Medicine in the Univer- 
sity of Vienna, and the Secretary is Dr. Hermann von 
Schrotter, of Vienna. The programme (" I'ordre du jour ") 
is as follows: — 1. Fatigue — its physiology and pathology, 
especially in relation to occupation and the effect of pro- 
fessional labour on the nervous system. Night work. 
2. Work in hot and damp air. 3. Anthrax (" charbon "). 
4. Pneumonoconioses. 5. Injurious effects of electricity in 
industrial pursuits. 6. Industrial poisons, especially 
anilin, mercury, lead. 7. Injurious effects of industrial 
work on hearing. 8. Miscellaneous communications. De- 
tailed information will be given on application to the General 
Secretary, Dr. Ludwig Teleky, Vienna IX., Tiirkenstrasse, 
23. 

LITERARY INTELLIGENCE. 

An important new work is about to be published, entitled 
" Researches on Rheumatism," by Dr. F. J. Poynton and Dr. 
Alexander Paine. From the preface we cull the following 
extract : — " We have collected in this volume the chief papers 
bearing upon a research on the subject of rheumatism which 
has extended over a period of fifteen years. In so doing we are 
well aware that few have the time to spend over reading the 
details of such investigations, but should the essentials of this 
research be eventually established, we feel that this book will 
stand as a landmark in the history of rheumatism in this 
country. Some of these papers were written before we demon- 



160 Periscope. 

strated what wo believe to be the exciting cause of the disease ; 
others elucidate the nature and action of that cause ; others, 
again, extending the main thesis, deal with allied conditions. 
At the conclusion of the volume the bearing of these investiga- 
tions upon clinical medicine and pubUc health is considered 
in a s|X)cial article." The work, which is to contain 100 black 
and white plates and a frontispiece in colour, will lx> ])ubHshed 
by Messrs. J. & A. Churchill, of 7 Gieat Marlborough Street, 
London, W. The same lirm has nearly ready the eleventh 
edition of 8\vayne's " Oljstctric A])h()risms," which is now 
edited by Dr. W. C. SA\aync, Professor of Obstetrics in the 
University of Biistol ; also the seventh edition of '* The 
Microtomist's Vade-Mecum," by Mr. A. B. Leo ; the sixth 
edition of the late Professor Cam])bell Brown's "Practical 
Chemistry," edited by Dr. Bt^ngough ; ami the third etUtion 
of " A Text-Book of Physics," edited by A. Wilmcr Duff. 

ROYAL COLLEGE OF SURGEONS OF EDINBFRGH. 

At a meeting of the College held on Wednesday, July Kith, 
11)13, the following gentlemen, having passed the requisite 
examinations, on 27th March, 1913, were admitted Fello^^'s : — 
Arthur Isaac Brown, M.D., CM., Trinity Medical College, 
Toronto, Regina, Sask., Canada ; William Barrio Brownlie, 
M.B., Ch.B. Univ. Glasg., Sprhigvale. .Strathaven ; Charles 
Corben, M.K.C.S., L.R.C.P. Lend., M.D. Univ. Durh., Hove, 
Sussex ; Ro}x)rt Crothere, L.R.C.P. & S.E., &c., Ashlea, Droit- 
wich ; Rustom Kershas]) Dadachanjl, L.M. & S., Bombay, 
M.R.C.S., L.R.CM*. Lond., Cumballa Hill, Bombay ; John 
Kolbe Milne Dickie, M.D.Univ. Edhi., Edinburgh : I\Tatthew 
Robertson Drennan. M.B., Ch.B. Univ. Edin., Edinburgh ; 
Edwin Charles East, M.R.C.S., L.R.C.P. Lond., Birmingham ; 
Max Groenberg, M.B., Ch.B. Univ. Edin., Edinburgh ; Francis 
Joseph Henry, M.B., Ch.B. Univ. Glasg., D.P.H. Camb., 
Mid(llos})orough ; Frederick Norton Haylock Maidment, 
M.R.C.S., LR.C.P. Lond., M.P>., Ch.B. Univ. Lond., Tw^-ford, 
Winchester ; Rol)ert Massie, L.R.C.P. & S.E., &c., Edinburgh ; 
Arthur Stanley Roo, M.R.C.S., L.R.C.P. l^nd., M.B., Ch.B. 
Univ. Oxford, Brisbane, Queensland ; Rolx^rt Stout, M.R.C.S., 
L.R.C.P. Lond., M D. Univ. Lond.. London ; Alfnd George 
Tall)ot, M.B., CM., M.R.CS., L.R.C.P. Ijond , Christchurch. 
New 2^niland ; John Watson, L.R.C.P. & S.E., &c., Glasgow. 



THE DUBLIN JOURNAL 

OF 

MEDICAL SCIENCE. 



SEPTEMBEK 1, 1913. 

PART I. 
ORIGINAL COMMUNICATIONS. 



Art. VII. — Medical Inspection of School Children. '^ By 
Sir William J. Thompson, M.D. Univ. Dubl., F.R.C.P.L, 
Registrar-General for Ireland, President of the Branch. 

The subject on which I propose to speak for a short time 
is " The Medical Inspection of School Children." This 
subject has been already very exhaustively and niost 
effectively dealt with by Mr. Story, President of the Irish 
Medical Association, in a paper read by him before the 
Royal Academy of Medicine in Ireland, in February, 1911, 
and also in a paper read before the Statistical and Social 
Enquiry Society of Ireland, in December of the same 
year ; by Mr. Gogarty in an address introductory of the 
Winter Session of 1911 at the Meath Hospital ; and by 
Mr. Jones, Professor of Economics in Queen's University, 
Belfast, who gave a public lecture on the same subject 
in the Theatre of the Royal Dublin Society in May, 1910. 
My only apology for bringing the subject forward again is 
that it is an urgent national one, and that although it has 

* The Inaugural Address delivered at the Annual Meeting of the 
Leinster Branch of the British ^[edical Association, held in the Royal 
College of Physicians of Ireland on July 15, 1913. 

VOL. CXXXVI. — ^NO. 501, THIRD SERIES. L 



162 Medical Inspection of Scliool Children. 

been before the public on these three or four occasions, 
still it would appear as if the whole community were not 
3^et aroused ,to the importance of the subject, and until 
they are it is useless to hope for legislation in this matter, 
and it is a matter tliat must be dealt with by legislation. 
Legislation can always be obtained on any particular 
matter, or for any particular object, if that matter or 
object is universally, persistently and perse veringly taken 
up by the public. The medical profession have on 
numerous occasions been the i>ioneers of, and have given 
valuable and effective help in bringing about, social reforms 
and useful legislation, and if the ])rofcssion, than whoni 
no other section of the community know so much, take up 
this subject, there is little doubt but that their opinion 
will have great weight with the general public. 

During the last twenty years, a period of history which 
is usually considered by us a progressive age, much has 
been and is being done, both by legislation and by volun- 
tary work, to improve the health of the people as a whole, 
principally that of the poorer classes. It is needless to 
enumerate the different Acts of Parliament passed during 
recent years, all having directly or indirectly this o})ject 
in view, not to mention the different voluntary organisa- 
tions and institutions which arc doing admirable work 
on much the same lines. 

It is only comparatively recently that public attention 
in this country has been directed to the health of children, 
especially to that of school children, although in different 
countries on the Continent the matter was taken up in 
a ]>ractical manner niany years ago. In the beginning 
of this century the subject aroused much attention, and 
was considered such an important one that in 1907 an 
Act was passed in England, and came into force on the 
1st of JanuarJ^ 1008, for the medical inspection of school 
children. It is difficult to say. and it is one of those things 
we cannot understand, why tlie Act was not ap])lied to 
Ireland ; and no one will question tlie fact that the 
children in this country require medical inspection just 



By Sir W. J. Thompson. 



163 



as much as the children in England — in fact the necessity 
for such is more urgent with us. 

It is a regrettable fact that the general death rate in 
Ireland is higher than that in England or Scotland ; for 
instance, the Irish death rate for the five years 1907-1911 
was 17.2 per 1.000 of the population ; in England and 
Wales it was 14.5 ; and in Scotland, 15.9. 

Examining more closely the deaths of the children of 
school age — viz., 5 to 15 years — we also find that Ireland 
compares unfavourably with England and Scotland. 

Table showing for Ireland, during the decade 1901-10, as compared with 
England and Wales, and Scotland, the average death-rate per 1,000 of 
the respective populations at age- periods, 5 and under 10 years, and 10 
and under 15. 



Countries 


Age 
Periods 


1901-1910 


Annual Rate per 1,000 of Population, 
• by Sexes, at ages specified 


Males 


Females 


Ireland 

England and Wales - 

Scotland 


r 5-10 
L 10-15 

r 5-10 

-< 

LlO-15 

r 5-10 

L 10-15 


3.7 
2.6 
3.4 
2.0 
3.9 
2.6 


4.2 
3.6 
3.5 
2.1 
4.3 
3.0 



From an examination of the causes of the deaths of 
children between 5 and 15 years of age during the year 
1910, the latest year in which the figures for the other 
countries in comparison with Ireland are available, it 
would appear that in Ireland 36.1 per cent, of all the 
deaths of children between 5 and 15 years of age were due 
to tuberculous disease, that in Scotland the corresponding 



164 Medical Inspection of Scliool Children. 

proportion was 28.9 per cent., and that in England and 
Wales it was 23.7 per cent. 

In the last Census year — viz., 1911 — 101,758 births 
were registered in Ireland ; the average number of births 
for the previous five years was 102,408. Taking the 
children born, and who had attained to the age between 
5 and 10 years, and those between 10 and 15 years, 
previous to the date of the Census, it will be found that 
about 85 per cent, of the former, and 80 per cent, of the 
latter were survivors at the date of the last Census. Of 
these, about 72 per cent, attend school, 69 per cent, 
attending primary schools (principally under the authority 
of the National Board of Education), and 3 per cent, 
other schools. This means that there were in Ireland 
on the 2nd of April, 1911, over 595,000 children who were 
attending school between the ages of 5 and 15, and who, 
therefore, if the same law was in force in Ireland as in 
England, would be under medical inspection. Of this 
nunibcr about 200,000 attend school in civic districts — 
i.e., towns with a population of 2,000 or upwards, and 
the remaining children, 395,000, in rural districts — a pro- 
portion of alniost one to two. The actual number of all 
ages, howevgr, attending school, as returned by the 
National Board of Education, was 634,000. 

The system of medical inspection adopted in England, 
as laid down by the Regulations of the Board of Education, 
framed from the Act of Parliament dealing witli the 
sul)ject, is that children should get a full and complete 
medical examination on their entrance to school (such 
children are termed " entrants ") ; again about the third 
year of school life (this is not compulsory) ; and lastly, 
on their leaving school, or about the sixth year of school 
life (these children are designated as " leavers "). It is 
computed in England that about one-third of all children 
attending school are examined each year — and this for 
Ireland would mean that about 200,000 school children 
would be medically exaniined each year if we had such an 
Act. 



By Sir W. J. Thompson. 165 

In a properly organised and constituted school the 
course of study should be regulated by the physical and 
mental condition of the pupils ; those, therefore, who are 
not of full mental and physical capacity should not be 
asked to do all the lessons that are supposed to be 
sufficient for ordinary normal healthy children ; then 
again those who are found to be below the normal state of 
health should get the necessary treatment to raise them 
to that state of health. Of course, amongst the latter 
will be found a certain proportion of mentally defective 
children, and there is no doubt about it that some of 
these children should not be allowed to attend an ordinary 
school. This subject of mentally defective children is 
now being dealt with by a Bill introduced by the Govern- 
ment, which is in course of passing through Parliament.-' 

The schedule of medical examination recommended by 
the English Education Board, and on the whole almost 
universally adopted by the Local Authorities, is so framed 
that it contains when completely filled up a vast amount 
of information in a comparatively small compass. It 
may be subdivided under four headings : — 

(1) Name, age, address, &c. 

(2) Personal history. — History of the previous ill- 

ness — principally dealing with the infectious 
diseases. 

(3) The personal medical history, including : — 

(a) General condition, height, weight, nutrition, 
cleanliness. 

(6) Special conditions — as to the state of the 
teeth, nose, eye, ear, mental con- 
dition, &c. 

(c) Disease or deformity — heart, lungs, nervous 
system, tuberculosis, other diseases, 
deformities, &c. 

(4) Observations and recommendations. 

This schedule has been by some authorities considerably 
added to, but it will be seen that it is pretty comprehensive. 

• Tiiis measure became an Act before Parliament was prorogued. 



1 66 Medical Inspection of School Children. 

Parents are always notified of the day and hour at which 
the children are to be examined, and when present are 
told what should be done if any disease is discovered. 
Quite a number of parents do attend, and this brings them 
into closer relationship with the school attendance officer, 
the nurse, the school medical officer, awd the teacher — 
a state of affairs which is very desirable. 

This inspection and examination, therefore, when 
properly carried out, not only deal with diseased and 
abnormal conditions, but must necessarily detect some 
affections in such an early stage that under proper care the 
disease is prevented from fully developing. 

The number of diseases — omitting for the present the 
zymotic diseases — that children are subject to during 
school age is a long list, and from the report of the Chief 
Medical Officer of the English Education Board, we find 
not only a great proportion of the children suffering from 
ordinary disease, but a large proportion suffering from 
diseases which, up to the introduction of medical inspection 
of school children, were thought comparatively rare 
amongst the juvenile population. For so far the medical 
inspection of school children has been almost confined to 
those attending schools under the local School Board of 
Managenient — that is all those schools under the control 
of the Education Board. This is a class of pu])ils whose 
parents or guardians, as a rule, do not seek medical 
advice until it is urgently needed, and pay com])aratively 
little attention to slight ailments, or what appear to them 
to be trivial matters, with the result that when the doctor 
is called in he may, and very often does, find the child in 
a very critical and hopeless condition. On the (>ther 
hand had he been called in earlier, serious and often fatal 
results would have been avoided. On this account 
medical inspection is niore urgent and more neccvssary 
aniongst the poorer class of children, than amongst those 
of the better class who attend the secondary or high class 
schools. 

Froni the Cliief Medical Officer's lucid and masterly 



By Sir W. J. Thompson. 167 

report for 1910, it appears that in London for that year 
over 172,000 children were examined, and of these over 
81,000, or only 47 per cent., were returned as normal — 
that is free from any definite organic defect or disease : 
and this we may consider about a fair average. 

Sir George Newman enumerates the organic defects or 
diseases as follow, and in the order mentioned : — 

(1) Malnutrition or " defective nutrition stands in 
the forefront as the most important of all 
physical defects from which school children 
suffer," In reference to this Dr. Butcher 
estimates that in Bedfordshire the percentage 
amongst children ranges from 18.5 in girls in 
rural districts to 23.7 in boys in urban dis- 
tricts ; and Dr. Badger, Wolverhampton, 
reports that the percentage of pupils aged 
5 to 13 years examined by him was as 
follows : — 

Good .. .. 31.7 

Normal . . . . 50.2 

Mal-nourished . . 18.1 

He states : " The last mentioned figure reports a seriously 
large proportion of scholars whose nutrition was con- 
sidered defective, and I confess it was a surprise to 
myself to find that so large a number had been included 
in that category." 

Amongst the causes which induce this may be 
mentioned : — 

Poverty. 

Inherent lack of vitality. 

Intestinal parasites. 

Unhealthy home conditions. 

Insufficient sleep. 

Rickets. 
* Carious teeth and oral sepsis. 

Improper and insufficient diet. 
{2) Ujicleanliness. — It is gratifying to know that this 



168 Medical Inspection of School Children. 

condition is much less since the introduction 
of school inspection. 

(3) Defective vision. — This amounted to 18,000 out 

of the 172,000 examined in London, or over 
10 per cent. 

(4) Defective hearing to half that number. 

(5) Adenoids, enlarged tonsils and glands. 

(6) Ringworm. 

Then come flat foot, organic disease of the heart, 
amomia, rheumatism, &c. 

One of the causes put down for malnutrition, as just 
mentioned, is dental caries, and considering that a diseased 
condition of the teeth with its accompanying oral sepsis 
has a most pernicious and injurious influence on the 
health of the child, this cannot be wondered at. The 
trouble is one which, under proper supervision in its 
early manifestation, in^y be readily recognised and 
successfully treated : hence the importance that steps 
should be taken to ensure that a beginning is made on a 
scheme directed both towards the prevention and cure 
of the disease. It is difficult to work out average per- 
centages for defective teeth amongst school children as 
the standard of each dentist or medical officer may vary. 
In the same annual report (1011), one county (Shropshire) 
is mentioned, in which the school medical officer has, 
since the inception of medical inspection, taken particular 
interest in the subject of dental disease, and figures are 
quoted from his report which are considered reliable. 
From these figures one gathers that the average percentage 
of children found to have sound teeth and a normal 
mouth amounts to not niore than about 6 per cent., and 
the percentage of pupils with one to three diseased teeth 
is about .30 — thus leaving the high percentage of 64 with 
what might be defined as defective, or we might almost 
say, seriously defective teeth. This must be looked upon 
as alarming. 

Dr. Starkie, Resident Commissioner of National Educa- 



By Sir W. J. Thompson. 169 

tion, in a paper read at the Sanitary Congress held two 
years ago in Dublin, describes the condition of the teeth 
of 200 children attending the Lough Cutra National School, 
Co. Gal way. These children, through the generosity of 
Viscount Gough, and with the consent of the Commis- 
sioners of National Education, were examined by a 
dentist who reported that " the children appeared to be 
unacquainted with the ideal of oral cleanliness, and the 
possession of a tooth-brush did not seem to be recorded." 

Dr. Starkie gave the percentage of these children at all 
ages having sound teeth as 4.5, which is lower than in 
any of the English counties. 

Medical inspection is made more effective by the pro- 
ceeding known as " following up " the ailing or defective 
child until it receives the treatment of which it stands in 
need. The various methods adopted to make fruitful 
the work of inspection are : — 

(1) The part taken hy the Parent. — It is most 

essential that the parent should closely co- 
operate in this matter. 

(2) The Teacher. — The importance of the part played 

by the teacher in assisting in the work of 
medical inspection and in securing attention 
to ailments discovered, or in regard to school 
hygiene generally, is not easy to exaggerate. 

(3) The School Nurse. — The efficient " following up " 

would be impossible unless the arrangements 
for the school medical services included a 
school nurse, or health visitor appointed for 
" whole " or " part time." One can readily 
understand how much of the success of the 
co-operation of the parents depends on the 
tact and sympathy of the nurse. 

(4) The School Attendance Officer. — The work of 

this officer varies widely in different areas, but 
his duties cannot be too lightly undertaken, 
as he plays an important part, not only in 



170 Medical Insjyection of School Children. 

reporting on the absence of pupils from the 
school, but also assists niaterially in the pro- 
cess of " following up." 
(5) Voluntary Agencies and Care Committees. — The 
work done by these organisations is found in 
a great number of districts to niaterially help 
and assist the officials in connection with 
medical inspection. 
Not only has the School Medical Officer to examine the 
pupils and recommend treatment ; but other important 
and far-reaching duties are imposed on him. For 
instance, his additional duties are described in the same 
annual report. 

(1) Advising or approving the closure of schools. 

(2) Authorising the exclusion of individual children 

from school. 

(3) Reporting on open air schools and similar 

institutions. 

It is also recommended that the sanitation of schools, 
the provision of meals, of special schools for defective 
children, and of physical training should be referred by 
the local educational areas, more or less directly to the 
School Medical Officer. 

In Ireland it is a notorious fact that the sanitation and 
hygienic condition of many national schools is most 
pernicious, and the Commissioners of National Education 
have themselves in different annual reports called attention 
to the defective and undesirable state of many of their 
schools. If this is so, what alarming re])orts might we not 
expect from School Medical Oilicers, had we such ? 

As I have said before, the intermediate medical 
examination is not compulsory, but it may be taken for 
granted that in the ordinary course every child is thus 
examined. In addition it is understood that at any time, 
if any child seems to be ailing or defective from any cause, 
that (;hild may, on the representation of the teacher, be 
niedically examined during any visit of the doctor, such 
cases being designated by the name of " specials." This 



By Sir W. J. Thompson. 171 

provision is of course absolutely necessary, as a child may 
at any time suddenly develop some serious trouble which 
requires immediate attention. In addition, if a child 
developed any of the fevers, it becomes necessary to 
isolate that pupil, and thus prevent the spread of infection. 
The last medical examination is about the sixth year 
of school life, or when the pupil is about to leave school — 
such pupils being known as " leavers." " This examination 
is of vital importance, and in view of the fact of the early 
employment of the child and of the requirements of the 
Certifying Factory Surgeon and the Post Office medical 
examinations, particular attention should be paid to the 
following points : — 

(1) Cleanliness, including head and body. 

(2) General health and physique (including height and 

weight). 

(3) Soundness of the special senses — in particular, 

vision and hearing. 

(4) Mental capacity. 

(5) Constitutional and organic conditions — heart and 

circulation, lungs, hernia, varicose veins, 
dyspepsia, anaemia, spinal disease. 

(6) Infectious or contagious disease, including skin 

disease. 

(7) Teeth. — Oral sepsis. 

(8) Impairment in use of limbs. 

This examination is pretty exhaustive, and any child 
creditably passing through the ordeal may claim to be 
able to undertake any ordinary avocation." 

The parents, as I have said before, are asked to be 
present on the day of examination, and can consult with 
the doctor and teacher as to the best and most suitable 
work. Employers are sure to make use of this examina- 
tion, for it is most desirable from their point of view that 
they should not get an inferior class of juvenile workers. 
In Germany, where in some parts medical inspection has 
been going on for a great number of years, use is made 



1 72 Medical Inspection of ScJwol Children. 

of this examination to the advantage both of the State, 
of the parent, and of the child. 

In the matter of schools and school children in Ireland, 
it is only fair to mention the work that Her Excellency 
the Countess of Aberdeen has done in connection with this 
subject, through the different branches of the Women's 
National Health Association. It was through her exer- 
tions that a Treasury Grant was given for the cleansing 
and disinfecting of schools, although half the aniount spent 
has to be raised locally. This — every one will agree — 
was, from a health point of view, a welcome and useful 
innovation. Many branches also have placed at the 
disposal of the teacher and manager of different schools 
the services of their nurse with most satisfactory results. 

Quite a number of the branches also have organised 
free, or almost free, school meals for children, and in the 
rural districts, where children have a long distance to go 
to school, the benefit of this cannot be over-estimated. 

The Association has also in some of the branches 
instituted dental treatment, and has also started " tooth- 
brush clubs " amongst school children, which are very 
popular. In all health lectures delivered to children in 
centres where the Health Exliibition visited, special 
attention has been directed to the care of the teeth. 

It may be of interest to know that last year — that is, 
the year ended 31st of March, 1913, the Treasury placed at 
the disposal of the National Education Commissioners a 
sum of £7,000 ; this was to be used for the equipment 
and the work of dental cliniques, but the proviso was 
added that, to secure a certain sum, an equal sum had 
to be raised locally. Advantage was taken of this only 
to the extent of a few hundred pounds, and that practi- 
cally all by the Women's National Health Association. 

I have not gone into the question of finance in this 
matter — an important one ; I have formulated no scheme 
whereby medical ins])oction can be carried out ; I have 
made no recommendations, as those could be readily dealt 
with were the subject seriously taken up by the Govern- 



Pathological Report of the Rotunda Hospital. 173 

ment and legislation contemplated. At present all I 
plead for is that we, the medical profession, should in 
season and out of season bring before all sections of the 
public the evils arising from non-medical inspection of 
schools. All sections of the community should be in- 
terested in this — the manufacturer, the business man, the 
farmer, all those engaged directly or indirectly in educa- 
tion, all local bodies and all philanthropic organisations. 
And if we can succeed in arousing the attention of all those 
institutions and organisations to the benefit that would 
accrue to them from having stronger and healthier young 
people to deal with, I venture to predict that in a short 
time we shall have medical inspection of schools in Ireland. 
This I hold would be the most important link in the chain 
which of late years has tended to the prosperity and 
health of our country. 



Art. VIII. — Pathological Report of the Rotunda Hos- 
pital for One Year, November 1st, 1911, to October 
dlst, 1912. a By Egbert J. Kowlette, M.D. (Dublin 
Univ.) ; F.K. C.P.I. ; Pathologist. 
The work of the Laboratory has continued to increase in 
the .year under review. In the twelve months ending 
October 31st, 1912, 335 specimens were examined, ex- 
clusive of 418 specimens of urine sent to the Laboratory 
for special report. The total number of reports furnished 
was 753, as against 393 in the previous year. The in- 
creasing use of vaccines in the practice of the hospital has 
further increased the work of the Laboratory. In the 
year under review, 47 puerperal patients w^ere so treated, 
as against 30 in the previous year. A number of patients 
on the Gynaecological side were also treated. 

Autopsies were performed in the case of sixteen adult 
patients, eleven of whom died in the Maternity, and five 
in the Gyna}cological Wing. Brief notes are appended. 

» Read in the Section of Pathology of the Royal Acaclemy of Medicine 
in Ireland on Friday, May 2, 1913. [For the discussion on this Report 
see page 213.] 



174 Pathologiral Report of the Rotunda Hospital. 

Case I. (Maternity). — M. L., aged thirty-seven, died 
November 13, 1911, one month after induction of labour for 
hyperemesis. 

Large abscesses in both h<r casts. 

Thoracic organs normal. 

Extensive thrombosis of rigid ovarian vein. 

Abscesses in both kidneys. 

Other organs normal. 

Cultures of Stajjliylococcus aureus from all abscesses. 

Case II. (Maternity). — E. L., aged forty, died November 
27, 1911, twenty-five days after delivery. 

Lungs congested at bases; otherwise normal. 

Heart normal. 

Abdomen full of blood and pus. 

Spleen quite disorganised ; several septic infarcts and 
abscesses; the organ badly ruptured. 

Kidneys also showed pyaemic infarcts. 

Live<r normal. 

Ovarian veins thrombosed, chiefly the right. 

Uterus normal. 

Cultures of St. aureus from pus in peritoneum, from 
spleen, kidney, and thrombus in ovarian veins. 

Case III. (Maternity). — M. H., nged thirty-nine, died 
December 16, 1911, the day after delivery outside Hospital. 

Thoracic organs normal. 

Abdojuen contained pure blood. 

Uterus showed large tear in lower segment, involving the 
cervix, the bladder, and the vagina. 

Case IV. ((rynnecological). — M. M., aged forty, died De- 
cember 29, 1911. 

TJioracic organs normal. 

Peritonitis in lower part of abdominal cavity. 

liarge myoma of uterus. 

Bladder. — Wall sloughing. 

OtJter organs normal. 

Case V. (Gynrecological). — M. C, aged sixty-four, died 
January 28, 1911. 

Lungs and Jieart normal. 

Massive cancer at pylorus involving liver, which haa 



By Dr. B. J. Bowlette. 175 

massive secondary deposits. Transverse colon also in- 
filtrated. 

Other organs normal. 

Case VI. (Maternity). — M. E., aged thirty-five, died 
March 12, 1912, six days after hysterectomy for myoma in 
pregnant uterus (child dead). 

Thoracic organs normal. 

Abdomen showed extensive peritonitis and effusion of blood. 

Kidneys and other organs normal. 

Case VII. (Gynaecologica'l). — M. G., aged thirty-three, 
seven months pregnant, died March 27, 1912, three days 
after removal of appendix. 

Lungs and heart normal. 

Abdomen. — Operation wound healthy and healing soundly. 
Appendicular site also healthy. No general peritonitis. 
Localised inflammation in region of right tube and ovarTj. 
Strong band connecting lower end of ileum with right broad 
ligam^ent, and similar band connecting sigm^oid with lejt 
broad ligament. 

Liver pale. 

Stomach dilated. 

Right kidney disorganised ; upper pole contained ^bscess 
and several infarcts throughout organ. 

Infarcts in left kidney. 

Other organs normal. 

Cultures of St. aureus from right kidney. 

Case VIII. (Maternity).— M. C, aged thirty, died 
March 28, 1912, six days after delivery. 

Ri}ght leg greatly swollen, gangrenous to the groin, and 
oozing bloody fluid. No thrombus found. 

Thoracic organs normal. 

Uterus inflamed internally, with purulent fluid. 

Phlebitis in right broad ligament. 

No peritonitis. 

Other organs normal. 

Case IX. (Maternity). — K. K., aged thirty-one, died 
April 14, 1912, four weeks after delivery. 

Right lung congested; large abscess with firm fibrous wall 
in base. 

Left lung congested at base; old scars at apex. 



17G Pathological Report of the Piotiinda Hospital. 

Heart flabby; no organic lesion. 

Abdo7ninal organs normal, except for purulent pyelitis of 
both kidneys. No peritonitis. 

Uterus contracted ; sloughing 2 inches by 2 inches internally. 

Cultures from abscess of lung of St. aureus and strepto- 
coccus; from kidney of D. coll. 

Case X. (Maternity). — A. E., aged thirty-five, died July 
10, two days after delivery ; eclampsia. 

Typical lesions of eclampsia in liver and kidneys. 
Other organs nonnal. 

Case XI. (Maternity). — D. P., aged thirty-two, died of 
eclampsia in seventh month of pregnancy. 

Typical lesions of eclampsia in liver and hidneys. 
Other organs normal. 

Case XII. (Maternity). — A. H., aged twenty, died August 
7, 1912, eight days after delivery, day after laparotomy for 
septic peritonitis. 

Large condylomata on labia and thiglis. 

Thoracic cxrgans normal. 

Abdomen full of pus. 

All r)rgans normal. 

Culture of streptococcus from pus. 

Case XV. (Matornity). — K. J., aged twenty-one, died 
August 7, 1912, twenty-three hours after delivery, having 
suffered from hyperemesis. 

No abnormality discovered post mortem. 

Case XIV. (Gynecological). — A. J., aged fifty-six, died 
four days after hysterectomy and resection of intestine for 
sarcoma of the uterus. 

All organs normal. 

Case XV. (Maternity). — K. J., aged twenty -one, died 
September 13, 1912, six days after delivery, three hours 
after laparotomy for septic peritonitis, during secondary syphilis. 

Thoracic orgaus normal. 

Abdomen full of pus; peritoneum much inflamed. 

Uterus inflamed. 

Other organs normal. 

Culture of St. aureus from j)us. 



By Dr. B. J. Bowlette. 177 

Case XVI. (Gynaecological). — M. D., aged thirty-two, 
died October 21, 1912, immediately after hysterectomy for 
ruptured uterus. 

Autopsy showed tear in fundus of bladder. 

Other organs normal. 

Curettings and other fragments were examined on fifty- 
two occasions for purposes of diagnosis (Table I.). 

Tumours and other operation specimens were examined 
on 111 occasions (Table III.). 

The epithelioma of the vulva was the second such 
tumour from the same patient, a malignant ulcer of the 
other labium having been removed two years and nine 
months previously. The glands of the groin were ex- 
tensively involved. 

The number of cases of malignant disease of the uterus 
dealt with is unusually small — 6. In the previous year 
there were 14 ; in 1910, 11 ; in 1909, 9. This decrease is, 
however, only apparent, being due to the fact that a larger 
proportion than usual of the cases of cancer encountered in 
the practice of the Hospital were in too advanced a state 
to permit of operation. It is curious, however, that no 
less than three cases of sarcoma of the uterus were met. 
This is as many as we had met in the previous seven years. 
In the three cases the tumour was primary, no fibroid 
being present. In one the growth was from the cervix. 

The examination of myomata as regards degeneration 
was again carried out. Of the 27 specimens, 14 showed 
no sign of degeneration, 3 were necrotic, 4 showed mucoid 
changes, 3 were calcareous, 2 were fatty, and 1 was in- 
flamed. 

Of the 29 cases of salpingitis, 10 were tuberculous. The 
proportion in eight years has been 39 out of 103. 

Including 5 dermoids and 2 lutein cysts, 26 cystic con- 
ditions of the ovary were examined. Of the 19 cystic 
tumours, 14 were ordinary multilocular, smooth- walled 
cysts, and 5 show^ed papillary grow-ths. Of the latter, 2 
showed definite evidence of malignancy, and a third, 
though not showing any evidence of malignancy to the 

M 



178 Pathological Report of the Rotunda Hospital. 

microscope in the parts examined, was bilateral and 
sprouting through its covering. In one of the malignant 
cases a papillary cyst had been removed sixteen months 
before. On the occasion of the present operation the 
patient v^as pregnant at full term. The operation for re- 
moval of the cyst was combined with a Caesarean section. 
Our experience during the year confirms the opinion ex- 
pressed in previous reports as to the dangerous character 
of cysts of the ovary in which there is any tendency to 
epithelial over-growth. 

One of the dermoids presented malignant characters of 
carcinomatous type. 

Among the cases of ectopic pregnancy was one of twins. 

In last year's Report I mentioned a case of chorion- 
epithelioma — the first recorded in Dublin for many years. 
Curiously enough, another case was met this year. A 
tumour, the size of an ostrich egg, was found lying in the 
pelvis, adherent to the uterus, intestines, and retro-peri- 
toneal tissue. Its nature was not recognised, and from its 
friable, blood-clot like nature, it was regarded at the 
moment of operation as a hfomatocele. Haemorrhage was 
very severe, and the patient died within a few minutes 
after removal of the tumour. Dr. W. G. Harvey, who, 
in my absence, kindly examined the masses removed, 
recognised their nature. Unfortunately, in the meantime, 
the body had been removed without an autopsy being per- 
formed. It is interesting to note that there was nothing 
in the history of the patient to suggest pregnancy, regular 
menstruation having taken place six weeks before admis- 
sion to the Hospital. (See " Clinical Report.") 

133 specimens of uterine lochia were examined in 
morbid cases. The same difficulty has been found as here- 
tofore in making an early diagnosis, particularly in cases 
where only diplococci are found in the smear preparations. 
T am in hopes that the routine use of blood-agar as a 
culture medium may assist in distinguishing streptococci 
more readily than hitherto. The gonococcua, as usual, 
proved a rare organism in ])roducing puerperal infection. 



By Br. K. J. Bowlette. 



179 



APPENDIX. 

Table I. — Examinations of Curettings and other Frag- 
ments for Purposes of Diagnosis. 



Endometritis ... 20 

Endocervicitis . . 4 
Adeno-carcinoma of corpus 

uteri .... 1 

Sarcoma of uterus . . 2 

Myoma of uterus . . 2 



&c. 



Chorionic villi, decidua 
Corpus luteum 
Carcinoma of peritoneum . 
Normal tissue, clot, debritt, 
&c. . . . . 



9 
1 
1 

12 



Table II. — Varieties of Endometritis. 



Glandular (including 4 
cystic) 



12 



Interstitial 
Septic 



Table III. — Operation Specimens. 



Fibroma of vulva . 


1 


Salpingitis or pyosalpinx 


Epithelioma of vulva 


1 


f non-tuberculous) 


19 


Epithelioma of cervix 


1 


Tuberculous salpingitis 


10 


Erosion of cervix 


3 


Cyst of ovary . 


21 


Adeno-carcinoma of uteru 


3 2 


Dermoid of ovary . 


5 


Sarcoma of uterus . 


3 


Oophoritis 


1 


Myoma of utenis 


27 


Parovarian cyst 


1 


Mucous polypus of uterus 


5 


Ectopic pregnancy . 


6 


Fibrosis of uterus . 


1 


Chorion- epithelioma 


1 


Septic uterus . 


1 


Appendix 


2 


Prolapsed uterus 


1 







Table IV. — Organisms Observed in and Isolated from the 
Lochia in Morbid Cases. 



Streptococci 
Staphylococci 
Diplococci 
Gonococci 



36 

21 

37 

2 



B. coli . 

Sapropli3'tes 

Negative 



12 
33 
35 



180 Some SequelcD of Labour. 

Art. IX. — Some Sequelce of Labour.^ By Bethel A. H. 
Solomons, M.D. (Univ. Diibl.) ; M.E.C.P.I. ; ex- 
Assistant Master, Rotunda Hosj^ital. 

I FEEL that my first duty is to apologise for bringing under 
your notice a subject that perhaps may be considered 
ancient history, but my excuse is that, as far as I can 
trace, there have been no post-labour statistics collected 
during recent years. It is a well-known fact that there 
would be very little gynaecology except for midwifery. 
The number of patients who attended the Rotunda Hos- 
pital Dispensaries because of complaints consequent on 
their confinements determined me to endeavour to gather 
together some statistics regarding those patients who were 
delivered in the hospital. In reviewing these figures one 
must bear in mind that most of these are women who had 
been delivered in a well-appointed hospital, under the 
best conditions, whereas a great number of those who are 
delivered outside the hospital run a much greater risk with 
less skilled attendants and less satisfactory surroundings. 
Having obtained the sanction of the Master, cards were 
printed and were given to all primiparnp as they left the 
hospital on the eighth day of the puerperium. The in- 
structions on these cards were to come for examination 
on that day week. If all those to whom cards were pre- 
sented had appeared these statistics would have been 
greater; but personally I am satisfied, for warning had 
been given to me that none would trouble to come. I 
shall now submit to you the results of examining 545 
primiparjp sixteen days after labour. In 543 cases there 
were : — 

Normal 210 

Cervix lacerated only ... - 219 

Sub-involution - - - - - 27 

Cervix lacerated, accompanied by retroversion 25 
Retroversion only - - - - 14 

■ Read before tlie Section of Obstetrics in the Royal Academy of Medicine 
in Ireland on Friday, May 23, 1913. 



By Dr. Bethel A. H. Solomons. 181 

Cervix lacerated : non-union of perineum - 12 

Cervix lacerated : non-union of perineum, re- 
troversion 
Non-union of perineum only 
Parametritis 

Non-union of perineum, retroversion 
Cystitis 
Prolapse 
Pyosalpinx 

Total - 
That is— 
Normal 

Lacerated cervix 
Ketroversion - 
Non-union of perineum 
Sub-involution 
Parametritis - 
Cystitis 
Prolapse 
Pyosalpinx 

Normal Cases. — It seems extraordinary to find that 
only slightly more than 40 per cent, of the cases ex- 
amined v^ere perfectly normal. But v^hen it is seen later 
that in the Table tears of the cervix from a third of an 
inch upwards are included this apparent phenomenon is 
explained. 

Laceration of the Cervix. — Some gynaocologists ex- 
amine a patient, find a lacerated cervix, and tell her that 
instruments were applied in the confinement. It will be 
seen by the vast number of these cases — viz., 48.62 per 
cent. — that a tear of the cervix does not depend on the 
application of forceps. In these 264 cases the injury 
varied from a third of an inch on one or other side to large 
bilateral tears, the size being absolutely independent of 
instruments. Colyer (1) and others have stated that the 



- 


- 


8 


- 


- 


7 


- 


- 


4 


ersion 


- 


3 


- 


- 


2 


- 


- 


2 


- 


- 


1 


- 


- 


- 543 


219 or 


40.33 


per cent. 


264 or 


48.62 




50 or 


9.21 




30 or 


5.52 




27 or 


4.97 




4 or 


.07 




2 or 


.035 




2 or 


.035 




1 or 


0.18 





182 Some Sequelce of Labour. 

extent of the tear depended ou the time before labour that 
the membranes ruptured — i.e., that the earher the mem- 
branes ruptured the greater was the tear. In this investi- 
gation I have no definite statistical evidence about the 
point, but on questioning some of those who had exten- 
sive tears I was informed that the " waters " had come 
away long before the birth of the infant. 

On finding such a large number of these lacerations one 
must needs inquire whether their occurrence can be avoided: 
also what steps should be taken when they are discovered. 
It seems impossible to avoid the former in natural deliveries. 
The latter opens up a large field for discussion. It is well 
known that the less intravaginal interference after the 
placenta has been delivered the better is the prognosis. 
If one could be sure that a cervical laceration was present 
one might advise vaginal examination, with suture after- 
wards. As this diagnosis without examination is impos- 
sible, the question arises as to whether examination should 
be indulged in or not. Also, if a laceration is found, 
whether one should immediately suture or operate 
secondarily. Dickinson (2) finds that tears of the cervix 
are so common that he always examines and sutures at 
the same time as the perineum, or else three to ten days 
later. He does not mention if he does denudation in the 
latter instance. In the discussion on this paper two other 
speakers concurred, but Cragin (3) " hit the nail on the 
head " when he said that although he approved of stitch- 
ing tears, yet he feared preaching this dictum to students 
owing to the skill and absolute aseptic technique re- 
quired. Baldy (4) does not suture tears if discovered, for 
he considers they heal spontaneously ; neither does he 
believe that cancer starts in a tear, as stated in many 
monographs, and noted by Ashton (5) in his ** Practice 
of Gynaecology. " Such a great authority as Whitridge 
Williams (6) advises against suturing unless there is 
h:rmorrhage. Davis (7), from a study of 53 cases, con- 
cludes that lacerations of half-an-inch should be primarily 



By Dr. Bethel A. H. Solomons. 183 

closed, but points out the necessity for capability and 
aseptic technique. He found good union in 45, and con- 
siders a tear smaller than half-an-inch heals spontan- 
eously. In this long paper he describes his technique, in 
which' there is nothing out of the common. Coles (8) 
quotes other authorities to show that tears occur in 5 per 
cent, to 15 per cent, of multiparao, and 25 per cent, to 50 
per cent, of primiparae. He says that this is too low a 
computation, and that 25 per cent, and 75 per cent, re- 
spectively have tears. From his investigations he con- 
cludes that involution should not be awaited, but imme- 
diate suture should be practised. Later he contradicts 
himself when he suggests that if oedema is present 
another operation is afterwards necessary. He finds that 
the better class of patient expects to be lacerated and 
demands to be sutured. Comment on such an observation 
is needless ! Heywood Smith (9) and Macnaughton 
Jones (10) favour immediate suture, the former drawing 
attention to the danger in unstitched cases of endocervi- 
citis, fatal sepsis in large lacerations, abortion, sterility, 
and cancer. Wm. E. Ground (11) finds immediate suture 
useless, and advises a secondary operation two months 
later. 

With such varied opinions of distinguished obste- 
tricians one must of necessity map out one's own course 
of treatment. (a) Should a vaginal examination be 
made immediately the placenta is delivered? The answer 
in normal cases appears to be in the negative : in 
fact, such teaching to inexperienced students would be 
nothing short of criminal. In traumatic haemorrhage 
aising from the cervix the laceration should be sutured. 
In those cases where an intrauterine douche is given the 
cervix should be examined, and if necessary sutured. 
(h) Should all women be examined two months after con- 
finement? Certainly, (c) Should they be informed that 
the cervix is torn and requires repair? If they are similar 
to those patients of Coles (12) they will be pleased. But 
if in this age of strenuous competition such news is heard 



184 Some Sequelcc of Labour. 

by the ordinary woman, who is feeUng recovered after her 
confinement, there will be a great tendency for her to em- 
ploy a different practitioner in the future. The best way 
out of a difficult position is to make a routine examination 
of patients, to tell them the dangers of cervical laceration : 
if such be found, to advise operation as a safeguard rather 
than as a necessity. One might argue against operations 
that there is a danger of a repetition of the tear in the 
following confinement. An alternative suggestion is that 
there should be a routine examination of all women at the 
end of their child-bearing period, when all lacerated 
cervices could be repaired. 

Backward Displacement of the Uterus. — This is of such 
common occurrence in the gynaecologist's practice that I 
was much surprised to find that only in 50 of the cases — 
i.e., 9.21 per cent. — was it present. Polak (13) found a 
nearly similar average — viz., 43 in 500 — when he ex- 
amined ten days after confinement. An examination of 
the same cases four to six weeks later revealed 231 in 
this series, of which 203 were mobile. 

The usual cause of post-partum retroversion is supposed 
to be the dorsal decubitus, and it is suggested that frequent 
change of position will overcome this. It seems doubtful 
whether the modern idea of early rising will militate for or 
against. Polak (14) recommends proper postural treat- 
ment — i.e., that the patient should assume the right and left 
lateral prone positions, that she should sit up early and leave 
bed to evacuate her bowels. In the discussion on this 
paper, (Jallant (15) advised the use of a pessary post- 
partum. Zicgcnspeck (IG) has come to the conclusion 
that bladder over-distension, perimetritis, and para- 
metritis are more common causes than have been sup- 
posed — the constant position on the back also predispos- 
ing. BoulTe de Saint Blaise (17) found only four retro- 
versiofis in 495 women examined. 

It seems from the above data that retroversion can be 
avoided. Proper postural treatment is the chief aim. 



By Dr. Bethel A. H. Solomons. 185 

Every patient should be examined once a month for at 
least four months after the confinement, when, if displace- 
ments are found, they can be easily corrected. Precau- 
tions should be taken against bladder over-distension. 

Non-union of the Perineum. — There were 30 of these 
in the cases examined. This number seems large, but 
the difficulty in persuading patients of the humbler class 
to remain reasonably quiet, or of persuading them to 
have a secondary operation when the first is unsuccessful, 
is enormous. 

This is not a fit time to introduce the question 
of the best operation, but the question of suture 
material is relative. In my first year as Assistant 
Master in the Eotunda Hospital, with the Master's 
permission, I experimentalised on about 50 primiparas 
in order to find the results from the use of catgut. 
Although union was fair in these cases they were not 
nearly as gratifying as those obtained with silk-worm 
gut. A great disadvantage in catgut for the skin is the 
tendency to avoid final examination of the wound, so that 
one may know if the work is satisfactory. Besides, it is a 
fact well known that catgut is an absorbent material. It 
is extraordinary how many doctors and nurses will proudly 
say that they had never had a patient with a lacerated 
perineum in their practice. How often have they sepa- 
rated the vulvar lips to search for those deep internal tears 
which are more serious than all the others? Polak (18) 
suggests a colpeurynter in the vagina before the baby is 
born to obviate the risk of tears. The main objection to 
this is the extra manipulation. A secondary operation 
within a week is very successful in clean cases. 

Sub -involution. — The uterus was just above the pubes 
in 27 cases, while discharge of a varied colour was present. 
Bouffe de Saint Blaise (19) found in 260 women that the 
uterus was palpable 4-9 cm. above the pubes when ex- 
amined on the ninth or tenth day. These cases of sub- 
involution soon yield to treatment, but one cannot urge 
too strongly the necessity for manual examination of the 



186 Some Sequelce of Labour. 

inside of the uterus in those women who have a larpje 
uterus and a foetid discharge in order that chorion- 
epithelioma may not be overlooked. 

Miscellaneous. — There were four cases of parametritis, 
two of cystitis, two of prolapse, and one of pyosalpinx, 
and these are of little importance. The cases of prolapse 
were only slight, and are no criterion, for one would 
expect prolapse to become serious at a much later date 
than sixteen days after confinement. Polak and Ziegen- 
speck (20) both consider cystitis to be due to insufficient 
emptying of the bladder. Retention of urine is a very 
unpleasant and awkward complication which is usually 
found in association with lacerations of the perineum. It 
is often a nervous condition, and sometimes catheterisa- 
tion has to be practised for many weeks. Ammonia to the 
nose often brings instant relief. Rupture of the sym- 
physis pubis is luckily very rare in this country, although 
Kriwski (21) collected 134 cases, of which two occurred in 
his own practice. Scheurer (22) also reports a case. I 
remember assisting at a subcutaneoous pubiotomy where 
sharp hn[^morrhage ensued when the needle was passed up, 
which was evidently due to its passage over a roughness 
in the bone where forcible delivery had been accomplished 
in the previous labour. A partial separation at some part 
of the pubic bone must often be an accompaniment of a 
forcible delivery. 

Emholism and Early Risinq. — One of the most dis- 
cussed questions of the present day is the date when a 
patient should rise after labour. There have been many 
])apers written on the .subject, and a conclusion seems as 
far distant as ever. In the Rotunda Hospital Report for 
1913 (23) Dr. Jellett writes :— " Provided that their con- 
finement was normal and that there had been no perineal 
laceration, they were allowed and encouraged to sit up in 
bed after the first twelve hours, and to get out of bed to 
pass water if they wished to do so. After forty-eight 
hours, if they continued well, they were made to leave 



By Dr. Bethel A. H. Solomons, 187 

their bed at least twice in the twenty-four hours to pass 
water. After seventy-two hours they were allowed to 
take a few steps or to sit for a few minutes on a chair or on 
their bed, the time they remained up being gradually in- 
creased so long as their state of health continued good. 
During the past year I have made no change in this plan, 
and I have found it most satisfactory," &c. 

Various foreign authorities have very different rules for 
their patients. Polak (24) allows his patients to get out 
of bed from the commencement to evacuate their 
bowels, Kosenfeld (25), Simon (26), v. Alvensleben (27), 
Martin (28), Kronig (29), all believe in early rising. They 
have found no complications, their patients feel better, 
and Simon noted a decrease in morbidity. Schucking (30) 
advises rest in bed with gymnastic exercises. Fromme 
(31) allows his patients after normal labour to rise for an 
hour on the second day. One patient died in three days, 
and the autopsy revealed thrombosis of the left ovarian, 
renal, and of all the left parametritic veins with em- 
bolism of the pulmonary artery. He considers that early 
rising is no preventive for thrombosis, and urges against 
it. In a question of this kind one must search surgical 
records, and Burnham (32), in an excellent paper on post- 
operative thrombo-phlebitis, notes that Klein claims 50 
per cent, decrease in thrombosis since adopting early 
rising ; but Burnham 's own experience puts him against 
this form of treatment. Thrombo-phlebitis is preceded 
by a slowing of the blood-stream and by local and 
general disease of the vessel walls. Eest in bed, ichthyol 
locally, lemon-juice internally, as recommended by 
Almroth Wright, elevation of the limbs, with bandaging, 
are the best preventives for thrombosis with embolism 
as its possible sequel. Blanchard Wilson (33), from his 
studies at the Mayo Clinic, finds that embolism is more 
common in women than in men, and is comparatively 
frequent after abdominal hysterectomies, whereas there 
was no fatal case in 449 vaginal hysterectomies. He 



188 Some Scquelce of Labour. 

suggests very early rising, free movement on the part of 
the patient, which must be done early enough to prevent 
the formation of extensive thrombi. He suggests drugs, 
such as the calcium salts, to increase the coagulability of 
the blood, and preaches the necessity for measures to 
cause a reduction of bacteroomia. It is impossible to 
make rules about a question of this kind, for although they 
may be followed by the educated i)atient, the woman in 
humble life is unable to follow them. The ideal treat- 
ment in a normal case seems to be free movements and 
gymnastic exercises from the beginning, rest in bed until 
the fourteenth day, when the uterus will certainly have 
the protection of the pelvis, and displacements will be less 
common. This rest in bed will favour involution of the 
contents of the pelvis, which early walking would seem to 
prevent. 

Conclusions. 

1. Cervical laceration after normal labour is very 
common. If it occurs, and h.Tmorrhage is present, 
immediate suture should be practised : if no haemorrhage, 
the tear should be sewn in two months, or else a routine 
examination should be made of all women at the end of 
their child-bearing period, w^hen all lacerated cervices 
should be repaired. 

2. Post-partum retroversion of the uterus, when not 
fixed back by inflammation, is caused by the dorsal decu- 
bitus. The best treatment, therefore, is postural. Every 
patient should be examined once a month for at least four 
months after confinement. 

3. When non-union of a stitched ])erineum occurs, a 
second ])erin{rorrhaphy should be done immediately in 
aseptic cases. 

4. No definite dictum can be laid down about early 
rising until some more statistics are published. In normal 
clean cases postural treatment and gynmastic exercises 
are advised. 



Epidemic Poliomyelitis, or " Infective Paralysis.'^ 189 



(1 
(2 
(3 
(4 
(5 

(6 
(7 
(8 

(9 
(10 

(11 
(12 
(13 
(14 
(15 
(16 
(17 
(18 
(19 
(20 
(21 
(22 
(23 
(24 
(25 
(26 
(27 
(28 
(29 
(30 
(31 
(32 
(33 



REFERENCES. 

S. Colyer. B. M. J. 1909. Vol. II. P. 1455. 

Dickinson. N. York Med. Journal. March 26, 1904. 

Cragin. Ditto. 

Baldy. American Journal of Obstetrics. Vol. I. P. 265. 

Ashton. Practical Gynsecology. 6th ed. P. 414. 

Whitridge Williams. N. York Med. Journal. March 26, 1904. 

Davis. American Journal of Obstetrics. Vol. LX. P. 377. 

Coles. American Journal of Obstetrics. Vol. LIX. P. 328. 

Heywood Smith. British Gynecological Journal. Nov., 1904. 

Macnaughton Jones. British Gynaecological Society Trans. 

July 9, 1903. 
Wm. E. Ground. American Med. Journal. Jan., 1906. 
Coles, {vide supra). 

Polak. American Journal of Obstetrics. Vol. LX. P. 1016. 
Ditto. 

Gallant. Am. Journal of Obstetrics. Vol. LX. P. 1017. 
Ziegenspeck. Zentralblatt f. Gyn. June 6, 1908. 
Bouffe de St. Blaise. La Gynecol. Nov. 12. 
Polak. {v. s.) 

BoufEe de St. Blaise, (v. s.) 
Polak and Ziegenspeck. (v. s.) 
Kriwski. Monat. f. Geb. und Gyn. April 10. 
Scheurer. Korrespondenz f. sch. Aerzte. 1909. No. 4. 
Rotunda Hospital Reports. 1913. P. 7, ante. 
Polak. (v. s.) 

Rosenfeld. Gyn. Rund. Heft 11. 1908. 

Simon. Muenchener med. Wochenschrift. 1909. No. 1. S. 47. 
V. Alvensleben. Zentralblatt f. Gyn. 1908. No. 36. 
Martin. Monatsschr. f. Gyn. Bd. XXVII. H. 12. 
Kronig, Deutches med. Wochenschrift. No. 37. 1908. 
Schucking. Zentralblatt f. Gyn. 1908. No. 51. 
Fromme. Zf. Gyn. 1908. No. 1. 
Burnham. Annals of Surgery. Vol. LVII. No. 2. 
Blanchard Wilson. Annals of Surgery. Vol. LVI. No. 6. 



Akt. X. — Epidemic Polioinyelitis, or " Infective 
Paralysis." ^ By John A. W. Ponton, M.D., Univ. 
Dubl. 

I HAVE the honour to submit to you a brief review of the 
cTtiology, histology, epidemiology, and clinical features 
of the disease known as epidemic poliomyelitis, or " in- 

* A Thesis read for the Degree of Doctor of Medicine in the University 
of Dublin, June, 1913. 



190 Epidemic Poliomyelitis, or " Infective Paralysis.^^ 

fective paralysis," with which I have been brought in 
contact during the recent outbreak in the Counties of 
Cornwall and Devon, in my capacity as Medical Officer of 
Health for one of the urban districts of the latter countv. 

Acute anterior poliomyelitis has long been recognised as 
a disease of children under the name of " infantile 
paralysis," and its clinical features and pathological 
characteristics are well known to every practitioner. 

In recent years, certain districts of Europe, America 
and Australia have been visited by an epidemic disease, 
apparently infectious in character, strongly resembling in 
its clinical and pathological features acute anterior polio- 
myelitis, and to this disease the name of epidemic polio- 
myelitis, or " infective paralysis," has been given. 

/Etiology of the Disease. — The morphology of the virus 
of this disease is unknown. While there are good grounds 
for suspecting it to be ultimately particulate, yet it is so 
minute that the highest microscopic powers fail to render 
it discernible. 

Between the virus of poliomyelitis and rabies there is 
great similarity : both are ultramicroscopic, and both are 
filtrable, readily passing through filters which do not 
transmit the smallest visible bacteria. 

The resistance of the virus to heat is small — it is de- 
stroyed by half an hour's exposure to a temperature of 
45° to 55° C. On the other hand, its resistance to freez- 
ing and drying is great. It is readily destroyed by ordi- 
nary disinfectants, such as permanganate of potassium, 
hydrogen peroxide, formaldehyde, and phenol. 

The chief method of investigating the disease has been 
by experiments on monkeys, and such experiments have 
established the fact that acute poliomyelitis is com- 
municable to monkeys. 

An emulsion of the spinal cord of a fatal human case, 
or of an infechnl monkey al the height of iho (1is(\Tsc, is 
used for inoculation. 

After an incubiilion jieriod of one or two weeks the 
prodromal symi)t()ms characteristic of acute j)oliomyeliti& 



By Dr. J. A. W. Pontoi^. 191 

set in, followed in a day or two by paresis and paralysis, 
and ending finally in atrophy and contracture. 

Histological features of the Disease. — As its name in- 
dicates, the chief lesion found in this disease is an acute 
inflammation localised in the anterior cornua of the grey 
matter of the spinal cord. 

In most cases, however, the mischief is not confined to 
the anterior cornua, but the white matter is to some 
extent also involved, and the brain and pia mater may 
also participate in the morbid changes. 

Microscopic sections of the cord show characteristic 
lesions. The meninges and anterior fissure are infiltrated 
with ' ' small round cells ' ' ; the grey matter of the anterior 
cornua shows perivascular infiltration, with discrete 
groups of small mononuclear cells, and in the acute stage 
of the disease is swollen and hsemorrhagic. The motor 
cells of the anterior cornua show striking degenerative 
changes ; they are first seen to be surrounded and infil- 
trated with phagocytic cells, and finally they entirely dis- 
appear, leaving in their place a heap of " small round 
cells." 

The cerebro-spinal fluid in this disease is generally 
clear, though exceptionally it may be found to be slightly 
turbid. 

Lymphocytes are present, but polymorphonuclear cells 
are conspicuously absent, and no bacteria are present. 

The amount of albumen is definitely increased ; the 
powder of reducing Fehling's solution is retained. 

Epidemiology of the Disease. — The first epidemic of 
acute poliomyelitis on record occurred in the fall of 1841 
in Louisiana, when some eight or ten cases of hemi- 
plegia or paraplegia were observed within the radius of a 
few miles in the course of a few months ; these cases 
excited observation and comment, but their true nature 
and significance were not then recognised. 

In the year 1887 an epidemic of 43 cases occurred in 
Stockholm, and gave rise to the first important literature 
on the subject. 



192 Epidemic Poliomyelitis, or ''Infective Paralysis.^* 

Since then epidemics have been recognised and de- 
scribed in various parts of the world with increasing fre- 
quency, due, doubtless, to greater accuracy of diagnosis. 
The chief outbreaks were those which took place in 
Norway and Sweden in the years 1905 and 1906, and 
which were fully described by Holt and Bartlett, followed 
by the New York outbreak of 1907. 

In 1909 the disease was prevalent in Germany, and it 
was estimated that one thousand cases occurred in Ger- 
many during that year. 

The first cases of epidemic poliomyelitis in Great 
Britain were recorded by Pasteur in 1897, who described 
seven cases occurring in one family. 

Treves reported eight cases in 1898 at Upminster, a 
small village in Essex. 

In 1909 an epidemic of some magnitude occurred in 
Bristol, and was the subject of an article by Dr. George 
Parker in the British Medical Journal. Thirty-seven 
cases were then reported. 

During the autumn of 1910 various small but interest- 
ing outbreaks were reported in various parts of England 
and Scotland. 

From a study of the reports of ej)idemics of this disease 
the following conclusions may be drawn as to the main 
characteristics of its e]iidemiology : — 

1. Epidemic poliomyelitis generally occurs in summer 
and autumn in temperate climates, though this does not 
jueclude the possibility of cases occurring at other seasons. 

2. While there is considerable variation in the age in- 
cidence, the majority of cases occur in children under six 
years of age. 

3. Males are attacked more frequently than females. 

4. Epidemics are most severe in small towns and rural 
districts, the larger cities sull'ering less in proportion to 
population. 

5. Laboratory experiments confirm the conclusion 
reached by epidemiological study, that the disease is 
capable of transmission from person to person by direct 



By Dr. J. A. W. PoktON". i93 

contact, though the infecfivity and virulence of the causa- 
tive agent vary greatly in different epidemics. Cases 
have been recorded where the disease has been borne by 
abortive cases and healthy "carriers" — playing a role 
similar to " carriers " in enteric fever and diphtheria. 

Some observers declare that articles of food, especially 
milk, may be responsible for transmitting the virus of 
infective poliomyelitis. Dust, insects, and domestic 
animals have also been accused of playing a part in the 
transmission of the disease. 

Clinical Features of Epidemic Poliomyelitis. — The 
clinical aspects of this disease are so varied, both in 
different epidemics and in individual cases occurring 
during the same epidemic, that it is impossible to draw a 
succinct clinical picture applicable to all cases. 

The prodromal symptoms preceding paralysis are often 
so indefinite, and have so much in common with the 
symptoms presented by the onset of any acute infectious 
or toxaemic disease, that the diagnosis in the early stages, 
before paralysis declares itself, is frequently a matter of 
considerable difficulty and uncertainty. 

The onset is generally sudden, attacking children in 
apparently good health, and is often attributed to a 
"chill," or "influenza," or even to "teething" : it is 
sometimes ushered in by a sore throat. 

A sharp rise of temperature is a fairly constant initial 
symptom, with great prostration and muscular weakness, 
general malaise, gastro-intestinal disturbances, irritability 
and restlessness, followed by drowsiness and apathy : 
somnolence is of frequent occurrence, and sometimes the 
victim of this disease may remain sleeping for several 
days, only waking when aroused to take nourishment : 
occasionally somnolence merges into coma : delirium is 
rare. 

Headache is generally present, but it is seldom so severe 
as in cerebro-spinal meningitis. 

Skin eruptions occur in only a very few cases, and are 
by no means characteristic ; when present the rash generally 

N 



194 Epidemic Poliomyelitis, or ^^ Infective Paralysis.^^ 

takes the form of a papular eritption covering the entire 
body. 

Pain and tenderness in the lower extremities, in the 
back of the neck, and along the spine, are often marked 
symptoms in the early stage of the disease, and may 
be so intense that the weight of the bedclothes is not 
tolerated, and the distressed patient cannot remain in one 
position for any length of time. With the onset of 
paralysis the pain subsides. 

Kigidity of the neck with retraction, and sometimes 
the presence of Kernig's sign, often make the diagnosis 
from cercbro-spinal fever or tuberculous meningitis ex- 
tremely difficult. 

The reflexes are abolished, but this is sometimes pre- 
ceded by a preliminary exaggeration. 

Following the a[)pearance of some or all of these pre- 
liminary symptoms, paralysis, generally of the lower 
extremities, sets in ; the paralysis is sudden, of the flaccid 
motor type, and reaches its maximum in one or two days ; 
then retrogression takes place, sometimes ending in com- 
plete recovery, but more often resulting in permanent 
paralysis of some group of muscles, followed by atr()j)hy. 

From a consideration of the foregoing facts we may 
conclude that epidemic poliomyelitis or " infective 
paralysis " is a distinct infectious disease siii generis. 

Whilst the diagnosis is often a matter of great difficulty 
and uncertainty, yet the correlation of the clinical picture 
with the result of lumbar puncture makes a fairly sure 
ante-mortem diagnosis possible, whilst the changes found 
in the cord post-mortem are characteristic. 



LITERARY NOTE. 

The late Honnor Morten wrote a cliamiing little book en- 
titled " Sketches of Hospital Tiife." This is of intense 
interest to the Nursing Sisters belonging to the St. John's 
Ambulance Brigado and to members of the Red Cross 
Society. A new edition, to be ready in a few days, is 
announced by Messrs. Sampson Low, Marsfcon & Co., Ltd. 



PART II. 
REVIEWS AND BIBLIOGRAPHICAL NOTICES. 



A Manual of Infectious Diseases occurring in Schools. 
(Issued by the Association of Preparatory Schools.) 
By H. G. Armstrong, M.E.C.S., L.S.A., Medical 
Officer to Wellington College; and J. M. Fortescue 
Brickdale, M.A., M.D., Physician to Clifton College, 
Assistant Physician, Koyal Infirmary, Bristol, Clinical 
Lecturer, University of Bristol. With chapters on 
"Infectious Eye Diseases," by K. W. Doyne, M.A., 
F.K.C.S., Margaret Ogilvy Header in Ophthalmology, 
University of Oxford; and "Ringworm" by H. 
Aldersmith, M.B., F.R.C.S., Medical Officer to 
Christ's Hospital. Bristol : John Wright & Sons, Ltd. 
1912. Pp. 150. 

This work is issued by the Association of Preparatory 
Schools for the assistance of masters and mistresses in 
dealing with cases of suspected infectious diseases 
occurring amongst their pupils. Though primarily in- 
tended for laymen, the book will be of real service to 
medical men engaged in school practice. Indeed, we think 
that it will be amongst the latter that its chief use will 
lie. In some respects the information given is too 
technical for the lay reader, and points are dealt with 
which would be much better left to the medical attendant-. 
In a work of the kind this fault is well-nigh unavoidable, 
and we recognise the difficulties which confronted the able 
authors in their task. 

The chapter on ringworm by Dr. Aldersmith is well 

worth perusal. 



196 RevietCfi and Bibliographical Notices. 

Supplement to the Quarterly Returns of the Marriages, 
Births, and Deaths Registered in Ireland during the 
Year 1911. Beint^ Statistics re^ardin<,^ the Vaccination 
of Children whose Births were Re^i^istered in Ireland in 
that Year. London : Published by His Majesty's 
Stationery Office. 1913. Folio. Pp. 44. 

We regard this Supplement as one of the most important 
documents that has been i^ublished by the Pegistrar- 
General for Ireland for very many years. It is rendered 
all the more impressive by the absence of any commen- 
tary on the startlin(i[ facts which it brings to light. Those 
facts, to our mind, constitute a very grave peril indeed to 
the welfare of Ireland. The mine is being laid, and all 
that is needed to cause an explosion of small-pox — that 
most loathsome of diseases — is that the fuse should be set 
alight by the introduction of a chance case from overseas. 

From the Vaccination Statistics contained in the 
Supplement it appears that of the 101 ,758 children whose 
births were registered in Ireland during the year 1911, 
73,85G were returned as having been successfully vacci- 
nated ; 2,990 as having had their vaccination postponed. 
In 151 cases the vaccinations were returned as unsuccess- 
ful on the ground of constitutional insuscejitibility of the 
vaccine disease; 0,484 children died before vaccination; 
4,518 were returned as " unaccounted for owing to re- 
moval from district or otherwise," and 13,809 were re- 
ported as defaulters who had not been granted an exten- 
sion of time under Form B., First Schedule. When ex- 
pressed in ])ercentages, it appears that 72.0 per cent, of 
the total were reported as successfully vaccinated ; 2.9 
per cent, were ))ost])oned on account of the children being 
unfit for vaccination; 0.2 per cent, were insusceptible of 
vaccination; 0.3 per cent, died before they w^ere vacci- 
nated; 4.4 per cent, were " unaccounted for owing to re- 
removal from district or otherwise " ; and 13.0 per cent, 
were returned as defaulters. 

The following table gives the condition as regards vacci- 
nation of the children whose births were registered in the 
year 1911, as compared with each of the preceding seven 
years : — 



Returns of Marriages, Births and Deaths in Ireland. 197 



Table I. — Showing particulars regarding the vaccination of the 
children whose births were registered in Ireland during 
each of the eight years, 1904-1911, with their ijercentage to 
the total births registered during each year. 









Insusceptible 






De- 










of Vaccine Disease 






faulters 










(Schedule D) 




Unac- 


who 
















counted 
for 


have 

NOT 






Success- 


Vaccina- 


On the 


In 








ful 


tions 


ground 


respect 


Died 


owing to 


been 


Total 




Vaccina- 


post- 


of 


of 


before 


removal 


granted 


Births 


Year 


tions 


poned 


Constitu- 


the 


Vaccina- 


from 


an ex- 


Re- 




(Form A, 


(Form B, 


tional 


Children 


tion 


District 


tension 


gistered 




First 


First 


Insuscep- 


already 




or 


of time 






Sched.) 


Sched.) 


tibility 

of the 

Vaccine 

Disease 


having 
had 

Small- 
pox 




other- 
wise 


under 
Form B. 

First 
Sched. 




1904 


84,068 


2,184 


118 


2 


7,105 


3,774 


6,560 


103,811 


1905 


84,326 


2,505 


90 


- 


6,624 


3,625 


5,662 


102,832 


1906 


83,223 


2,555 


121 


- 


6,955 


4,229 


6,453 


103,536 


1907 


81,841 


2,360 


88 


- 


6,656 


3,567 


7,230 


101,742 


1908 


80,504 


2,601 


96 


- 


6,808 


3,217 


8,813 


102,039 


1909 


80,455 


2,715 


118 


- 


6,651 


3,884 


8,936 


102,759 


1910 


78,839 


2,754 


83 


- 


6,680 


3,694 


9,913 


101,963 


1911 


73,856 


2,990 


151 


- 


6,434 


4,518 


13,809 


101,758 


/o 


0/ 
/O 


/o 


/o 


/o 


/o 


/o 


9/ 
/o 


1904 


81.0 


2.1 


0.1 


0.0 


6.9 


3.6 


6.3 


100.0 


1905 


82.0 


2.4 


0.1 


- 


6.5 


3.5 


5.5 


100.0 


190G 


80.4 


2.5 


0.1 


- 


6.7 


4.1 


6.2 


100.0 


1907 


80.4 


2.3 


0.1 


- 


6.6 


3.5 


7.1 


100.0 


1908 


78.9 


2.5 


0.1 


- 


6.7 


3.2 


8.6 


100.0 


1909 


78.3 


2.6 


0.1 


- 


6.5 


3.8 


8.7 


100.0 


1910 


77.3 


2.7 


0.1 


- 


6.6 


3.6 


9.7 


100.0 


1911 


72.6 


2.9 


0.2 


- 


6.3 


4.4 


13.6 


100.0 



198 



Reviews and Bibliographical Notices. 



From a comparison of the figures relating to the 
provinces it appears that the successful cases of vacci- 
nation in the province of Leinster numbered 16,651, or 
61.0 per cent, of the total births registered; in Munster 
the successful vaccinations numbered 16,512, or 70.2 per 
cent, of the total births registered therein ; in Ulster the 
successful vaccinations numbered 30,858, or 82.6 per cent, 
of the total births registered ; and in the province of Con- 
naught the number of successful vaccinations re[X)rted 
was 9,835, or 72.3 per cent, of the total births registered. 

Detailed information regarding vaccinations for the 
counties ; superintendent registrars' districts (or poor-law 
unions), arranged by provinces and counties; registrars' 
districts ; and superintendent registrars' districts, 
arranged alphabetically, will be found in Abstracts I., 
II., III., and IV., respectively, a])pended to this Re[X)rt. 
Extracts from the notes presented by the Registrars are 
also published. 

Table II. — Showing the number of succe&sful primary vaccinations in 
Ireland during each of the years 1882 to 1911. [Extracted from 
Quarter!}' Reports.] 





Numbdr of 




Number of 




Number of 




Successful 




Successful 




Successful 


Year 


Primary 


Year 


Primary 


Year 


Primary 




Vaccinations 




Vaccinations 




Vaccinations 




in each year 




in each year 




in each year 


1882 


107,013 


1892 


89,527 


1902 


94,303 


1883 


10(),901 


1893 


88,095 


1903 


95,955 


1884 


105,021 


1894 


107,204 


1904 


91,970 


1885 


102,080 


1895 


92,227 


1905 


89,394 


1880 


97,137 


1890 


88,817 


1900 


iK),171 


1887 


90,800 


1897 


89,732 


1907 


89,207 


1888 


93,520 


1898 


87,109 


1908 


88,676 


1889 


92,021 


1899 


84,937 


1909 


80,799 • 


1890 


93,308 


1900 


91,150 


1910 


88,098 


1891 


92,207 


1901 


88,520 


1911 


84,011 



Returns of Marriages, Births and Deaths iyi Ireland. 109 

In the foregoing tabular statement the number of 
successful vaccinations returned for each of the years 1882- 
1911 is given. 

The following table shows the number of deaths from 
small-pox registered in Ireland in each of the years 1864- 
1911 :— 



Table III. — Showing the mimber of deaths from small-pox registered in 
Ireland in each of the 48 years, 1864 to 1911. 



Year 


Number of 

Deaths 
registered 

frbm 
Small pox 


Year 


Number of 

Deaths 
registered 

from 
SmaU-pox 


Year 


Number of 

Deaths 
registered 

from 
Small- pox 


1864 


854 


1880 


389 


1896 


4 


1865 


461 


1881 


72 


1897 


3 


1866 


194 


1882 


129 


1898 


- 


1867 


21 


1883 


16 


1899 


1 


1868 


23 


1884 


1 


1900 


1 


1869 


20 


1885 


4 


1901 


2 


1870 


32 


1886 


2 


1902 


1 


1871 


665 


1887 


14 


1903 


40 


1872 


3,248 


1888 


3 


1904 


16 


1873 


504 


1889 


- 


1905 


5 


1874 


569 


1890 


- 


1906 


- 


1875 


535 


1891 


7 


1907 


1 


1876 


24 


1892 


- 


1908 


- 


1877 


71 


1893 


1 


1909 


- 


1878 


873 


1894 


72 


1910 


- 


1879 


672 


1895 


146 


1911 


- 



It will be observed that the last record of mortality from 
small-pox in Ireland was in the year 1907, when one 



death was registered. 



200 Reviews and Bibliographical Notices. 



Forensic Medicine and Toxicology. By C. 0. Haw- 
thorne, M.D., F.R.F.P.S.G. ; Lecturer on Forensic 
Medicine in the London School of Medicine for Women ; 
Physician to the North-West London and Royal 
Waterloo Hospitals. Third Edition. London : Edward 
Arnold. 1912. Pp. 344. 

We have formed a high opinion of Dr. Hawthorne's work 
as being an excellent students' guide to Forensic Medicine. 
The style is clear and lucid, and the proportionate values 
of the various subjects treated appear to be well main- 
tained. Hence it will be found to be an easy book to read and 
from which to make up the subject. The paper and printing 
leave nothing to be desired. It is much more difficult to 
condense knowledge and to choose wisely what is to be 
included and what omitted than it is to write a large and 
exhaustive book. We consider that Dr. Hawthorne has 
been quite successful in these respects. While the chap- 
ters on each subject are short, they are nevertheless 
reliable and sufficient. 

We think that the author has, perhaps, attributed too 
little vahie to the precipitation test for blood. " These tests 
promise," he says, "to be of considerable medico-legal 
value in the hands of experts." We think that promise 
has been fulfilled. It might also have been well to men- 
tion that this test is not primarily one for hlood ; it will act 
with other fluids, such as semen, as well as with blood. 

The Practitioner's Encyclopccdia of Medicine and Sur- 
gery i)i all their Branches. Edited by J. Keogh 
Murphy, M.C, F.R.C.S. Second Edition. London: 
Henry Frowde, Oxford University Press, and Hodder 
& Stoughton. 1913. 4to. Pp. xxvi + 1443. 

The fact that a large edition of this work has been ex- 
hausted between September, 19P2, and April, 1913, quite 
absolves the reviewer from making any laboured efforts 
in commendation. It is sufficient for us to congratulate 
Mr. Murphy on his success, and to express the opinion 



ScHACHNER — Dr Ephraim McDowell. 201 

that his work merits its continuance. An important 
feature in the new edition is the amplification of the 
index, a change that will make the work even more 
accessible than it was to the busy practitioner. 



Dr. Ephraim McDowell, " Father of Ovariotomy " ; His 
Life and Work. By August Schachner, M.D., 
Louisville, Ky. Keprinted from the Johns Hopkins 
Hospital Bulletin, Vol. XXIV. No. 367. May, 1913. 
8vo. Pp. 17 and four Plates. 

The operation of ovariotomy has now become such a 
commonplace and safe procedure that it is difficult for us 
to realise the terrible condition of women with cystic 
ovaries in the early part of the last century. The tumours 
grew to an enormous size, and made the unfortunate 
woman's life literally a burden to her. While this was so, 
the operation of puncture, or tapping the cyst — the only 
means of giving relief — was attended with a frightful 
mortality. A. de Krassowsky, writing on this subject in 
1868, states that in five years he operated in this way on 
forty-three patients, with one complete cure, one doubtful 
cure, and thirty-four deaths — the history of the remain- 
ing seven patients not being known. It was instead of 
the treatment that produced these results that the opera- 
tion of ovariotomy was introduced. 

Ephraim McDowell, who was the first to devise and to 
perform successfully this operation, was born in Virginia 
in 1771, and for a while studied surgery in Edinburgh 
under John Bell, but left the University without taking 
any degree. Tradition asserts that McDowell's fore- 
fathers had come to the North of Ireland from Scotland 
during the Commonwealth, and it is known that his 
great-grandfather assisted in defending of Derry against 
James II. in 1689. Subsequently, in the early part of 
the eighteenth century he emigrated to America, and 
settled in Virginia. Dr. Schachner denies the right of 
Ireland to make any claim to the ancestry of McDowell ; 
but there is no doubt that his family was for many years 



202 Reviews and Bibliographical Notices. 

resident in the country, and the name has been well 
known and respected there for considerably more than 
two centuries. 

The story of Ephraim McDowell's life and work has 
been told several times, but it will well bear repetition, 
and even yet it does not seem to be known as it should. 
Those of us who are old enoufj^h to remember the dread 
with which the operation of ovariotomy was looked upon 
in the seventies and ei^^ities of the last century can a]ipre- 
ciate the work of McDowell in 1809. As a previous bio- 
•^a-apher has said : — " When we think of one living on the 
border of Western civilisation, in a little town of five 
hundred inhabitants, far removed from the opportunity of 
consultation with any one w^hose opinion might be of 
value, and nearly a thousand miles from the nearest 
hospital or dissecting room, performing a new and untried 
o|)eration of such magnitude upon the living, before the 
days of anaesthesia, with a full sense of the reponsibility 
and danger, without skilled assistants, our admiration for 
McDowell's courage and skill rises to its full height." 

We tender our thanks to Dr. Schachner for his work in 
perpetuating the fame of such a man. 



IIow to diac/iiose Small-pox. A Guide for General Prac- 
titioners, Post-Graduate Students, and others. By W. 
M'C. Wanklyn, B.A. Cantab.; M.E.C.S., L.K.C.P., 
D.P.H. ; Assistant Medical Oflicer of the London 
County Council, and formerly Medical Superintendent 
of the River Ambulance Service (Small-pox) of the 
Metropolitan Asylums Board. Wilh Illustrations. 
London: Smith. Elder & Co. 1913. Demy 8vo. 
l^p. xi + KM. 

Tin-: early diagnosis of small-pox is a matt(T of grave im- 
portance, not only because of the appalling character of 
the disease in its more malignant forms, but because of 
the risk to the community if the disease should not be 
recognised at the very start of an outbreak. 

The author is w(>ll (pialified for his self-imposed task 



Wanklyn — How to diagnose Small-pox. 203 

in writing this book. He was formerly Medical Superin- 
tendent of the small-pox receiving stations and river 
ambulance service of the Metropolitan Asylums Board, 
and is now an Assistant Medical Officer of the London 
County Council. In these responsible positions he gained 
an experience of small-pox which must be almost without 
a parallel. It extended over twenty years, and has been 
based on the revision of the diagnosis in about 10,000 
cases certified as smaU-pox and sent from London in 
the epidemic of 1901 and 1902 to the small-pox receiv- 
ing stations in the Thames. Experience so vast and wide 
must command attention. But, apart from this, the book 
is written in such an easy style and in such simple and 
colloquial language that it is quite refreshing to read its 
well-leaded, large-typed pages. We suppose we must 
accept without demur the colloquial verb " diagnose " in 
lieu of the grammatical form " diagnosticate." 

Dr. Wanklyn is somewhat iconoclastic in his views. In 
arriving at a diagnosis he properly postpones the patient's 
medical history to the last. *' It seems to me," he 
writes (page 29), " that, if the man is accused of small- 
pox, so to speak, and you are to judge and sentence him, 
the evidence which ought to w^igh most with you is your 
own direct observation, and the reading of what is before 
you." " To be groping about for a history is to lean upon 
rotten supports which you are better without. Sir George 
Murray Humphry used to say, of examining cases in 
general, ' Eyes first. Hands next. Tongue last and 
least.' " (Page 34.) 

We do not go so far with him when he minimises the 
diagnostic value of the " shottiness " and " umbilication " 
of the rash of small-pox. He reverses the order of these 
words, so erring against chronology. His words are : 
** It is a characterisation absolutely wide of the mark for 
purposes of diagnosis " (page 36). This is going too far, 
but we agree with the author that it has been the practice 
to attach more importance to these characters than they 
deserve. Dr. Wanklyn further dismisses with scant 
courtesy the further classical sign of " loculation " — " the 



204 Reviews and Bibliographical Notices. 

small-pox vesicle is said to be multilocular and the 
chicken-pox vesicle to be unilocular." We agree with 
him that this "is not always the case," but we do 
not agree with him that the point is of litt'le assistance in 
practice — at least in the vesicular and early pustular stages 
of the small-pox eruption. 

Curiously enough, in the other direction, Dr. Wanklyn, 
to our mind, lays undue stress as a diagnostic of small-pox 
on the fact that the rash especially favours sites of irrita- 
tion. This is perfectly true, but such a distribution of the 
rash peculiar to other eruptive fevers such as scarlatina 
and measles and also chicken-pox is quite common. The 
principle of " ubi irritatio, ibi affluxus " was recognised 
long ago. The opposite holds good also, for Dr. William 
Stokes based his preventive treatment of pitting in small- 
pox on the observed fact that the rash was scanty and the 
inflammation slight over portions of the body-surface the 
vascularity of which had been reduced. Stokes's paper 
was published in the fifty-third volume of this Journal in 
the year 1872. It is replete with sound, ])ractical advice. 

The author very properly alludes to early and extreme 
prostration as a feature of severe small-pox. He considers 
that it is a characteristic feature, which may be of 
material assistance in diagnosis. But we must remember 
that this symptom is common to small-pox, typhus and 
pneumonia. 

As to differential diagnosis, Dr. Wanklyn mentions 
(Chapter VIII.) that in the year 1902, of 7,842 cases cer- 
tified in Tjondon as small-]>ox, and sent to the Receiving 
Stations, 607 were found not to be small-pox. We are not 
surprised to find 203 cases of chicken-pox among the 
number. *' (renerally speaking," writes Dr. Wanklyn, 
" Ihc resend)lances between small-pox and chicken-])ox 
are very remarkable ; so much so as to suggest they are 
descended from a common ancestor " (page 90). To this 
suggestion we cannot subscribe, while we admit that 
striking resemblances exist between the two diseases. 
" The conclusion is that there is no single touchstone 
for the differentiation of small-pox and chicken-[X)x." 



Zm^BER~&TEm— Diseases of the Mouth. 205 

While this is true, at least a dozen valid reasons may be 
advanced to show that these diseases are entirely distinct. 

Dr. Wanklyn rightly lays stress on the diagnostic 
and prognostic significance of the so-called ' ' bathing- 
drawers " rash (" eruption de cale^on de bain ") in pur- 
puric small-pox. The distribution in the groins of this 
ominous initial rash is well shown in a series of dia^^jrams 
inserted between pages 84 and 85. 

The subject-matter of the book is further illustrated by 
a number of telling photographs of small-pox and chicken- 
pox, and by a chart showing the prevalence of small-pox 
in London between 1885 and 1912. 

J. W. M. 



Diseases of the Mouth : Syphilis and Similar Diseases. 
For Physicians, Dentists, Medical and Dental Students. 
By Professor Dr. F. Zinsser, Director of the De- 
partment of Dermatology at the City Hospital, Linden- 
burg ; Dozent at the Academy for Practical Medicine, 
Cologne. Translated and Edited by John Bethune 
Stein, M.D. ; Professor of Physiology at the New York 
College of Dentistry ; late Instructor in Genito-Urinary 
Diseases at the College of Physicians and Surgeons 
(Medical Department of Columbia University), New 
York City. With 52 coloured and 21 black and white 
illustrations. London : Kebman, Ltd. Pp. 269 + xvi. 

This is an excellent work upon the subject of which it 
treats. For descriptive purposes the book may be said to 
consist of two parts. The first sixty-seven pages consist 
of a resume of the modern literature of syphilis, and it con- 
stitutes an efficient exposition of the subject. The second 
portion of the book partakes of the nature of an atlas of 
venereal and other pathological conditions affecting the 
mouth and throat. The book supplies a want, and a very 
distinct one, for those who have not opportunities for 
observing in their routine practice the important conditions 
which the illustrations depict. It will furnish medical 
and dental practitioners not only with a clear, concise, 



206 Reviews and Bibliographical Notices. 

and ample monograph on syphilis, but also with the 
means of readily distinguishing the lesions produced in 
the mouth and throat by this disease from those due to 
other pathological causes, and, further, it will incidentally 
enable the precise nature of the latter to be similarly 
diagnosticated. 

The following are some of the conditions illustrated 
and described in the work before us : — Gummatous per- 
forations, mercurial ulcerations; lichen ruber planus; 
idiopathic polymorphous erythema; herpes labialis ; 
aphthous ulcer; follicular tonsillitis; syphilitic tonsillitis; 
]^lant-Vincent angina ; mycotic tonsillitis ; the geo- 
graphical tongue ; leukoplakia ; tuberculosis of the mucous 
membrane of the hard palate; tuberculosis of the fauces, 
soft palate and uvula ; cancer of the tongue ; gumma of 
the tongue. 

We found Professor Zinsser's book interesting and 
instructive, and have pleasure in recommending it to our 
readers. . S. S. 



The Modern Hospital: Us Inspiration; its Architecture; 
its Kqnipment ; its Operation. By John Allan 
HoRNSBY, M.D., and Richard E. Schmidt, Architect. 
With 1^07 Illustrations. rhiladel|)hia and London : 
W. B. Saunders Company. 11)13. Svo. Pp. G44. 

It is not often in this country that any one has the 
opportunity of designing or building a modern hospital, 
jind in most instances one has to be content with the 
adaptation of existing buildings to the requirements of 
modern medicine and surgery. Even when opportunity 
does occur, the available funds are usually so limited that 
one has to be content with a building which too often is 
far from satisfactory. It is probably due to this lack of 
opjiort unity that so little attention has been devoted to 
the problems of hospital building in this country. 
Whether this be the true explanation or not, it is quite 
evident that very few of those who have the management 
of our hosjiitals have ever set themselves to understand 
or to solve the many problems of elKicient hosj^tal con- 



HorNsby — Schmidt — The Modern Hospital. 207 

struction and equipment. Yet surely these problems are 
worthy of the most careful study, for the efficient and 
economical working of the hospital largely depends on its 
proper construction and equipment at the outset. The 
great difficulty, of course, lies in the fact that medical 
men w^ho are to use the place know little, if anything, 
of architecture, and the architects who undertake the con- 
struction seem to know nothing of the needs of those who 
are to use their building. 

In the book before us some attempt has been made to 
overcome this difficulty, and Dr. Hornsby, who, as 
Secretary of the Hospital Section of the American Medical 
Association, has had considerable experience of hospital 
management, has associated with him Mr. Richard E. 
Schmidt, an architect of considerable experience. The 
result of this collaboration is to afford a mass of material 
on almost every point in connection with hospital build- 
ing and equipment. The work, of course, largely em- 
bodies the individual experience of the joint authors, and 
as such will not receive universal acceptance, but it is the 
experience of individuals w^ho have closely studied the 
subject and are ready to give reasons for the faith that 
is in them. Even the most minute details have been 
considered, and plans have been accepted or rejected as 
they may have been found useful or otherwise in prac- 
tice. An instance of this may be seen in the section deal- 
ing with vacuum cleaners. Having described the various 
methods for using this means of removing dust, the 
authors go on to say ' ' hospital . administrators need not 
expect to cut down their cleaning by other means when 
they install vacuum cleaners. The same amount of hand 
cleaning will have to be done. In short, the vacuum 
cleaner is a most attractive device theoretically, and has 
more good * talking points' than almost any other hos- 
pital convenience." 

In such a w^ealth of material it is impossible to par- 
ticularise, but we should recommend all those who have 
to deal with the administration of our hospitals to con- 
sult this book before they decide on any ])lan of recon- 
struction or equipment of the hospital under their charge. 



208 Reviews and Bibliographical Notices. 

The Prospective Mother. By J. Morris Slemons. 
London : D. Appleton & Company. 1913. Cloth 8vo. 
Pp. 343. 

The author of this book has in view the thorough instruc- 
tion of the educated mother in both the hygiene of preg- 
nancy and also the preparation for the confinement itself. 
The book treats of the whole subject in a wonderfully 
simple and explicit style, avoiding technical terms other 
than those which are explained ; but many members of the 
general public would be rather alarmed at so much in- 
struction being given. To a sensible, well-educated 
woman the book should prove most interesting, however, 
and will impart knowledge in a pleasant, easy way. 



Diseases of Women: a Clinical Guide to their Diagnosis 
and Treatment. By Georc.e Ernest Herman, M.B., 
F.K.C.P. Lond., f!^K.C.S. Eng. ; Consulting Obstetric 
Physician to the London Hospital ; Consulting 
IMiysician- Accoucheur to the Tower Hamlets Dispen- 
sary ; late President of the Obstetrical Society of London 
and of the Hunterian Society, &c. Enlarged Edition, 
revised by the Author, assisted by R. Drummond 
Maxwell, M.D. Lond., F.R.C.S. Eng.; Assistant 
Obstetric Physician to the London Hospital and 
Physician to Queen Charlotte's Lying-in Hospital. 
With 8 Coloured Plates and 292 figures in the text. 
London, New York, Toronto, and MeJbourne : Cassell 
& Co., Ltd. 1913. Pp. xiv + 899. 

TiTE main alteration in the new edition of Dr. Herman's 
work is the introduction of Dr. K. D. Maxwell to help in 
the revision of the parts of the book relating to operative 
technicpie. For the most part Dr. Maxwell's descriptions 
of operations are good, though often they are somewhat 
sketchy. The rest of the book is as it has always been, 
and needs a very thorough revision to make it descriptive 
of modern gyufrcology. 



PAET III. 
MEDICAL MISCELLANY. 



Reports, Transactions, and Scientific Intelligence. 



ROYAL ACADEMY OF MEDICINE IN IKELAND. 



President— Walter G. Smith, M.D., F.K. C.P.I. 
General Secretary— J. A. Scott, M.D., F.K. C.S.I. 

SECTION OF PATHOLOGY. 

President — Professor A. H. White. 
Sectional Secretary — W. Boxwell, M.D., F.E. C.P.I. 

Friday, May 2, 1913. 

The President in the Chair. 

Organs from a Case of Amyloid Disease. 

Sir John Moore said amyloid disease was sufficiently rare 
at the present day to warrant exhibition. The specimen 
shown was taken post-mortem from a man, aged forty-six, 
who had been admitted to the Meath Hospital on the 11th 
of November, 1912. When admitted the patient was in a ' 
state of extreme emaciation. Hegave a history of pains in 
his right hip and knee. About seven months prior to ad- 
mission the right hip began to discharge. The right leg was 
noticed to be wasted when compared with the left, and the 
hip showed two discharging sinuses. The pus was described 
as thin, watery, and of a yellow colour. An interesting 
feature of the case on physical examination was the promi- 
nence of the upper part of the abdomen as compared with 
the generally wasted condition of the patient. The liver was 
much enlarged, hard, and smooth. The left side also was 
occupied by a large tumour, which at first was taken to be 

O 



210 Royal Academy of Medicine in Ireland. 

the spleen. Cultures were made from the pus discharged 
from the sinuses, and the patient was injected with 10 
millions of a pseudo-diphtheria bacillus. Subsequently, 
Staphylococcus aureus was isolated, and he was four times 
injected with a vaccine prepared from this, containing 
200,000,000 or 250,000,000 organisms, but this treatment 
did not appear to do him any good. The patient's tempera- 
ture throughout was sub-normal. He gradually sank from 
exhaustion. 

At the autopsy, the liver was found enormously and uni- 
formly enlarged, hard, and smooth. It weighed 152 ounces. 
In one of a series of six illustrative cases reported by 
Murchison the liver was stated to have weighed 131 ounces, 
and it was described as smooth and moulded over the ad- 
jacent parts ; in another of the same series the liver weighed 
184^ ounces, both lobes were equally enlarged, and the 
under surface was marked by deep impressions correspond- 
ing to the right kidney on one side and to the spleen on the 
other. According to Dr. Hale White, an amyloid liver may 
weight 14 lbs. — that is 224 ounces. 

The tumour which was thought to be the spleen was 
found to be the left lobe of the liver. The right kidney was 
embedded in the right lobe, and the left kidney had moulded 
itself into the amyloid spleen, which in turn had made for 
itself a bed in the left lobe of the liver. These points were 
considered interesting from the clinical as well as the 
pathological j)oint of view. Here and there over the surface 
of the liver and kidneys a few miliary tubercles were to be 
seen and also in the spleen. Sections of the liver stained a 
mahogany colour with Lugol's iodine solution, and when 
• subsequently treated with sulphuric acid yielded a bluish 
colour. The spleen was but slightly enlarged, with mere 
traces of amyloid material distributed here and there 
through the pulp. The amyloid change was more pro- 
nounced in the kidneys, showing up in sections stained with 
methyl violet. 

Prokkssor Mettam referred to cases of amyloid disease 
met with in the lower animals, and pointed out that in such 
cases the syphilitic element had to be excluded. It was by 
no means uncommon in his experience to find this disease 
in a certain number of cases in connection with tubercle. 
It was also occasionally met with in the horse, often without 



Section of Pathology. 2ll 

anything to account for it. The cHnical history in such cases 
was usually that the horse died suddenly with symptoms of 
ruptured liver, and amyloid disease was found on 'post- 
mortem examination. He mentioned that amyloid disease 
was not at all uncommon in animals used for the production 
of anti-toxic serum, and he suggested that its origin 
appeared to be toxic. It was remarkable that the amyloid 
infiltration occurred generally in the walls of the smaller 
vessels. He would like to know if the condition was a 
diffuse one, or was the spleen of the sago type. He in- 
quired if an extended examination of the tissues was made 
to ascertain if there were any deposits in the heart, tongue, 
or other organs. He also inquired if any deposits were 
found in the central nervous system, and whether any 
change had been observed in articular or other cartilages. 

Dr. Boxwell said there was not much disease in the 
spleen, and what was there was diffuse. Microscopic sec- 
tions were not made of the heart, nor was the central 
nervous system examined. 

Post-mortem, examinations were strictly limited, and 
thorough investigation of the points raised by Professor 
Mettam on the average hospital patient was impossible. 

Sir John Moore, in replying to the remarks, said the 
intestines were examined, but were not found to be mate- 
rially altered. The heart was singularly small, but other- 
wise apparently healthy. As to the size of the enlargement, 
it was pointed out that Hale White reported a case of 
amyloid liver weighing 141bs. In the " Pathological 
Transactiions " a sarcoma of the liver was recorded as 
weighing 171bs. The spleen was not a characteristic sago 
spleen. The lesion in the hip was tubercular, but it was 
recognised that in man amyloid disease does not accompany 
tubercle unless suppuration took place, and of course there 
was much suppuration in this case. 

C(brcinom.a of the Larynx. 

Dr. H. Stokes said that the patient from whom this speci- 
men was taken was a man who was admitted to the Meath 
Hospital in a state of delirium t<remens. Attention was drawn 
to the fact that he could not swallow. He ran a tempera- 
ture for about a week and then developed a cough with ex- 
pectoration. Death resulted fix)m pneumonia and heart 



2l2 Royal Academy of Medicine in Ireland. 

failure. On post-^nortem examination an abscess was found 
in the larynx and tubercle in the lung. 

Professor A. C. O' Sullivan said that both lungs were 
tuberculous; one showed miliary tuberculosis and the other 
a large focus. The pharynx on the right side showed a 
large, deep ulcer. It was gangrenous and greenish in colour 
when fresh. On the opposite side there were a couple of 
apparently papillomatous growths. The impression from a 
naked eye examination was that the ulceration was tuber- 
culous. There was great oedema of the glottis. It was dis- 
covered that both sides of the pharynx were cancerous. The 
epithelial cells were deep down in the fibrous tissue. 

Tubercle of the Cerebellum. 

Dr. W. Boxwell exhibited a specimen of the above, which 
was taken from a boy, aged ten years, the only child of a 
father dead of phthisis. He was admitted to the medical 
wards for observation on the 15th of January, 1913, having 
a somewhat vague history of headache, vomiting, and de- 
fective sight. He was a well-developed, intelligent child, 
and explained that he had had severe headache at fairly 
frequent intervals, but that vomiting came on when play- 
ing or romping, rather than after food, or when at rest. 

On physical examination his gait was found to be strutting 
in character, with some ataxia, but without tendency to reel 
to one or other side. The jerks were variable, but generally 
increased, especially in the right leg, and a clonus could 
sometimes be developed. The plantar reflexes were also 
variable, sometimes quite active, at other times absent. 
The abdominal reflexes were present, the right cremasteric 
generally absent. Nystagnuis was marked. Sight for 
distant objects was bad. There was no complaint of vertigo, 
no history of fits, and there was no tremor. His hearing 
was good. His pupils were large and even, tongue nonnal. 
On the 1st of February, after getting out of bed, he became 
giddy and frll, and about this time he had his first and only 
attack of vomiting. On the 4th of February a " lower 
neuron " paralysis of the left facial nerve set in, followed 
on the 8th of Fc^bruary by deafness in the left car. At this 
stage Dr. Euphan Maxwell kindly examined his eye 
grounds, and rei)orted " double-choked disc," with atrophy 
in the left eye." On the 9th of February Ik^ IckI an attack 



Section of Pathology. 213 

of convulsions. The diagnosis of a growth of some sort, 
probably tubercular, situated in the left lobe of the cere- 
bellum, was now partly obvious, and the almost sudden 
development of dysdiadochokinesis of the left arm 
strengthened the impression. 

A decompression operation, with a view to saving his sight 
was" now undertaken by Mr. William Taylor, but the child 
never quite recovered from the shock of the operation, and died 
two days after. 

A large tubercular mass, one and a quarter inches in 
diameter, was found at the post-morte7n, occupying the left 
lobe of the cerebellum, and displacing the right lobe con- 
siderably to the right side. No other evidence of tuber- 
culosis was found. 



Pathological Report of the Rotunda Hospital. 

[Dr. Eowlette's Report will be found in full at page 
173.] 

Dr. O'Farrell asked if autogenous vaccines were made 
from the lochia, and how the infecting bacteria had been 
isolated. He also was anxious to know how the results of 
autogenous vaccines compared with those of stock vaccines. 
He inquired if there was any method of distinguishing 
tubercular pyosalpinx. 

Dr. O' Kelly inquired if cultures were made from the 
thrombosed ovarian veins. Arising out of one of the speci- 
mens, he would like to know if the uterus had been ex- 
amined, as it was suggested that the blood-vessels dilate 
within the area of the uterine artery. 

The President, referring to the bacillus found in the 
discharges, said that within the last eighteen months he 
had obtained a pseudo-diphtheritic bacillus from such a case. 
The condition was a very chronic one, and got well only by 
inoculation with vaccine. 

Dr. Rowlette said, with regard to the bacillus in the 
lochia, the vaginal discharge in cases of puerperal sepsis was 
never examined, the reason being that this discharge con- 
tains such a quantity of organisms that it would be difficult 
to separate one from the other. His practice was to obtain 
the discharge direct from the uterus. In every case the patient 
is treated first with a stock vaccine made from some other 



214 Royal Academy of Medicine in Ireland. 

patient, and if she reacted well, the treatment with this 
vaccine is continued, and an autogenous vaccine is not pro- 
pared. In cases that did not react to the stock vaccine, if 
the organism can be isolated an autogenous vaccine was 
made. The results with autogenous vaccine were best. 

As to the diagnosis of pyosalpinx, in nearly all cases that 
came to operation the pus was sterile, and one had to decide 
by direct microscopic means. Occasionally streptococcus 
was met with. The diagnosis of tubercle he had never made 
from microscopic examination. He considered that tuber- 
culous tubes fell into either one or other of two types — i.e., 
peritoneal or mucous. In the majority of cases of tuber- 
culosis the infection was found near the Fallopian end of the 
tube rather than the uterine end, the latter being free ex- 
cept in very advanced cases. With regard to the type of 
sarcoma, the type he had most commonly seen was the 
large round-celled variety. He had seldom seen giant cells. 
He had never observed the growth of new vessels inside the 
uterus after the termination of pregnancy. 



Fnday, May 30, 1913. 
The President in the Chair. 



Congenital Sacral Tiunours. 

Dr. W. D. O'Kelly read a paper on this subject, and illus- 
trated it with lantern slides. 

Professor O' Sullivan suggested that the material de- 
scribed as heart muscle might be voluntary striped muscle. 
He thought it was the case that in some dermoid cysts of 
the ovary small solid portions are found which may contain 
a great variety of different structures. 

Dr. T. T. O'Farrell suggested that Dr. O'Kelly should 
mount some of the sections and present them to the College 
Museum. He inquired if Dr. O'Kelly had met with para- 
sitic cysts in the region. 

Dr. Boxwell was not sure as to the theory about dermoid 
cysts. 

Dr. O'Kelly, replying to the remarks, said as to the 
h(mrt muscle, he did not see anything that he considered 
distinctive, but be thought the fibres were short. He con- 



Section of Pathology. 215 

sidered that the ovarian dermoids were really teratomata. 
He did not know that parasitic cysts were likely to grow in 
that situation. 

Innominate Aneurysm. 

Dr. Parsons said the subject of this disease was a painter. 
He was admitted to hospital complaining of painful swelling 
in his neck. Until twelve months before this he enjoyed 
perfect health. The first symptoni was a sharp, stinging pain 
in the shoulder, which would disappear when the limb was 
rested. About May, 1912, a tender swelling about the size 
of a marble was noticed about the middle of his collar bone. 
Shortly afterwards he had a sore throat, and lost his voice, 
but had no difficulty in swallowing. This was followed by 
tenderness at the shoulder, and a pain of a sharp, shooting 
nature ran up along his neck behind the ear. On the 18th 
of March, 1913, there was complete abductor and adductor 
paralysis of the right recurrent laryngeal nerve. The right 
arytenoid and vocal cord remained perfectly immobile on 
respiration and vocalisation, and the right vocal cord was 
slightly more prominent than the left, and the true vocal 
cord on the right side also appeared rounded or thickened. 

The tumour increased with extraordinary rapidity, and the 
patient succumbed six weeks after admission. Sleepless- 
ness was a very common symptom, and morphine was given 
hypodermically. Shortly before death a very offensive 
odour came from his breath. Examination of the blood 
gave a well-marked positive Wassermann. A slide, showing 
the size and position of the swelling about a week before 
death, was thrown on the screen. 

Dr. Adrian Stokes showed the aneurysm removed post- 
mortem, and described its position. 

Ruptured Thoracic Aneurysm. 

Dr. Boxwell showed a specimen which was taken from a 
man aged fifty. He was admitted to hospital spitting 
blood. There was a history of blood-spitting for two years, 
and he had dulness and crepitation all over the left lung. 
He was too weak for a complete examination on admission, 
and the case was thought to be one of tubercular pneu- 
monia. After a second haemorrhage the patient died. 



216 Royal Academy of Medicine in Ireland. 

Post-mocrtcm examination showed the left lung bound up 
by adhesions, and an aneurysm, which was adherent to the 
pleura, had burst into the substance of the left lung. It 
had also eroded the vertebrae. The specimen showed that 
the rupture of an aneurysm is not necessarily attended with 
a very sudden termination of life. 

Malignant Endocarditis. 

Dr. a. Stokes, for Dr. T. G. Moorhead, said the patient 
was a man, aged about thirty, who came to the dispensary 
complaining of pain in the abdomen. No cause could bo 
found for the pain, but an examination of the heart dis- 
covered a double aortic munnur. He was admitted to hos- 
pital and died next morning. The patient was in the habit 
of drinking to excess, and had a distended stomach. The 
urine contained albumen and tube-casts. 

Post-mortem examination showed the lungs to be normal, 
but there was a densely adherent pericarditis. The heart was 
very much enlarged, the right side was normal, but the left 
side showed ulcerative endocarditis of the valves. There 
was a certain amount of underlying chronic endocarditis, 
and the valves were calcified and hard. 

A pure culture from the valves gave a cross between 
streptococcus and pneumococcus. A point of interest in the 
case was that one of the branches of the mesenteric artery 
had a double aneurysm on it. 

Tumour of iJic Mesentery. 

Dr. H. i)k L. Crawford said the subject from whom the 
tumour was taken was a woman of sixty-two. She com- 
plained of tumour in the pelvis, which was going on for 
about a year. It grew steadily from the time it was first 
noticed. She was troubled with constipation, which got 
steadily worse, and occasionally vomited when she took 
solid food. 

The diagnosis was not clear before o|)erati()n. On oj)ening 
the abdomen a tumour was found which was freely movable 
and easily removed. There was a large hole in the gut, 
communicating with the tumour. Sections of the tumour 
showed that it was a round-ci'lled sarcoma. He suggested 
that the hole was an ulcer due to the tumour penetrating 
the wall of the gut at that point. 



Section of Pathology. 217 

Congenital Cystic Kidneys. 

Dr. Henry Stokes said the patient was aged twenty-eight, 
and was found to be suffering from an enormous abdominal 
tumour. The only point in the previous history was that 
there was a certain amount of constipation. The diagnosis 
was not certain. The abdomen was opened, and a small 
amount of tumour was taken out, and proved to be kidney 
tissue in a cystic condition. The patient died, and post- 
mortem examination discovered double cystic kidneys. 
Instead of 10 grains to the ounce urea, the urine contained 
only 5 grains, but the excretion of the urine was excessive. 
The kidneys weighed 81bs. and 91bs, respectively. 

Congenital Cystic Kidneys. 

Dr. T. T. O'Farrell showed two specimens. One of the 
kidneys weighed 21bs. 6oz., and the other 51bs. The age of 
the patient was twenty-nine. There was very little of the 
kidney substance left, and even what was to be seen was 
cystic. There was also a stone found in one of the kidneys. 
The patient came for treatment of interstitial nephritis. 

Congenital Cystic Kidney from a Calf. 

Professor Mettam showed a specimen of cystic kidney re- 
moved from a calf. When fresh the kidney had the appear- 
ance of a huge frog spawn. 

Actino-bacillosis. 

Professor Mettam also showed a specimen of actino- 
bacillosis of the ox's tongue. He said the organism was a 
small non-gram staining one, which was easily grown, and 
when it was inoculated into oxen developed large clubs. In 
actino-bacillosis there was a tendency to pus-formation. 

He also showed a tumour taken from a pig in which there 
appeared to be a number of necrotic sinuses which were 
softened sinuses containing pus and streptothrix. 



SANITARY AND METEOROLOGICAL NOTES. 

Vital Statistics. 

For jour weeks ending Saturday, July 12, 1913. 

IRELAND. 

The average annual death-rate represented by the deaths — 
exclusive of deaths of jxirsons admitted into public institutions 
from without the respective districts — registered in the week 
ended July 12, 1913, in the Dublin Registration Ai'ea and 
the twenty-six principal provincial Urban Districts of Ireland 
was 15.5 per 1,000 of their aggregate population, which for the 
purposes of these returns is estimated at 1,199,180. The 
deaths registered in each of the four weeks of the period 
ending on Saturday, July 12, and during the whole of that 
period in certain of the districts, alphak^tically arranged, 
correspond to the following annual rates per 1,000 : — 



County Boroughs, <fec. 


Week ending 


Average 
Bate 
for 4 
weeks 


June 
21 


June 
28 


July 
5 


July 
12 


27 Town Districts 


16.5 


16.7 


16.4 


15.5 


16.3 


Dublin Reg. Area 

Dublin City 

Belfast 

Cork 

Londonderry 

Limerick 

Waterford 


17.6 
19.3 
14.0 
17.0 
14.0 
19.0 
38.0 


14.9 
16.1 
16.9 
16.3 
15.3 
10.8 
26.6 


16.8 
19.1 
15.9 
16.8 
15.3 
13.0 
17.1 


19.9 
21.8 
14.2 
15.6 
8.9 
16.2 
11.4 


17.3 
19.1 
15.3 
16.3 
18.4 
14.9 
23.3 



The deaths (excluding those of persona admitted into public 
institutions from without the respective districts) from certain 



Sanitary and Meteorological Notes. 219 

epidemic diseases registered in the 27 districts during the Aveek 
ended Saturday, July 12, 1913, were equal to an annual rate 
of 1.7 per 1,000. Among the 108 deaths from all causes in 
Belfast were 3 from scarlet fever and 7 from diarrhoeal diseases. 
One of the 23 deaths from all causes in Cork was from typhus. 
Two deaths from enteric fever are included in the 12 deaths 
from all causes in Limerick. Included in the 6 deaths from 
all causes in Waterford are 2 from measles and one from 
diarrhoea of a child under 2 years of age. One of the 3 deaths 
from all causes in Newry was from measles, and one of the 
4 deaths from all causes in Tralee was also from measles. 

DUBLIN REGISTRATION AREA. 

The Dublin Registration Area consists of the City of Dublin, 
as extended by the Dublin Corporation Act, 1900, together 
with the Urban Districts of Rathmines, Pembroke, Blackrock, 
and Kingstown. The population of this area is 403,000 ; 
that of the City being 308,187, Rathmines 38,769, Pembroke 
29,942, Blackrock 9,161, and Kingstown 16,941. 

In the Dublin Registration Area the births registered during 
the week ended July 12 amounted to 223 — 111 boys and 112 
girls, and the deaths to 166 — 88 males and 78 females. 

DEATHS. 

The deaths registered, omitting the deaths (numbering 12) 
of persons admitted into public institutions from localities 
outside the Area, represent an annual rate of mortality of 
19.9 per 1,000 of the population. During the twenty-eight 
weeks ending with Saturday, July 12, the death-rate averaged 
21.2, and was 1.7 below the mean rate for the corresponding 
portions of the ten years, 1903-1912. 

The total deaths registered, numbering 166, represent an 
annual rate of 21.5 per 1,000. The annual rate for the past 
twenty-eight weeks was 22.6 per 1,000, and the average annual 
rate for the corresponding period of the past ten years was 24. 1 
per 1,000 of the mean population for all deaths registered. 

The registered deaths included 4 from scarlet fever, 3 from 
whooping-cough, 4 from diphtheria, 1 from influenza, and 
10 deaths from diarrhoea or enteritis of children under 2 years 
of age. 

In the preceding three weeks deaths from scarlet fever had 



220 Sanitary and Meteorological Notes. 

l)een 0, 0, and ; (Ictaths from whooping-cough, 4, 0, and 2 ; 
deatlis from diphtheria, 2, 0, and 3 ; deaths from influenza, 
2, 0, and 1 ; and deaths from diarrhoea or enteritis of children 
under 2 years of age, 3, 7, and 4, respectively. 

Deaths from tuberculous disease, which in the tliree preced- 
ing weeks numbered 30, 24, and 27, resjiectively, fell to 19 in 
the week under notice, including 15 from ])ulmonary 
tuljerculosis, one from tulx^rcular meningitis, 2 from abdominal 
tuberculosis, and one from disseminated tuberculosis. 

There were 10 deaths from cancer.. 

Six deaths were caused by broncho-pneumonia, 3 by lobar 
pneumonia, and 3 by pneumonia {ty[)o not distinguished). 

The deaths of 7 infants under one year of age were ascribed 
to pramature birth, and 6 deaths were attributed to congenital 
debility. 

Organic diseases of the heart caused 14 deaths and 
bronchitis 13 deaths. 

Two deaths attri})uted to accident wore caused by a motor- 
cycle collision. 

In 5 instances the cause of death was " imcertified," there 
having ]x)en no medical attendant during the last illness. 
These cases include the deaths of 3 infants under one year old. 

Forty-six of the jK^rsons whose deaths were registered during 
the week under notice were under 5 years of age (30 l)eing 
infants under one year, of whom 16 were under one month old) 
and 40 were aged 65 years and upwards, including 29 ^x^rsoiLs 
aged 70 and upwards. Among the latter were 12 aged 75 and 
upwards. 

STATE OF INFECTIOUS DISEASE IN THE DUBLIN 
UEGISTRATION AREA AND IN BELFAST. 

The usual returns of the numlK>r of cases of infectious 
diseases notified under the " Infec^tious Diseases (Notification) 
Act, 1899," and the " Tulx^rculosis Prevention (Ireland) Act, 
1908," as sot forth in the following table, have Iwon furnished 
by Sir Charles A. Cameron, C.B., M.D., Medical Superintendent 
Oflicer of Health for the City of Dublin ; by Mr. Fawcett, 
Executive Sanitary Ofhcer for Rathmines and Rathgar Urban 
District ; by Mr. Manly, Executive Sanitary Officer for 
Pembroke Ur))an District ; by Mr. Heron, Executive Sanitary 
Officer for Blackrook Ur])an District ; by the Executive 



Sanitary and Meteorological Notes. 



221 



Sanitary Officer for Kingstown Urban District ; and by 
Dr. Bailie, Medical Superintendent Officer of Health for the 
City of Belfast. 



Table showing the Number of Cases of Infectious Diseases notified in the Dublin 
Registration Area (viz. — the City of Dublin and the Urban Districts of Kathmines 
and Rathgar, Pembroke, Blackrock, and Kingstown), and in the City of Belfast, 
during the week ended July 12, 1913, and during each of the preceding three 
weeks. An asterisk {*) denotes that the disease in question is not notifiable in the 
District. 

































^ 






Cities and 


Week 




O tn 


> 
0) 




to 


a 


O 


a ^ 
"Soe 

■§1 


> 


ta 


O 

<D 

PC4 


3 
o 
u 

in 


-a 


03 

■iS» 

to « 

3'S 


CO 

o t-> 




Urban Districts 


ending 




cs'Ph 




O) 


a 


« 


ss- 


.S5S 


^ o 


"3 






2^) 


CD CO 














a. 


c8 


a. 


S5 






03 
>» 




o 
o 


Si 


h6 


2 

3 


5 








" <D 






<u 










u 








^ 










^ 


M-tJ 


w 


H 


Oi 


a, 


1^ 


fu 


'^ 


w 


0^ 


|5- 


u 


PU 


<1 


H 


( 


June 21 






13 


^ 


_ 


3 


. 


1 


1 


1 


^ 




_ 


18 


_ 


37 


City of Dublin A 


June 28 
July 5 






22 
12 


- 


: 


U 

5 


- 


- 


6 
3 


3 

3 


- 




- 


14 

14 


: 


56 

37 


I 


July 12 






11 


- 


- 


5 


- 


1 


2 


6 


- 




- 


16 


- 


41 


Rathmines and f 


June 21 






_ 


_ 


_ 


2 


_ 


_ 


_ 


_ 


_ 




* 


• 


« 


2 


Ratligar 


June 28 






2 


- 


- 


- 


- 


- 


1 


- 


- 




• 


« 


• 


3 


Urban 


Julv 5 






- 


- 


_ 


3 


_ 


- 


- 


1 


- 




* 


« 


• 


4 


District I. 


July 12 






1 


- 


- 


1 


- 


- 


- 


- 


- 




• 


» 


* 


2 


Pembroke ( 
Urban < 
District 1 


June 21 
June 28 
July 5 
July 12 


10 


- 


- 


- 


- 


1 
2 


1 


- 


1 
1 


1 
1 


- 


2 
1 

3 


*• 
* 


2 

•2 


« 
* 
* 


16 
2 
5 
6 


Blackrock ( 
Urban < 
District 1 


June 21 
June 28 
July 5 
July 12 






1 


- 


- 


3 


- 


- 


- 


-, 


- 




- 


• 
• 


* 
• 


1 
3 


Kingstown | 
Urban \ 
District 1 


June 21 
June 28 
July 5 
July 12 






- 


- 


- 


- 


- 


- 


- 


- 


- 






- 


* 
* 

m 


- 


Oity of HelfiiNt 


June 21 






49 


_ 


_ 


2 


_ 


_ 


_ 


7 


_ 




• 


8 


w. 


66 


June 28 
July 5 






ti 


- 


- 


8 
7 


- 


1 


1 


1 


- 




• 


ir, 
11 


• 


72 

57 


July 12 






83 


- 


~ 


3 


~ 


~ 


~ 


4 


- 




4i 


9 


« 


49 



a Continued Fever. 

Cases of Infectious Diseases under Treatment in Dublin 

Hospitals. 

During the week ended July 12, 1913, 2 cases of enteric 
fever were discharged from hospital, there was one death, and 
21 cases remained under treatment in hospital at the close of 
the week, the respective numbers in hospital at the close of 
the three preceding weeks having been 26, 31, and 24. 

Two cases of measles were discharged from hospital, and 6 
cases remained under treatment at the close of the week. At 



222 Sanitary and Meteorological Notes. 

the end of the 3 preceding weeks such cases were 11, 10, and 8 
respectively. 

Eighteen cases of scarlet fever wore admitted to hospital, 
22 were discharged, there were 4 deaths, and 76 cases remained 
under treatment at the close of the week. At the close of the 3 
preceding weeks the cases in hospital were 80, 81, and 84 
resjiectively. This number is exclusive of 22 patients under 
treatment at Beneavin, Glasnevin, the Convalescent Home of 
Cork Street Fever Hospital. 

Eight cases of cUphtheria were admitted to hospital, 2 were 
discharged, and there was one death. The cases in hospital, 
which at the close of the 3 preceding weeks numbered 37, 36, 
and 30, respectively, were 41 at the close of the week under 
review. 

In addition to the above-named diseases, 7 cases of pneu- 
monia were admitted to hospital, 5 were discharged, and 21 
cases remained under treatment at the end of the week. 

ENGLAND AND SCOTLAND. 
The mortality in the week ended Saturday. July 12, in 96 
large English towns (including London, in which the rate was 
11,1) was equal to an average annual death-rate of 11.4 }X)r 
1,000 persons living. The average rate for 16 principal towns 
of Scotland w<vs 13.6 |X)r 1,000, the rate for Glasgow Ijcing 14.1, 
and for Echnburgh 13.0. 

INFECTIOUS DISEASE IN EDINBURGH. 

The Registrar-General has l)een favoured by A. Maxwell 
Williamson, M.D., B.Sc, Medical Ofliccu- of Health for Edin- 
burgh, with a copy of his lieturn of Infectious Diseases 
notified during the week ended July 12. From this RoiK)rt it 
appears that of a total of 54 cases notified, 20 were of scarlet 
fever, 18 of phthisis, 8 of diphtheria, 6 of orysi]x^]as, and 2 of 
enteric fever. Among the 342 cases of infectious diseases in 
hospital at the close of the week were 134 ciises of scarlet- 
fever, 107 of pthisis, 35 of dii)hthoria, 20 of whooping-cough, 
16 of measles, 8 of enteric fever, 6 of erysipelas, 4 of chicken- 
pox, and one of puerperal fever. 



Sanitary and Meteorological Notes. 



223 



Vital Statistics 
For four weeks ending Saturday, August 9, 1913. 



IRELAND. 

The average annual death-rate represented by the deaths — 
exclusive of deaths of persons admitted into public institutions 
from without the respective districts — registered in the week 
ended August 9, 1913, in the Dublin Registration Area and 
the twenty-six principal provincial Urban Districts of Ireland 
was 15.5 per 1,000 of their aggregate population, which for the 
purposes of these returns is estimated at 1,199,180. The 
deaths registered in each of the four weeks of the period 
ending on Saturday, August 9, and during the whole of that 
period in certain of the districts, alphabetically arranged, 
correspond to the following annual rates per 1,000 : — 



County Boroughs, &c. 


Week ending 


Average 
Rate 
for 4 
weeks 


July 
19 


July 
26 


Aug. 
2 


Aug. 
9 


27 Town Districts 


15.2 


16.4 


16.6 


15.5 


15.9 


Dublin Reg. Area 


15.9 


15.1 


17.3 


17.9 


16.5 


Dublin City 


16.1 


16.2 


17.8 


19.6 


17.4 


Belfast 


15.8 


15.8 


15.9 


15.1 


15.7 


Cork 


13.6 


25.2 


25.8 


15.0 


19.9 


Londonderry 


14.0 


12.7 


19.1 


12.7 


14.6 


Limerick 


14.9 


19.0 


8.1 


9.5 


12.9 


Waterford 


24.7 


19.0 


22.8 


30.4 


24.2 



The deaths (excluding those of persons admitted into public 
institutions from without the respective districts) from certain 
epidemic diseases registered in the 27 districts during the week 
ended Saturday, August 9, 1913, were equal to an annual rate 



224 Sanitary and Meteorological Notes. 

of 2.8 per 1,000. Among the 115 deaths from all causes in 
Belfast were 1 from scarlet fever and 28 from diarrhoeal 
diseases. Included in the 22 deaths from all causes for Cork 
are 4 from diarrhoeal diseases. The 16 deaths from all causes 
for Waterford included 6 from measles and 2 from diarrhoeal 
diseases, and one of the 3 deaths from all causes recorded for 
Gal way was from whooping-cough. 

DUBLIN REGISTRATION AREA. 

The Dublin Registration Area consists of the Citv of Dublin, 
as extended by the Dublin Corporation Act, 1900, together 
with the Urban Districts of Rathmines, Pembroke. Blackrock 
and Kingstown. The population of tliis area is 403,000 ; 
that of the City being 308,187, Rathmines 38,769, Pembroke 
29,942, Blackrock 9,161, and Kingstown 16,941. 

In the Dublin Registration Area the births registered 
during the week ended August 9 amounted to 199 — 103 boys 
and 90 girls, and the deaths to 144 — 67 males and 77 females. 

DEATHS. 

The deaths registered, omitting the deaths (numbering 6) 
of persons admitted into pul)lic institutions from localities 
outside the Area, represent an annual rate of moitality of 
17.9 per 1,000 of the po])ulation. During the thirty-two 
weeks ended with Saturday, August 9, the death-rate 
averaged 20.6, and was 1.8 ])elow the mean rate for the cor- 
res])onding portions of the ten years, 1903-1912. 

The total deaths registered, numl)ering 144, represent an 
annual rate of 18.6 per 1,000. Tlie annual rate for the past 
thirty-two weeks was 22.0 per 1,000, and the average annual 
rate for the corresponding period of the past ten years was 
23.5 per 1,000 of the mean ])()]Uilati()n for all deaths registered. 

The deaths included 1 from measles, 2 from diphtheria, 
and 18 from diarrhoea and enteritis of children under 2 years. 
In each of the 3 preceding weeks deaths from measles had been 
0, 0, and 0; deaths from di])htheria had been I, 1, and ; 
and deaths from diarrlura and enteritis of children uiuler 2 
years had l)een 11, (>, and 11. The deaths from diarrha^a 
include one of a cliild under 2 years admitted to hospital from 
outside the city. 

Of 2() deaths from tuberculosis (all forms), 17 were attril)uted 



Sanitary and Meteorological Notes. 225 

to pulmonary tuberculosis, 4 to tubercular meningitis, one to 
abdominal tuberculosis, and 4 to disseminated tuberculosis. 
In each of the 3 preceding weeks, deaths from all forms of 
tuberculosis had been 21, 26, and 30. 

There were 11 deaths from cancer. 

The deaths of 5 infants were caused by convulsions. There 
was one death of an infant from premature birth, and there 
were 3 deaths from congenital debility. 

The deaths from pneumonia included 2 from broncho- 
pneumonia, 4 from lobar pneumonia, and 2 from pneumonia 
(type not distinguished). 

Twenty-two deaths were caused by organic diseases of the 
heart. There were 6 deaths from bronchitis. 

The deaths from accidental causes or negligence, 6 in number, 
included the death of one child between the ages of 2 years 
and 5 years from burns. There was one death by suicide. 

In two instances the cause of death was "uncertified," 
there having been no medical attendant during the last 
illness. These cases include the death of an infant under 
one year of age. 

Forty-one of the persons whose deaths were registered during 
the week were under 5 years of age (22 being infants under 
one year, of whom 3 were under one month old) and 29 were 
aged 65 years and upwards, including 21 persons aged 70 and 
upwards ; among the latter were 11 aged 75 and upwards. 

STATE OF INFECTIOUS DISEASE IN THE DUBLIN 
REGISTRATION AREA AND IN BELFAST. 

The usual returns of the number of cases of infectious 
diseases notified under the " Infectious Diseases (Notification) 
Act, 1889," and the " Tuberculosis Prevention (Ireland) Act,. 
1908," as set forth in the following table, have been furnished 
by Sir Charles A. Cameron, C.B., M.D., Medical Superintendent 
Officer of Health for the City of Dublin ; by Mr. Fawcett, 
Executive Sanitary Officer for Rathmines and Rathgar Urban 
District ; by Mr. Manly, Executive Sanitary Officer for 
Pembroke Urban District ; by Mr. Heron, Executive Sanitary 
Officer for Blackrock Urban District ; by the Executive 
Sanitary Officer for Kingstown Urban District ; and by 
Dr. Bailie, Medical Superintendent Officer of Health for the 
City of Belfast. 

P 



226 



Sanitary and Meteorological Notes. 



Table showing the NuMnKii of Casks of Infectious Diseasks notified in the Dubl 
Rej^istration Area (viz. — tlie ('ity of Dublin and the Urban Districts of Kathmim 
and Kathgar, Pembrolte, lilackrock, and Kingstown), and in the City of Belfas 
during the week ended August 9, 1913, and during eacli of the preceding tin- 
weeks. An asterisk (*) denotes that the disease in question is not notifiable in tl 
District. 



ClTIKS AMI) 

Ukhan Dihtuicts 


Weeli 
emliiiu 


en 
d 


1 — 

O en 

c 


V 

o 


"c. 


a 

'3 


.5 

'u 
- 


en 

h 

1^ 


•&= 

X c 

0) r 

u 
>• 


> 

f 'c 


J) 

'x 
>. 

u 


1 

3 

Oh 


6C 
3 
O 
u 

u 

c 

'5. 
o 
o 

if 


"3 


^3 

04 


ffl 

3 
O 

< 


C 


City of Dulilin ] 

Katliinines uml ( 
Ratli^nr | 
Urban | 
District [ 

Peinl)rol<e 
Urhaii ' 
DJHt.rict 

Blackrock | 
DiHlrict 

KingHtown [ 
Uri)an { 
DJHtrict 

nty of Helfast 


July 19 
July 2G 
Aug 2 
Auk. 9 

Julv 19 

July '2G 
Au>r. 2 
Aug. 9 

Julr 19 
July '26 
Auk- 2 
Aug. 9 

Julv 19 

July 2fi 
Au^'. 2 
Aug. 9 

July 19 
Julv 20 
Aug. 2 
Aug. 9 

July 19 
July 'if) 
Aug. 2 
Aug. 


- 


- 


12 

14 

6 

10 

1 
1 

1 

1 
1 

34 
2D 
34 

37 


8 
4 

1 


- 


6 
2 

4 

3 

1 

3 

1 
1 
1 

1 

1 

4 

3 

10 

5 


1 


1 


2 

7 
8 
5 

1 

1 

1 

2 
3 

2 


2 

I 
3 

5 

1 
1 

4 

6 
4 
3 


- 


4 
7 
3 


* 
• 
• 
• 

• 
• 
• 

« 

• 
• 

• 
• 
• 
* 


13 
22 
20 
11 

• 
• 
• 
• 

• 
• 
• 
• 

2 

1 
13 

n 

2 




4 

4 
3 

4{ 

f): 



a Continued Fever * 

b Not including one case of cercbro-spinal meningitis. 



Cases of Infectious Diseases under Treatment in Dublin 

Hospitals. 

During the week ended August 0, 1013, 6 cases of enteric 
fever were admitted to hospital, 3 were discliarged, and 45 
cases remained under treatment in hospital at the close of the 
week, the respective numbers in hospital at the close of the 
three preceding weeks having been 25, 34, and 42. 

Ten cases of typhus remained under treatment in hospital 
at the close of the week. At the close of the 3 ])revious weeks 
the cases in hos])ital had been 8, 11, and 10 res])ectivcly. 

Two cases of measles were admitted to hospital, one was 



Sanitary and Meteorological Notes. 227 

discharged, and 3 cases remained under treatment at the close 
of the week. At the end of the 3 preceding weeks such cases 
were 5, 1, and 2 respectively. 

Thirteen cases of scarlet fever were admitted to hospital, 
14 were discharged, and 65 cases remained under treatment 
at the close of the week. This number is exclusive of 21 
patients under treatment at Beneavin, Glasnevin, the Convales- 
cent Home of Cork Street Fever Hospital. At the close of 
the 3 preceding weeks the cases in hospital had been 76, 76, 
and 66. 

Four cases of diphtheria were admitted to hospital, 9 were 
discharged, and there was one death. The cases in hospital, 
which at the close of the 3 preceding weeks had numbered 35, 
31, and 32 respectively, were 26 at the close of the week under 
review. 

In addition to the above-named diseases, 8 cases of 
pneumonia were admitted to hospital, 4 were discharged, there 
were 2 deaths, and 19 cases remained under treatment at the 
end of the week. 

ENGLAND AND SCOTLAND. 
The mortality in the week ended Saturday, August 9, in 
96 large English towns (including London, in which the rate 
was 11.4) was equal to an average annual death-rate of 12.0 
per 1,000 persons living. The average rate for 16 princii)al 
towns of Scotland was 14.1 per 1,000, the rate for Glasgow 
being 14.7, and that for Edinburgh, 12.7. 

INFECTIOUS DISEASE IN EDINBURGH. 

The Registrar-General has been favoured hy A. Maxwell 
Williamson, M.D., B.Sc, Medical Officer of Health for Edin- 
burgh, with a copy of his Return of Infectious Diseases 
notified during the week ended August 9. From this Report it 
appears that of a total of 50 cases notified, 19 were of scarlet 
fever, 14 of phthisis, 11 of diphtheria, 4 of erysipelas, 1 of 
enteric fever, and 1 of puerperal fever. Among the 338 
cases of infectious diseases in hospital at the close of the week 
were 137 cases of scarlet fever, 96 of phthisis, 38 of diphtheria, 
34 of measles, 11 of whooping-cough, 7 of enteric fever, 5 of 
erysipelas, and 1 of chicken-pox. 



30.120 


inches 


30.423 


>> 


20.858 


>» 


58.5°. 




55.3°. 




52.4°. 




.397 


inch. 



228 Sanitary and Meteorological Notes. 

Meteorology. 

Abstract oj Observations made in the City of Dubliji, Lat. 53° 20' 
N., Long. G° 15' W., for the Month oJ July, 1913. 

Moan Height of Barometer, - 

Maximal Height of Barometer (2n(l, at 9 a.m.). 

Minimal Height of Barometer (Gth, at 9 a.m.). 

Mean Dry-bulb Temperature, - - - 

Mean Wet-bulb Temix)raturo, 

Mean Dew-point Temperature, 

Mean Elastic Force (Tension) of Aqueoiis Vapour, 

Mean Humidity, . . _ . go 5 per cent. 

Highest Temperature in Shade (on 2nd), - 72.0°. 

Lowest Temperature in Shade (on 8th), - 44.1°. 

Lowest Temperature on Grass (Radiation) (8th), 41 .8°. 

Mean Amount of Cloud, - - - 02.4 per cent. 

Rainfall (on 13 days), - - - .034 inch. 

Greatest Daily Rainfall (on 18th), - - .100 ,, 

General Directions of Wind, - - - N., N.E., N.W. 

Remarks. 

A generally fine, uneventful month, of clouded skies, hazy 
iitmosphere, scanty rainfall, and remarkably "jx^rsistent 
northerly winds. The mean temperature was 1.3° l)elow the 
average, the mean diurnal range, which was sn>all for July, lx>ing 
only 12.0° — that is, from 52.9° (the mean mininnim) to 05.5° 
(the mean maximum). The former value was 1.3" Ik'Iow the 
average (54.2°), the latter was also an equal amount Inflow the 
average (00.8°), and so it came to pass that the mean iem- 
perature of the month was 1.3° ])elow the average. The fore- 
going remarks a])])ly es]x^cially to Dublin. S]>eaking more 
generally, the weather in Ireland was much liner than that 
ex]X)rienccd in Great Britain, and particularly along the 
cast coast of England. The last-named region was swept by 
a very destructive polar gale on the night of Tuesday, the 
22nd, and the forenoon of Wednesday, the 23rd. At AlK>rdeen 
a s(|uall from N.W. blow with a velocity of 47 miles an hour 
at 11 p.m. of the 22nd ; at S])urn Head, the wind reached a 
like velocity at a.m. of the 23rd. The storm was connect<>d 
with the ra])i(l movement of an atmospheric <leprcssion from 



Sanitary and Meteorological Notes. 229 

the south of Sweden to Holland ; at 7 a.m. of the 23rd the 
barometer fell to 29.62 inches at the Helder, whereas it stood 
as high as 30.31 inches at Malin Head, Donegal, and 30.37 
inches at Stornoway (Hebrides). The prevailing northerly 
winds of the month were determined by a persistent high 
pressure system (anticyclone) over the Atlantic between 
Iceland and the British Isles, while atmospheric pressure was 
relatively low and conditions cyclonic in Scandinavia and over 
Central Europe. 

A notable feature in the month also was a spell of tropica] 
heat felt at Haparanda, on the Gulf of Bothnia (lat. 65° 58' N.), 
from the 10th to the 18th, the thermometer rising to 86° at 
that Arctic Circle station on the 17th. Another noteworthy 
point was the showery, dull character of the middle fortnight 
of the month. This spell was followed by uninterrujDted dry 
weather from the 22nd to the close. 

In Dublin the arithmetical mean t-emperature (59.2°) was 
1.3° below the average of the 35 years 1871-1905 (60.5°) ; 
the mean dry-bulb readings at 9 a.m. and 9 p.m. were 58.5°. 
In the fortj^-nine years ending with 1913, July was coldest in 
1879 (" the cold year ") (M. T. = 57.2°). It was warmest in 
1905 (M. T. = 63.8°) ; and in 1887 (M. T. = 63.7°). In 1912 
the M-. T. was 58.9° ; in 1911 it was 63.5°. 

The mean height of the barometer was 30.120 inches, or 
0.205 inch above the corrected average value for July — 
namely, 29.915 inches. The mercury rose to 30.423 inches at 
9 a.m. of the 2nd, and fell to 29.858 inches at 9 a.m. of the 6th. 
The observed range of atmospheric pressure was, therefore, 
0.565 inch. 

The mean temperature deduced from daily readings of the 
dry-bulb thermometer at 9 a.m. and 9 p.m. was 58.5°, or 1.9° 
above the value for June, 1913. Using the formula Mean 
Temp. = Min. + {Max. — 3Iin.) x .465, the value was 58.8°, 
or 1.3° below the average mean temperature for July, calcu- 
lated in the same way, in thf> thirty-five years, 1871-1905 
inclusive (60.1°). The aiithmetical mean of the maximal and 
minimal readings was 59.2°, compared with a thirty-five years' 
average of 60.5°. On the 2nd the thermometer in the screen 
rose to 72.0° — wind, N. ; on the 8th the screened thermometer 
fell to 44.1° — wind, N., N.W. The minimum on the grass 
was 41.3°, -^Iso on the 8th. 



230 Sanitary and Meteorological Notes. 

Tho rainfall wiis .634 inch, distributed over 13 daj's. The 
average rainfall for July in the thirty-five years 1871-1905, in- 
clusive, was 2.080 inches, and the average number of rain-days 
was 17. The rainfall, therefore, was less than one-fourth of the 
average, whereas the rain-days were only 4 below the average. 
In 1880 the rainfall in July was very large — G.087 inches on 
24 days ; in 1890, also, 5.474 inches fell on 18 days. On the 
other hand, in 1870, only .539 inch was measured on 8 days ; 
in 1809 th(^ fall wius only .739 inch on 9 days ; and in 1808 
.741 inch fell on Init five days. In 1911, 2.994 inches fell on 
14 days, and in 1912, 3.055 inches on 17 da^'S. 

No high winds were noted in Dublin. T^Mn]x>rature reached 
or exceeded 70° in tho screen on only 5 days, comi)ared with 
4 days in 1912, 21 days in 1911, 4 days in 1910, 3 days in 1<)09, 
9 days in 1908 and 1907, 10 in 190(), 17 in 1905, and 10 in 1904. 
Tho thermometer never failed to reach 60°. In 1888 the 
maximum for July was only 68.7°. 

A thunderstorm occurred on the afternoon of the 14th. 
Solar halos wore seen on the 8th and 23rd. There was marked 
visil)ility on the morning of the 12th, following by a fog in the 
evening. From tho 24th the atmosphere was very hazy. 

The rainfall in Dublin during the seven months ending July 
31st amounted to 15.731 inches on 117 days, com])ared with 
10.811 inches on 127 days in 1912, 10.723 inches on 94 days in 
1911, 21.032 inches on 127 days in 1910, 15.377 inches on 
106 days in 1909, 13.809 inches on 120 days in 1908, 14.358 
inches on 127 days in 1907, 13.664 inches on 122 days in 1906, 
11.022 inches on 109 days in 1905, 13.905 inches on 117 dayp 
in 1904, 19.072 iiu^hes on 131 days in 1903. 15.507 inches on 
115 days in 1902, 11.432 inches on 93 days in 1901, only 
7.935 inches on 80 days in 1887, and a thirty-five years' 
(1871-1905) average of 14.710 inches on 113 days. 

At the Normal Climatological Station in Trinit\ College, 
Dublin, the o])Herver, Mr. 0. D. Clark, re])orts that the mean 
valueof the readin!ji;H()f the dry-bulb thermometerat 9 a.m. and 

9 i).m. was 59.0\ The arithmetical nu'an of the daily maxinuil 
and minimal temperatures was also 59.0°, the mean maximum 
being 65.9°, and the mean mininnim 52.0°. The screened ther- 
nu)meters rose to 74.0° on the 23rd, and fell to 43.2° on the 
Sth. On the 8th the grass minimum was 38.0°. Kain fell on 

10 days to the amount of .596 hich, the greatest fall in 24 hours 



Sanitary and Meteorological Notes. 231 

being .143 inch on the 18th. The duration of bright sunshine, 
according to the Campbell-Stokes recorder, was 150.2 hours, 
of which 13.5 hours occurred on the 1st. The mean daily 
duration was 4.9 hours. In July, 1904, there w^ere 201 hours 
of bright sunshine ; in 1905, 162.2 hours ; in 1906, 184.8 hours ; 
in 1907, 178.1 hours; in 1908, 174.3 hours; in 1909, 139.8 
hours ; in 1910, 205.0 hours ; in 1911, 221.8 hours ; and in 
1912, 153.0 hours. The mean sub-soil temperatures at 9 a.m. 
were— at 1 ft., 60.6° ; at 4 ft., 56.8°. 



Captain Edward Taylor, D.L., recorded a rainfall of 1.16 
inches on 10 days at Ardgillan, Balbriggan, Co. Dublin. This 
measurement was 1.55 inches below the average, and the rain- 
days were 5 in defect. The largest rainfall in 24 hours w^as 
.41 inch on the 21st. The July rainfall at Ardgillan in recent 
years has ranged from 7.03 inches in 1895 to 0.52 inch in 1898. 
Since January 1, 1913, 16.58 inches of rain have fallen at 
Ardgillan on 113 days, the precipitation being 1.33 inches 
over the average and the rain-days 6 in excess. The shade 
temperature in July ranged from 68.9° on the 1st and 23rd 
to 40.8° on the 8th. 

Mr. T. Bateman reports that the rainfall at The Green, 
Malahide, Co. Dublin, was .92 inch on 11 days. The largest 
daily fall w^as .47 inch on the 14th. The mean shade tem- 
perature was 55.6°, the extremes being — highest, 69° on the 
2nd ; lowest, 40° on the 7th. 

At the Ordnance Survey Office, Phoenix Park, rain fell on 

13 days to the amount of .800 inch, the greatest rainfall in 
the 24 hours being .200 inch on the 8th. The total duration 
of bright sunshine was 151.5 hours, the greatest daily sunshine 
being 15.0 hours on the 1st. The thermometer rose to 74.1° 
in the screen on the 1st, having fallen to 35.2° on the 8th, 
when the grass minimum was 28.0°. 

Miss C. Violet Kirkpatrick reports a rainfall of .75 inch on 

14 days at Cheeverstown Convalescent Home, Clondalkhi, Co. 
Dublin. The heaviest fall in 24 hours wus .23 inch on the 18th. 

The rainfall recorded by Mr. George B. Edmondson at Manor 
Mill Lodge, Dundrum, was .68 inch on 12 days. Of this 
quantity, .14 inch fell on the 18th. The mean temperature 
w^as 59.6°, the thermometer rising to 77° on the 23rd, and 
falling to 45° on the 7th and 8th. 



232 Sanitary and Meteorological Notes. 

At Marino, Killiney, Co. Dublin, Mr. W. J. MCabe, observer 
for the Right Hon. Laurence Waklron, registered a rainfall of 
.99 inch on 13 days. The heaviest fall in 24 hours was .30 inch 
in the thunderstorm of the 14th. The average rainfall in July 
in the twenty -four years, 1885-1908, at Killiney (Cloneevm) 
was 2.408 inches on 15 days. 

Dr. John H. M. Armstrong, M.B., reports that the rainfall 
at Coolagad, Greystones, Co. Wicklow, was .03 inch on 11 
days, the maximal daily fall being .31 inch on the 14th. Since 
January 1, 1913, the rainfall at that station equals 23.27 
inches on ] 20 days. A thunderstorm occurretl from 5 35 to 
6 45 ]).m. of the 14th. At 6 30 a.m. ot the 12th a panoramic 
view of the Welsh Hills was seen from Coolagad. Lunar halos 
appeared on the nights of the 20th and 21st. 

Mrs. Sydney O'Sullivan returns the rainfall at Aubiu-n, 
Greystones, as .76 inch on 13 days, the maximal measurement 
in 24 hours being .36 inch in a thunderstorm on the 14th. 

At the Royal National Hospital for Consum])tion for 
Ireland, Newcastle, Co. Wicklow, Dr. Charles D. Hanan, M.D., 
Resident Medical Superintendent, reports a rainfall of only 
.33 inch on 8 days, the greatest daily rainfall being .09 inch 
on the 14th, and again on the 20th. The screened thermometers 
rose to 72° on the 23rd, and fell to 42° on the 8th. The mean 
maximum tem])crature was 63.9°, the mean minimum was 
51. 2"^ aiul the mean temperature 57.6°. 

At the Rectory, Dun man way, Co. Cork, the Rev. Arthur 
Wilson, M,A., recorded a rainfall of only ,31 inch on 6 days. 
The only wet day was Tuesday, the 8th, when .23 inch fell. 
The rainfall was 3.04 inches less than the average for July in 
the past eight years. The weather was es])ecially warm on 
the 1st and 2nd. and from the 11th to the eiul of the month. 
It was cool fiom the 3rd to the lOtli. The rainfall at Dun- 
manway for the 7 c()ni])!etod months of 1913 amounts to 
39.63 inches, compared with an average of 30.41 inches. It 
was, therefore, 9.22 inc^hes in excess. From June 23rd to 
August 4th the rainfall at Dunnumway was only .33 inch. 



PERISCOPE. 

ERGOT AND ITS PREPARATIONS. 

Since the last revision of the British Pharmacopoeia in 
1898 our knowledge of the chemistry and pharmacology of 
ergot has been advanced to so great an extent that it is now 
possible to devise processes for the official ergot prepara- 
tions based upon the known properties of the active ingre- 
dients instead of adhering to the empirical methods which 
were necessarily adopted at the time of the previous re- 
vision. 

In a paper by Carr and Dale, read before the British 
Pharmaceutical Conference on July 23rd it was shown 
that the properties of the most important active sub- 
stance in ergot — namely, the alkaloid ergotoxine — are such 
that the usual methods employed for making extracts of 
ergot tend to exclude rather than to include it — an explana- 
tion is thus given of the uncertainty with which these pre- 
parations are regarded by some members of the profession. 
The authors further recommend processes by which phar- 
macopoeial preparations of high activity may be made. The 
chief active principles of ergot are ergotoxine, p-hydroxy- 
phenylethylamine (" tyramine ") and ^-iminazolylethy- 
lamine (" ergamine "), all of which can now be obtained 
in pure crystalline condition. The alkaloid ergotoxine is 
the essential active principle of ergot, and is capable by 
itself of producing the true therapeutic effect of ergot. The 
amines, ** tyramine " and *' ergamine," have also an im- 
portant stimulant action upon the muscular wall of the 
human uterus, and their presence in ergot extracts is a 
useful adjuvant to the action of the ergotoxine. 

To the latter, however, greatest importance is attached. 
Although the amines are readily extracted by water, and so 
are present in extracts and infusions, ergotoxine has proper- 
ties exceptional in an alkaloid, whereby it is very apt to be 
left unextracted or to be precipitated from solutions. Its 
salts are very little soluble in water, though they may form 
colloidal solutions, from which they are thrown down by 



234 Periscope. 

strongly ionised acids or their salts. Ergotoxine is unstable 
in the presence of alkalis, while heating with strong alcohol 
converts it to inert ergotinine. 

With a knowledge of these properties the reader will easily 
understand what the authors have actually found to be the 
case — namely, that as made under pharmacopcxMal directions 
both the extractum ergotae (ergotin) and extractum ergotae 
liquidum possess but an insignificant proportion of the 
activity of the ergot, for in the fonner instance the alkaloid 
extracted initially by alcohol is precipitated, firstly, by the 
removal of the alcohol during evaporation, and, secondly, by 
the addition of hydrochloric acid; such addition would pre- 
cipitate ergotoxine from pure solutions, but in this instance 
the process is facilitated by the absorbent action of the resins 
also thrown down ; while in the latter instance the liquid ex- 
tract, which is made with water, contains only a very small 
proportion of the sparingly soluble ergotoxine, the amount 
so dissolved being slightly greater in the case of a particu- 
larly acid ergot or if fermentative changes set in during the 
process. These extracts are rich in amines, and to such 
they chiefly owe what activity they possess, which, how- 
ever, does not in any way represent the true clinical value 
of the drug. 

On similar grounds the infusum ergotae is criticised, 
while the instability of the ammoniated tincture is accounted 
for by the action of the added alkali. The authors 
propose a revision of that section of the British Phanna- 
copcL'ia relating to ergot, and indicate the following 
changes: — 1. The present extractum ergotae to be aban- 
doned, and, if necessary, a soft total extract made with 60 
I)er cent, alcohol acidified with citric acid, substituted for 
it. 2. The fluid extract of the United States Pharmacopcpia, 
made with 49 per cent, alcohol, containing 2 per cent, of 
acetic acid, should take the place of extractum ergotie 
li(jnidum. 3. The injectio ergotae to be abandoned and suit- 
a})le salts of ergotoxine, either alone or combined witli the 
active amines, ergamine and tyramine, to be em])loyed in 
place of it. 4. The adoption of a liquid extract such as that 
described would render the tincture imnecessary, but such, 
if retained, should be made by percolation with 60 per cent, 
alcohol without ammonia. 

Another [)oint of interest is that it has been shown by 



Periscope. 235 

testing ergots of other grasses, such as that of wheat and of 
a wild grass from New Zealand, called Festuca arundi- 
nacea, that they possess even more activity than ergot of rye, 
ergot of festuca being found approximately three times as 
active as good rye, and ergot of wheat slightly more active 
than the latter. The authors suggest that if an acceptable 
method of testing ergot can be found such ergots should 
receive official sanction. 



PHYSIOLOGICAL CRITERIA FOR MEDICINAL SUBSTANCES. 

The testing of medicines constitutes one of the most im- 
portant and practical branches of modern scientific research 
work, and deserves even more attention than has hitherto 
been accorded to it. It is a task which has been shown by 
experience to pass outside the self-imposed limits of ordinary 
analytical chemistry, and it is, therefore, especially interest- 
ing to note the contributions which have been made, during 
recent years to this branch of study, by specialists in 
physiology and bacteriology. The pamphlet recently issued 
by the Wellcome Physiological Eesearch Laboratories under 
the above title admirably epitomises current practice, and 
gives some extremely interesting reports, illustrating the 
progress made towards the ideal of precise physiological 
standardisation of potent medicines. In choosing a physio- 
logical test, the method pursued at the Laboratories has 
been to select one definitely related to the therapeutic effect 
of the drug, or, when the active principle is known, to use 
that one of its actions which produces an easily measurable 
effect. A rise of blood-pressure, or the minimal lethal dose 
for animals of uniform weight, are examples of data sus- 
ceptible of accurate measurement, and, therefore, suitable 
for establishing an exact system of dosage. The application 
of the lethal dose method to the digitalis series is described 
in some detail. 

The testing of tincture of digitalis is carried out by 
means of the common English frog (Rana temporaria), 
the heart of a medium-sized specimen coming to a 
complete systolic standstill within three hours, when the 
frog is injected with a dose of 0.0075 c.c. of the standard 
tincture per gramme of body weight. Theoretically equiva- 
lent specimens of tincture and other preparations of digitalis 



236 Periscope. 

as ordinarily purchased on the market, have been found to 
vary in activity in the proportion of 1 to 4, when tested by 
this method, and the extreme importance of maintaining a 
physiological standard in regard to so potent a drug is, 
therefore, obvious. The frogs used should be freshly caught; 
healthy males of about 25 grammes, during the months of 
July and September, give the most uniform results. The 
curious fact is noted that the toad — which Shakespeare 
described as " ugly and venomous " — possesses a secretion 
of the skin, digitalis-like in its action. Being remarkably 
resistant to the drugs of this series, toads are unsuitable for 
testing the activity of digitalis. Some interesting tables 
showing the results of doses of the tincture of digitalis, 
squill, and strophanthus upon frogs of known weight, are 
given, and the method of determinging an average minimal 
lethal dose is indicated. 

Cannabis indica being a drug of very variable activity, 
of which the active principle, although known, does not lend 
itself to chemical methods of standardisation, has furnished 
another field for physiological research. 

The various methods which have been suggested for 
standardising preparations of the supra-renal gland arc 
next discussed. Adrenine is a notoriously unstable sub- 
stance, and neither the optical rotation test nor the chemical 
estimation methods hitherto devised have proved suitable 
for routine standardising purposes. It has remained for the 
physiologist to devise a test, and this has been done by 
measuring the rise of arterial blood-pressure produced upon 
an animal organism as the result of an intravenous injec- 
tion. Pithed cats under artificial respiration are utilised 
for this purpose, and the method, as stated by an observer, 
is found to be capable of the mechanical accuracy of a 
chemical balance. Some instructive diagrams illustratiiig 
this part of the subject are given. A noteworthy example 
of the fruitful alliance between chemical aiid ])hysiological 
methods in the examination of medicinal substances is to be 
seen in the production of " Epinin(\" which was the out- 
come of independent investigations at the Wellcome 
Chemical Research Tiaboratories, Owing to its synthetic 
origin and the fact that its salts are readily crystallisable, this 
substance can be prepared in a state of uniform purity which 
precludes the necessity for the constant repetition of physio- 



Periscope. 237 

logical tests. In its therapeutic effects it closely resembles 
the supra-renal active principles. 

Pituitary (infundibular) extract, which has attained in 
recent years a wide therapeutic importance, is a preparation, 
the chemistry of which is by no means in so advanced a 
state, and here the need for exact physiological criteria is 
specially apparent. Such data are obtained at the Wellcome 
Physiological Research Laboratories by measuring the action 
of a batch of pituitary extract upon the isolated uterus of a 
virgin guinea-pig suspended in warm oxygenated Einger's 
solution — a method which excludes the errors due to toler- 
ance of successive doses in animals. 

The remainder of the book is devoted to the elucidation 
of the complex, but deeply interesting, problems connected 
with ergot and its standardisation. 

** Physiological Criteria " should be read by all who desire 
to obtain an insight into modern methods of the physio- 
logical control of drugs, and it abundantly demonstrates not 
only the importance of this work but also the thorough and 
scientific manner in which it is being carried out at the 
Wellcome Physiological Research Laboratories. 



EXHIBIT AT THE INTERNATIONAL CONGRESS OF MEDICINE. 

The firm of Messrs. Burroughs, "Wellcome & Co., took the 
whole of the large vestibule of the University of London Im- 
perial Institute, South Kensington, for its series of exhibits, 
of which there were five in all. A comprehensive picture of 
the firm's varied activities is thus presented, the objects 
being clasified as follows: — (1) Pharmaceutical prepara- 
tions and fine chemicals; (2) Medical equipments and first- 
aid; (3) Surgical appliances and instruments; (4) Physio- 
logical section ; (5) Materia Medica farm exhibit. 

On the left, the first of these sections contained the chemical 
and pharmaceutical exhibit comprising many specimens of the 
" Wellcome " chemicals and of ** Tabloid " products. Some 
of these are specially interesting as being the outcome of the 
chemical research work undertaken by the firm. Of these, 
" Nizin," a zinc salt of sulphanilic acid, and " Soamin," 
one of the arylarsomates, are examples. The extreme purity 
attained in the chemicals issued under the ** Wellcome " 
brand has rendered them specially serviceable for scientific. 



238 Periscope. 

therapeutic, and diagnostic use; thus "Wellcome" bis- 
muth carbonate, owing to its freedom from load, is used in 
examination by x-rays of the conditions of the stomach and 
oesophagus and for other purposes where large doses are 
necessary. 

On the right, another section was devoted to " Tabloid " 
medical equipments and cases. The compact and service- 
able equipments for physicians and surgeons, here dis- 
played, are adapted for the needs of everyday practice 
at home as well as for the exigencies of travel and ex- 
ploration in distant lands. In addition there are equip- 
ments for special purposes, such as the " Soloid " water 
analysis case, the bacteriological case, and cases for blood- 
testing, urine-testing, &c. In this exhibit there were also 
shown some very interesting x-ray photographs, the nega- 
tives of which were developed with " Eytol." That of a 
hand showing injury to the lower epithesis of the ulna is 
very striking. 

In the surgical appliances group, besides many ex- 
cellent hypodermic and ophthalmic syringes and cases, 
including the new Burroughs, Wellcome & Co. tuberculin 
syringe, there are the pleated and compressed dressings 
originated by this firm and well adapted for every surgical 
requirement. A noteworthy example is the " Tabloid " 
adjustable head dressing. 'The easy and rapid, method of 
fixing this bandage, which is made in two sizes, was shown 
on a model head. With the " Tabloid " dressings were 
shown the " Tabloid " antiseptic products with which accu- 
rate solutions of definite strength can be readily prepared. 

In the pathological section, occu])ying a space in the fur- 
ther corner on the left-hand side of the hall, many interest- 
ing specimens were shown of ])roducts and ])r<>cesses with 
])hysiological standardisation. Kymographic tracings, illus- 
trating the action of " Epinine," " Ernutine," and " In- 
fundin " on living organisms, were also exhibited. Two 
such tracings show very clearly the difference in effect 
between g(K)d and bad s])ecimens of pituitary extract. 

Spatial fornuila models constructed of variously coloured 
wooden balls connected by wires serve to demonstrate, in 
a very instructive fashion, the chemical composition of such 
organic substances as " Tyramine," " Ejjinine," " Erga- 
niin(\" kc. The " Wellcome " serums, vaccines, and 



New 'Preparations and Scientific Inventions. 239 

tuberculins shown in this part of the exhibit included the 
concentrated diphtheria antitoxin " Wellcome," and the 
tuberculin (W.) Vases demonstrating the great difference 
in bulk of equivalent doses of the Diphtheria Antitoxin 
Serum and the " Wellcome " Concentrated Diphtheria 
Antitoxin were shown. It is to be noted that all the tuber- 
culins issued by Burroughs Wellcome & Co. are made in 
England, being prepared at the Wellcome Physiological 
Research Laboratories at Heme Hill. 

The remaining portion of the exhibit was rendered ex- 
tremely attractive by the fine collection of medicinal plants 
and herbs. They are specimens from the ** Wellcome " 
Materia Medica Farm at Dartford, where a wide range of 
medicinal herbs, both for experimental and manufacturing 
purposes, is now grown. The " Wellcome " Galenical 
Preparations, such as the granular green extract of Bella- 
donna and the standardised concentrated tincture of 
digitalis, were on view on this stand, side by side with 
specimens of the plants from which they are prepared. 



NEW PREPARATIONS AND SCIENTIFIC INVENTIONS. 

Tablets Helmitol Co. (Bayer). . ' 

Tablets ** Helmitol " Co. (Bayer) contain equal parts 
(^ gramme or 7| grains) of helmitol and acid sodium phos- 
phate, and have been introduced at the express request of 
a number of medical men in whose experience the addition 
of the acid phosphate is advisable in certain conditions asso- 
ciated with pronounced alkalinity of the urine. Especial 
importance has been attached to the use of the compound 
in Bacillus coli infections. Helmitol is a salt built up of 
hexamethylenetetramine, formaldehyde, and citric acid, 
while acid sodium phosphate, as is generally known, is the 
natural acidifying agent of the urine. In a discussion at a 
recent meeting of the Therapeutic Section of the Royal 
Society of Medicine, it was pointed out that, especially in 
Bacillus coli cases and in gonorrhoea, the value of helmitol 
is materially enhanced by the addition to each dose of a 
suitable proportion of acid sodium phosphate. This pro- 
nouncement, following previous suggestions of a similar 
nature, has led to the introduction of these tablets. Further 



240 New Preparations and Scientific Inventions. 

support is found in an article entitled: "Modem Urinary 
Surgery," in The P>ractitioner, April, 1913, in which the 
addition of the phosphate is said to accentuate the bacteri- 
cidal effect. Of helinitol itself the following definite state- 
ments may be made in comparison with hexamethylene- 
tetramine, from which it differs considerably in com- 
position : — 1. It liberates more fonnaldehyde, bulk for bulk, 
and hence is a more powerful antiseptic. 2. Less of the 
drug is eliminated unchanged, and its action is accordingly 
more intensive. 3. It is much more palatable, and much 
less likely to irritate the stomach or interfere with digestion. 
It should be added that helmitol itself, since it is active 
either in an acid or an alkaline medium, may be employed in 
conditions in which an alkaline urine is desired. Accord- 
ingly it is therapeutically compatible with remote alkalies, 
such as potassium citrate or acetate. A formula of this type 
was, in fact, recently ])ublished {TJie Lancet, 18th May, 
1912), containing in each dose : helmitol gr. 5 and potas- 
sium citrate gr. 20. The dose is 2 to 3 tablets dissolved in 
plenty of cold water three times a day, and the tablets are 
dispensed in original tubes of 20. 

Tahlctfi of Synthetic Hyclrastininc Ilydrochloridc (Bayer). 

This pre])aration is of great interest, as the synthesis of the 
complicated alkaloid is looked upon as a chemical achieve- 
ment. The synthetic alkaloid has been found to be in every 
way identical with that obtained by oxidation from the 
hydrastine of the rhizome. The tablets have the advantage 
over the ordinary galenical preparations of hydrastis of 
definite comjx)sition. It is also now recognised that hydras- 
tinine has advantages over hydrastine in that its styptic 
action is more jKiwerful and lasting, it is less depressing to 
the heart, and it does not cause tetanic spasms. The 
tablets, which are silver-coated and packed in tubes of 15, 
are of special service in checking hoBinorrhages and dis- 
charges. The dose is one tablet swallowed with a draught 
of wat(>r three or four times a day. 



THE DUBLIN JOURNAL 

OF 

MEDICAL SCIENCE. 



OCTOBEK 1, 1913. 

PART I. 
ORIGINAL COMMUNICATIONS 



Art. XL — Some Scattered Remarks on Stomach Cases. '^ 
By T. GiLLMAN MooRHEAD, M.D., F.R.C.P.I., Physician 
to the Royal City of Dublin Hospital. 

In selecting a subject for a communication to the Club 
this year I thought it likely that a short paper dealing 
with some of the commonplaces of medical work in 
connection with the diagnosis and treatment of diseases 
of the alimentary tract would be more likely to give rise 
to discussion than a more elaborate paper on a single case 
or on any more defined subject. For the very common- 
place nature of the various points touched on I will make 
no apology, as the very object of the communication is 
to deal with ordinary every day matters. 

The first point I wish to make a few remarks about 
concerns the presence or absence of hydrochloric acid in 
the gastric contents, and I wish, in the first place, to 
emphasise a fact which is no doubt wideh?" known, but 
which is often I think forgotten — namely, that the actual 
findings in material that has been vomited is in this respect 

* A Paper read before the Dublin Biological Club, 1913. 
VOL. CXXXVI. — NO. 502, TIIIKI) SKKIES. Q 



^42 Some Scattered Remarks on Stomach Cases. 

of no diagnostic value. It has frequently occurred to me to 
be told that vomited material contained no HC'l and to find 
that its absence has given rise to alarming suspicions, but 
my own experience is that HOI is almost invariably absent 
in the vomit in cases of acute dyspep^^ia and also in the 
vomited material in many chronic disorders ot the stomacli, 
although subsequently it is found to be present in a test 
meal washed out in the usual way. Frequently enough 
vomited material is intensely acid to litmus paper, but 
as a rule the acidity will be found to be due to the presence 
of organic acids which may and often do occur under such 
circumstances in large quantity. The explanation is, of 
course, obvious. In diseases — especially acute ones — that 
give rise to vomiting the gastric secretion is presumably 
inhibited, abnormal fermentation takes place and hence 
the absence of HCl and the presence of organic acids. 

The second point to which I wish to allude is the 
impossibility of relying on a single negative result in the 
estimation of HCl, or even on a series of negative results 
unless the evacuation of the stomach is carried out at 
varying periods after the administration of a test meal. 
When an examination for HCl in a case of gastric cancer 
is only to be looked on as an artistic finish to a case 
already complete as far as diagnosis is concerned, a single 
examination will no doubt suffice, and may afford infor- 
mation which will round off a clinical lecture ; but in the 
dou})tful case, when early diagnosis is all important, the 
care I indicate is to my mind al)solutely essential. The 
case that originally impressed this fact most forcibly on 
my mind some years ago was that of a lady, aged fifty, 
who came to me suffering from pain in the stomach, 
flatulence, vomiting and loss of weight. She looked ill, 
was somewhat an.Tmic, and on examination I found the 
stomach extending well below the umbilicus, but was 
una))le to detect any tumour. A test meal of the usual 
Kwald type removed an hour after taking showed no 
HCl, and the same meal re])eated on three subsequc^nt 
occasiojis also gave a negative result. I was still, however, 



By Br. T. G. Moorhea6. U^ 

not satisfied, and in consequence gave another test meal, 
but by accident was late in arriving to wash it out, and, 
in consequence, the meal was not removed till over two 
hours after administration. To my surprise on this 
occasion I found HCl present in considerable quantity, 
and on repeating the observation subsequently, again 
found HCl present. Possibly with my present experience 
I would immediately now recogniss such a case as one of 
pure gastric neurosis, for the almost complete recovery 
of the patient proved it to be this in the case in question, 
but I am still of opinion that it is this type of case that 
is likely to give rise to difficulty and anxiety if one desires 
to recognise carcinoma at the earliest possible moment. 
I have since then seen several similar cases, and have 
satisfied myself of the importance of examining gastric 
contents at a variable time after administration of the meal. 
The last point I wish to mention in reference to HCl 
is the fact that its presence in diminished or increased 
quantity is no definite guide to the administration of 
acids or alkalies respectively. This is no doubt a truism, 
and will especially be accepted by the older therapeutists, 
but in scientific days it is a truism that is likely to be 
neglected. I more especially call attention to the fact 
owing to the occasional appearance of papers in which 
the various gastric disorders are classified in accordance 
with the analysis of test meals and the appropriate 
remedy for each disorder is indicated in much the same 
way as one would work if the body were a test tube. No 
doubt in some cases treatment along definite chemical 
lines is useful, and in hypochlorhydria tonics and acids 
are most frequently beneficial, but it must not be forgotten 
that it is in these cases that alkalies administered some 
time after a meal are most symptomatically useful by 
neutralising the organic acids to which abnormal fermen- 
tation, permitted perhaps by the hypochlorhydria, 
has given rise. In hyperacidity due to excessive HCl I 
personally find that the removal of the cause, such as 
excessive smoking, excessive drinking, or excessive nerve 



244 Some Scattered Remarks on Stomach Cases. 

strain in any foiin is much more useful tlian alkaline 
treatment. Some cases even do better on acids than 
alkalies, but to pursue this subject further would bring 
me into details which are hard to express in general terms. 

The next point I wish to allude to is the salol test for 
gastric motility. This test, as is well known, depends on 
the fact that salol passes through the stomach unclianged, 
and only splits up on reaching the intestme. If the time 
that intervenes between the formation of salicylic acid in 
the intestine and its elimination in the urine be regarded 
as a constant, one will obviously be al)le to form some idea 
of the relative motility of tli 3 stomach in different cases 
by the varying times of a])])earance of the urinary reaction. 
In normal cases the average time of a})])earance of the 
reaction is from 00 to 75 minutes. I have not kept an 
accurate record of my results with this test, but have 
used it fairly regularly for several years, and of late have 
been able to contrast the results given with radiographic 
examinations after the administration of a bismuth meal. 
The conclusion I have come to is that the test is on the 
whole reliable. In cases of pyloric obstruction there is 
abnost invaria))ly delay, and in a recent case 1 found that 
the reaction did not appear until over three hours after 
the salol liad been taken. In cases of tem])orary severe 
atonic dilatation 1 have several times found delay of over 
two hours. The test is, of course, open to many olijections 
and the infonnation it gives can be obtained in other ways, 
but as a means of gi^ ing precision to one's ideas concerning 
the mus(;ulature of the stomach it is, I think, worth 
(Mnph)yiilg regularly, more especially as it involves very 
little trouble for either doctor or ])atient. 

I next wish to make a few remarks on tlie results of 
bismuth meal examinations from the stand])oint of a 
physician. No one will deny the extreme value of such 
examinations, and in many cases tliey afford valuable 
infonnation that (^aiuxot otlierwise be easily obtained, but 
as a result of increasing ex])erience I am l)egin]iing to 
feel that their aid may frequently be dispensed with, and 



By Dr. T. G. Moorhead. 245 

that in any case they should only be regarded as one of 
many factors in arriving at a diagnosis. In saying this 
I am probably merely saying what every body admits, 
but the accurate visualisation that they permit of the 
stomach and intestines at work causes one at first, I think, 
to regard such examinations as possessing a more positive 
value in contrast with other physical signs and with 
symptoms than they actually possess. The first case 
which I encountered which threw doubt on the method 
was that of a man, aged thirty-five, who came to me some 
years ago complaining of a foul stomach. His symptoms 
were those of dilatation of the stomach, and physical 
examination, including distension of the stomach with gas, 
showed the existence of considerable gastrectasis. There 
was no history of gastric pain, and HCl was abundant, 
but I was inclined to regard the case as one of obstructive 
gastrectasis because the fluid removed from the stomach 
several hours after a meal was extremely fetid and sour, 
and I may here say that I always regard butyric acid 
fermentation and the accompanying unpleasant smell as 
almost diagnostic of pyloric obstruction as distinct from 
simple muscular atony in cases of dilatation. A bismuth 
meal, however, seemed to negative the existence of 
obstruction. It showed quite plainly that the stomach 
was enlarged, but also showed the passage of the bismuth 
into the duodenum, and in four hours the stomach was 
completely empty. On the strength of this I told the 
patient that for the present it was better to try lavage, 
massage, careful dieting, &c., and to see what improvement 
would be obtained by these measures. No great benefit 
resulted and two months later an operation showed the 
existence of an old pyloric ulcer with considerable narrow- 
ing, and a gastro-cnterostomy brought about a complete 
cure. As compared with the bismuth method I am 
inclined to think that the old-fashioned plan of giving 
half a dozen raisins at bed time, and ascertaining if they 
are present on washing out the stomach in the morning 
is a better test for obstructive as distinct from atonic 



246 Some Scattered Remarks on Stomach Cases. 

gastrectasis. The most atonic stomach generally manages 
to empty itself during eight or nine hours recumbency, 
more especially of solid contents, while solid indigestible 
substances are retained in cases of pyloric stenosis. As 
regards the condition of atony and ptosis, I am inclined 
to think that the bismuth method conveys to one's mind 
an exaggerated idea of the importance of the change in 
shape, size and position of the stomach. A couple of years 
ago I saw a girl, twenty-eight years of age, emaciated to 
an extreme extent, constantly vomiting and reduced to 
the familiar condition of fearing to take almost any article 
of food on account of the pain and discomfort it caused her. 
I rapidly made up my mind that a Weir-Mitchell course 
would cure her, but in deference to the wishes of her father 
I had a preliminary complete examination of the alimen- 
tary tract made. The a;-ray showed a dilated sunken 
stomach with the greater curvature well down in the true 
pelvis, and in size apparently three to four times the 
normal. The condition was so extreme in fact that it 
was with considerable doubt in my mind that I insisted 
on the rest course being carried out, as I confess I found 
it hard to believe as I looked at tlie radiogra})h that the 
stomach was not really seriously at fault and in fact the 
primary cause of the disease, and as far as one could 
ascertain the stomach had already had more rest than 
food during the previous year. The result, however, was 
most satisfactory. As far as I can ascertain the patient's 
stomach is little altered, but as a result of the rest cure 
she gained two stone in weight, and has since remained a 
normal healthy individual. One must also remember 
that conditions sliown by the bismuth method may bo 
quite temporary. Passing atony of the stomach accom- 
])anying overwork or ill -health from any cause is apt to 
assume in one's mind a more permanent form when it has 
been definitely shown that there is delay in emptying a 
somewhat dilated stomach, but I have met now with 
many cases of the sort in which complete recovery followed 
a few weeks' rest and chansje. 



By Dr. T. G. Moorhead. 247 

A further fallacy and one I think of considerable interest 
is illustrated by the following case : — A gentleman, aged 
sixty-nine, consulted me last October on account of 
troublesome flatulence, which had first begun to bother 
him about a year previously. His appetite, he stated, 
was quite good ; he never vomited, and his bowels were 
regular ; but he had lost weight, and did not feel as strong 
as formerly. His chief complaint, however, was of the 
eructation of gas, which both he and his wife described as 
extremely offensive. On examination in my study I was 
unable to detect anything abnormal, but a few days later, 
on washing out a test meal, I myself experienced the 
offensive odour of which he complained. The smell of the 
eructated gas resembled the smell with which anyone who 
has ever attended a case of gangrene of the lung will be 
grievously familiar. As soon as I detected it I made up 
my mind that the patient was suffering from a malignant 
ulcer of the stomach, possibly complicated by a small 
subphrenic extension ; of this, however, there were no 
physical signs. The test meal proved free of HCl on this 
and on a subsequent occasion, and, further, a small 
fragment of tissue was found in the end of the stomach 
tube — the only occasion, by the way, that I have ever got 
assistance in this way — which proved to be necrotic 
granulation tissue. The patient appeared to me to be one 
in whom an exploratory operation might justifiably be 
performed on the chance of removing the carcinoma, but 
before operation, at the patient's own request, a complete 
bismuth meal examination was carried out. This appar- 
ently revealed a quite unusual state of affairs. The 
bismuth appeared to pass very rapidly into a pouch beyond 
the stomach, and the appearance as viewed on the screen 
and also on the :i;-ray plates strongly suggested either a 
most unusual hour-glass stomach or else that the bismuth 
had passed into a large sac external to the stomach. 
Subsequent events, however, proved this quite wrong. 
At operation a malignant growth of the cardiac end of the 
stomach was found ; it was adherent to the diaphragm, 



248 Some Scattered Remarks on Stomach Cases. 

and quite irremovable. The patient made a rapid recovery 
from the operation, and was satisfied to think that every- 
thing possible had been done. The explanation of the 
curious x-ray phenomenon seems to have been that an 
irritable and unusually active stomach rapidly expelled its 
contents, and that two coils of sjnall intestine simul- 
taneously filled with bismuth, parallel to one another, and 
overla])ping, produced the a])pearance of a secondary sac. 
The experience is, I think, one worth relating. 

In contrast to the above cases in which, as I have stated, 
I have been more impressed with the difficulties of 
interpretation of .r-ray results than with the aid thus 
affoi'ded, and I now exhibit an .r-ray photograph showing a 
typical hour-glass stomach in which a complete cure was 
achieved by operation. The patient, a lady, aged thirty- 
five, consulted me three years ago with symptoms pointing 
to chronic ulcer of the stomach, located most proba])ly in 
the middle of the lesser curvature. I advised — as I always 
do in such cases — a systematic course of medical treat- 
ment. This was carried out with ap])arently much 
benefit. 'Hie ))atient left hospital after six weeks, able to 
eat ordinary food without paiji. was c^uite free of any 
tendency to vomit, and had gained 7 lbs. in weight. I lost 
sight of her completely until last July, when she again 
came to see me, and told me that during the three months 
previously she had again ])egun to suffer from pain and 
fulness after meals and a tendency to vomit. Examina- 
tion reveal(Hl a tender s])()t about midway between the 
umbili(uis and tlie steinuin, and a distinct splash was 
obtained. I (^ame to the conclusion that the ulcer was 
agaiji a(;tive, and advised an operation, but before having 
this carried out got an r-ray taken. This at once showed 
the existence of a ty|)i(tal hour-glass stomach, and frag- 
ments of bismuth could be seen adherent to the surface 
of an irregulai" mass in the middle of the lesser curvature. 
The o])(Mati(m of gastro-gastrostomy was ])erformed by 
Dr. Wheeler with spb jidid results. I heard from the 
])atient at Christmas to say that sh(> had gained 21 lbs. 



. By Dr T. G. Moorhead. 249 

in weight, and no longer had any stomach troubles 
whatsoever. The actual operative procedure carried out 
is one which I understand does not commend itself to 
every surgeon, and it is therefore I think worth reporting 
the extremely good results obtained in this case. 

While speaking of a case of chronic gastric ulcer I would 
here like to emphasise my belief that a large number of such 
cases are quite curable permanently by medical means — 
i.e., by careful rest and dieting. I need not quote cases 
to prove this contention and indeed I only mention it 
because so recently it was thought that medical treatment 
was useless for chronic duodenal and gastric ulcers, and 
that the sooner they were all operated on the better. 
Now, largely, I think, as a result of the stimulus adminis- 
tered by surgeons, medical treatment has become more 
systematised and more successful. If one fails to cure a 
case after adequate medical treatment, surgical advice 
should invariably be invited and acted on. 

The last point I wish to allude to is the subject of 
peritoneal adhesions, more particularly in reference to 
a single case the details of which I will briefly recount. 
It is stated that in adults peritoneal adhesions somewhere 
or other are invariably found at autopsy, just as pleural 
adhesions more or less are invariably found. Into the 
general subject of their significance I need not go, though 
I am under the impression that they are often made a 
scapegoat undeservedly for much abdominal discomfort. 
In the following case a single adhesion was possibly the 
reflex cause of serious vomiting : — The patient, a girl, aged 
thirty, came under my care complaining that for some 
years she had suffered from indigestion, which had become 
worse of late, and that during the last three months she 
had vomited after nearly every meal to such an extent 
as to make life intolerable and to reduce her weight 
considerably. A complete examination, including the 
administration of a test meal, and a bismuth examination, 
revealed the existence of marked general enteroptosis, but 
showed that the stomach was capable of emptying itself in 



250 Smne Scattered Remarks on Stomach. Cases. 

less than the normal time. Careful dieting and sedatives 
of different sorts, including full doses of bromides, made 
no difference in the vomiting, and as the patient was 
obviously very neurotic I removed her to a private home 
in order to get her away from over-sympathetic sur- 
roundings and to keep her in the recumbent position. 
In the home, vomiting went on as before ; even peptonised 
milk, which proved quite palatable, was rejected, and the 
patient continued rapidly to lose flesh, and to suffer from 
want of fluid. There was a history of jaundice a year 
previously, and, searching about for a possible reflex cause 
of the trouble, I came to the conclusion that the most 
likely was a gall-stone in the gall-bladder, though there 
was nothing else but the vomiting to confirm this view. 
After nearly a month's treatment I asked a surgeon to see 
the case, but he was so much impressed by the neurotic 
disposition of the patient, whom he had previously known, 
that he was indisposed to operate, and in consequence we 
delayed for another ten days. During that interval the 
vomiting continued as bad as ever, and as the patient was 
herself anxious that something should be done before she 
got too weak, I then rather pressed the operation. At this 
time the general superficial tissues were so inelastic from 
want of fluid that on pinching up the skin the fingers left 
a definite mark. On opening the abdomen marked ptosis 
was revealed, but at first, to my disa])pointment, nothing 
else. The gall-bladder, stomach, a])pendix, and colon were 
carefully examined, and, with the exception of those fila- 
mentous adhesions so commonly seen in cases of ptosis, 
nothing could be made out. Just, however, as the abdomen 
was being closed, a finn cord -like adhesion was seen 
extending from the great omentum to the umbilicus. This 
adhesion, which could readily be overlooked, as on opening 
the abdomen by a iiuMliaii incision it is turned to one side 
with the abdominal wall, was so situated as to press 
directly on the greater curvature and antei'ior surface of 
tlie low-lying stomach. Wlu^n I saw it 1 remembered a 
similar case, which had come untler my notice some years 



Case of Puncture Wound over the Rigid Clavicle. 251 

back, in which constant dragging pain in the abdomen 
had been at once relieved (after two previously unsuccess- 
ful exploratory operations) by removing just such an 
adhesion ; I accordirgly asked the surgeon to separate and 
remove it, and this was done. The patient's convalescence 
was, unfortunately, interrupted by a severe attack of 
pneumoria, which set in on the tenth day after operation ; 
but prior to this she had been able to take almost normal 
food for three or four days, and after the subsidence of 
the pneumonia again returned to normal food. Still later, 
I regret to say, some of her sj/mptoms returned, and even 
now, some months after the operation, she suffers from 
some regurgitation of the stomach contents at night, but 
she is able to eat fairly well and no longer suffers from 
nausea during the day. 

Whether the adhesion was the partial cause of her illness 
and aggravated the symptoms resulting from the entero- 
ptosis or not is a matter upon which it is hard to be 
dogmatic, but to my mind an adhesion of this sort should 
be quite capable of producing reflex emesis, and as I 
understand that it is far from uncommon I think it is 
worth looking for as a routine in cases of exploratory 
laparotomy performed for unexplained and persistent 
vomiting. If not specially looked for it may be easily 
missed. 



Art. XII. — Case of Puncture Wound over the Right 
Clavicle, causing Loss of Pulsation in the Arteries of 
the Arm. By Henry Stokes, M.D. Univ. Dubl. ; 
F.K.C.S.I. ; Surgeon to the Meath Hospital and 
County Dublin Infirmary. 

Case. — Thomas K., a labourer, aged thirty-three years, 
was admitted to the Meath Hospital on 2nd August, 1913, 
suffering from a wound above the centre of the right clavicle. 
He stated that while working in a hay field he had tripped 
and fallen on to a prong of a tumbling rake (a machine used 
for collecting hay) on which he was suspended, being unable 



252 Case of Puncture Wound over the Right Clavicle. 

to reach auy support with his hands. He further said thai 
he had to be Ufted of! hy his coin])anions, and that on account 
of great weakness they Immght him to the liospital. 

On examination the patient was found to be a strong, heavy 
man of about 14 stone weight, short necked and broad chested. 
There was a punctured wound three-quarters of an inch long 
over the right clavicle discharging a small quantity of blood. 
There had been no coughing of blood. The house surgeon 
painted the wound and the neck with tincture of iodine and 
aj^pUed a dressing. 

On the next morning emphysema had developed in the 
up]Kn' half of tlie right side of the chest, and no pulsations could 
be felt iji tlio radial, ulnar, brachial and axillary aiteries of that 
side althoiigii there was a very distiiutt ])ulsation in the carotids 
and in all the other arteries. The ])atient looked very ill. 
and had considerable ]min in the right side of his chest. 

Diirirtg the next ten days the temperature kept continually 
above normal, varying from 00° to 102^, his pulse running 
from 11") to J 40, and the re.>])irations about 35 a minute. 

On the 8th of August a careful examimition showed that there 
had been no nervous lesion, and that there was a large area of 
dulliu^ss undeilying the emphysema and extending down to 
the base of the right hmg. On the lOth of August Dr. Hoxwell. 
who was asked to see the case .sus])e(!ted an empyema, but 
on four occasions the as])irating hyixxlermic needle drew off 
pure blood. The patient's temperature ke])t varying from 
07° to 102' for three weeks, doubtless due to the absor})tion 
of the haemorrhage, the dulness slowly disa])])eared, and 
personally he felt uumh better. On the 7th of September he 
was allowed u]), and he was discharged convalescent on the 
12th of September. An examination on that date failed to 
reveal any trace of pulsation in the arteries of his right arm. 
At no time was there any swelling, pulsation or murmur in the 
neighbouihood of the ])un(tt.ure wound. 

The above case opens up many dilBcult questions. First, 
was the subclavian artery perforated? This does not 
seem to he probable, as il is very unlikely that the ]wtient 
would not have rapidly h\v(\ to death. Secondly, if any 
branch of the subclavian bad been perforated, would the 
pressure of the resulting liannorrhage have caused occlu- 



Certain Preparations of Spleen, Pancreas, <fcc. 253 

Gion of the subclavian. This also seems unlikely, as there 
was no tumour in the neck, no venous congestion in the 
arm ; the only large haemorrhage v^as into the pleural cavity. 
Thirdly, was the absence of pulsation in the arteries of 
the right arm of old standing? It is, in the absence of 
evidence, impossible to answer this question, but as the 
arm was well developed, strong and muscular, it is not 
probable, and no congenital malformation could account 
for pulsation not being felt somew^here in the arm. 

The patient is being kept under observation, the 
prognosis as regards the development of an aneurysm 
being regarded as very grave. 



Art. XIII. — On the Every-day Application of Certoiin 
Preparations of Spleen, Pancreas, dec. By G. W. 
Carnrick, Hornsey, London, N. 

The results of almost innumerable experiments prove that 
not a few diseases are due to the partial or complete loss of 
certain internal secretions or hormones. Physiologists 
have devoted years of experiment to show^ the relations of 
the internal secretions, and thus have paved the way for 
their successful application in the treatment of disease. 

Twenty years of experience with thyroid extract has 
placed it among our few specific remedies, and it is a 
panacea for certain conditions due to a lack of this par- 
ticular secretion. The study of the suprarenal gland and 
the physiologic influence of its extracts has also assumed 
a definiteness which cannot be gainsaid ; and we are learn- 
ing successfully to procure and use various other hormones 
in conditions presumed to be due, in part at least, to a 
corresponding lack. 

The writer has done much experimental work in apj^ly- 
ing this idea to the treatment of diabetes, and the sugges- 
tions initiated ten or more years ago are now rapidly 
becoming "rational." Opinions change; and numerous 
personal communications, as well as published articles, 
have emphasised my conclusions that a certain secretion 



254 Certain Preparations of Spleen, Pancreas, (fb6. 

of the pancreas is an effective remedy in the treatment of 
many cases of diabetes. This, however, is not an extract 
of the pancreas, nor is it that remarkable duodenal extract, 
secretin, which has such a decided influence upon the 
functional capacity of the pancreas. While these prepara- 
tions are undoubtedly useful, they do not supply the 
specific factor which appears to be missing in so many 
cases of diabetes. Here one needs to antagonise the re- 
sults of the disturbed hormone-balance, and thus give to 
the body the much-needed sugar which is in such profu- 
sion in the blood, but which it can only utilise with the 
\w}\) of the pancreatic activator. The clinical experiences 
of hundreds of physicians in all parts of the world have 
demonstrated beyond all (question that an extract of the 
tail of the pancreas, containing the islets of Langerhans, 
supplies to many diabetics a power to utilise carbohydrates 
which is sometimes remarkable. Unfortunately, however, 
diabetes is not always due solely to Langerhansian dis- 
order, and the administration of this hormone is not as 
specific as is thyroid extract in myxoodema ; but to secure 
results in 55 per cent, or GO per cent, of cases is most en- 
couraging, and to be able to afford relief — temporary in 
certain cases and permanent in others — is well worth 
while, and justifies a thorough clinical trial on the part of 
the physician. 

Since Starling and his associates first discovered 
secretin at University College, London, and Pawlow 
named enterokinase, and defined its remarkable ]iroj:)erties 
as a result of his work in St. Petersburg, much time has 
been devoted to attempts to procure in sufficient quantities, 
and suitable stable form, preparations of pyloric, duo- 
denal, and pancreatic secretins which could be used to 
satisfactorily stimulate the digestive glands. This has 
been done, and for several years this natural stimulator 
has been used with good results. The mere fact that one 
can supply to the body a pure, physiologic stinuilus to the 
digestive glands is an immense step in the therapeutics of 
indigestion; and the use of secretin in the treatment of 



By Mr. G. W. Carnricic. 255 

digestive insufficiency is beyond reasonable comparison 
with the digestants and stimulants still so generally in use. 
The results obtained are not far short of astounding, and are 
possible only because we are able to procure from animals 
those substances w^hich would have activated their digestive 
organs if those animals had been permitted to live. 
The secretins are not quite " specifics," for frequently 
indigestion involves numerous other factors besides the 
secretory capacity of the glands ; but they excel any 
other remedies previously recommended for the same 
purpose. 

Extensive study of the physiology of the spleen has 
shown that it plays a far wider role than its well known 
blood-forming function. The spleen undoubtedly con- 
tains a hormone which, by activating trypsinogen and in 
several other ways, increases the nutrition and resistance 
of the body. A combination of extract of spleen with 
pancreatic enzymes and calcium lactate is affording en- 
couraging results in the treatment of malnutrition, especi- 
ally in the tuberculous, where this factor i§ by all odds 
the most important ; and its influence upon the weight 
and general health is usually quickly seen. 

One other point, in closing, is worth mentioning. The 
term " pluriglandular therapy " is destined soon to come 
into more general usage. It refers to the application of 
balanced combinations of internal secretions in certain 
indefinite and generalised conditions. In neurasthenia, 
suboxidation, convalescence, and " run-down " conditions 
in general, the manifestations are not confined to the 
digestion, nerves, or muscular system. This physiologic 
laziness — if I may coin a term — is general, including, of 
course, the work of the internal secretory organs. This 
hindrance to their normal function is an extremely im- 
portant factor in preventing rapid recovery and lowering 
the resistance still further — and it is almost invariably not 
taken into consideration, and just as secretin gives the 
needed stimulus to the digestive glands, and thyroid 
extract supplies the missing factor in athyroidia, so can 



256 Certain Preparations of Sjjleen, Pancrefid, dbc. 

one add to the ortho<^lox treatment of the conditions in 
the class just mentioned a combination of hormones with 
the idea of enhancing' the whole work of the system. 

The results of the use of a tonic combination of hor- 
mones will be found to be very pleasing. J)i^^estion is 
increased, nervous stability returns, the capacity for both 
mental and muscular work is greater, and a <i:eneral in- 
vigoration follows what has been called the hormotonic 
treatment. 

More than twenty years of the writer's life has been 
devoted to the laboratory side of this most interestintj 
work, and the success of several preparations bearin«i my 
name is proof that this field of endeavour is far from fruit- 
less. I am always very pleased to hear from physicians 
interested in this subject with a view to convincin«T them 
by literary and clinical means of the every-day application 
of hormone therapy in routine practice. 



• I'UOSTATECTOMY IN THE AGED. 

Dr. H. a. Moore, Indianopolis, reports the successful per- 
formance of prostatectomy on two |)atients, both of whom 
were over ninety years of age. The perineal method was 
followed in each case, and in neither of them was any diffi- 
culty exj)erienced in slielling out the hypertroi)hied glan- 
dular tissue. Both cases recovenil without shock. — Inter- 
state Mcdicdl Journal. Saint Louis, Mo., Vol. XX., No. 7. 
July, 1013. 

on. OK CKDAK POISONING. 

Drs. Thomi'sun and Aiu'iiii5.\Ln. ol Saint I^ouis, report a 
case of oil of cedar wood |)oisoning. The })atient, a woman, 
aged twenty-two years, was found in her nipht-elothes, 
partly lying out of bed, and there was a slight amount of 
vomitus on the floor, wliieh was tinged with bl(X)d. 
Autopsy. — Taw rigid, tij) of tlie tongue protruded between 
teeth; vessels of the omentum, mesentery and pelvis deeply 
injected ; distinct hyiMTtemic areas of the cokm ; kidneys 
deeply congested, as w;is the pia mater. — Ut supra. 



PART II. 
REVIEWS AND BIBLIOGRAPHICAL NOTICES. 



Glandes Surrenales et Organes Chromafflnes . By M. 
LuciEN, Associate Professor of Anatomy ; and J. 
Parisot, Associate in Medicine ; Faculty of Medicine, 
Nancy. Paris: Societe d 'Editions Scientifiques et 
Medicales (F. Gittler, Directeur). 1913. 8vo. Pp. iv + 
453. 

This is the first of a series of monographs on the Glands 
of Internal Secretion to be brought out by the same 
publishers. Others are to follow on the Pituitary, the 
Thyroid, &c. The aim in each case is to give a concise 
but complete account of the anatomy, phj^siology, 
pathology, and diseases associated with each gland. 

In the present instance it may be said at once that the 
object in view has been admirably achieved. 

The work is divided into four parts. The first part is 
mainly anatomical, and includes five chapters, four of 
which are devoted to the comparative anatomy, develop- 
ment, descriptive anatomy, and histology of the supra- 
renals proper. In chapter V. an account is given of the 
accessory suprarenal and chromaffine organs. 

Part II. deals with the physiology of the organs in a 
very complete way. It comprises eight chapters, four of 
which treat successively of the effects of extirpation 
(partial or complete) ; the physiological action of extracts ; 
the biochemistry of the glands, in particular of the lipoids, 
the pigments, and of adrenalin. The methods of detection 
and estimation of adrenalin are particularly well done. 
Then comes a very minute account of the cardio-vascular 
effects of extracts of the gland, both immediate and 
remote, together with a discussion of the mechanism by 
which they are produced. This is followed by chapters 
dealing, respectively, with the special action of adrenalin 



258 Reviews and Bihliograpliical Notices. 

on other organs, such as those of digestion, of respiration, 
&c. ; with its influence on metabolism and general 
nutrition ; with the physiology of the accessory supra- 
renals ; treating lastly of the glands as organs of defence. 

In the third section of the book the pathology of the 
glands is considered. This is mainly confined to the 
structural changes which accompany atrophy, hyper- 
trophy, degeneration, vascular and inflammatory lesions, 
and the growth of tumours in the suprarenals as well as 
in other chromaffine organs such as the parotid gland. 

The last part is entitled the " Suprarenal Syndromes in 
Pathology," and is one of the most interesting sections 
of the book. It begins with a general consideration of the 
symptoms associated with suprarenal disease, and then 
goes on to consider in succession the syndromes cor- 
related with chronic affections, with acute infections and 
intoxications, with conditions in which other glands of 
internal secretion are involved (pluriglandular s^^ndromes), 
and with the growth of tumours in these organs. 

Then follows an important chapter on the suprarenal 
glands in legal medicine. Here it is shown that many 
cases of sudden death, of death from so-called surgical 
shock, and of sudden death after minor operations, are 
due to suprarenal deficiency or to the paralysing effect of 
chloroforjn on the functions of the glands. A plea is in 
consequence made for the careful examination of the 
su])rarenal bodies in all cases of ap])arontly unaccountal>le 
sudden deaths. In this chapter also a method is suggested 
for asceitaining in niedico-legal cases whether the onset of 
death has been slow or rapid. If the former, the quantity 
of adrenalin present in the glands is greatly reduced ; if 
the latter, it is normal. The method of dosage is very 
simple. It consists in making an extract of the glands, 
])()iliiig to remove proteins, and adding a few droj)s of a 
saturated solution of ferricyanide of potassium to the 
extract whicli lias ])reviously been rendered alkaline by 
ajnmonia (method of Cevidalli). A red colour is developed, 
the de-|)tli of tint varying with the amount of adrenalin 
present. 



A Plea for the Investigation of Christian Science. 250 

The last chapter of the book is devoted to the apphca- 
tions and results of suprarenal organo-therapy. In it is 
discussed very fully and impartially the different methods 
of administration, the results which have been obtained, 
the indications for and against, and the various affections 
of the organs in which treatment by this means has been 
more or less successful. 

The work as a whole is a valuable and practical one 
which cannot fail to be appreciated by medical men. It 
is illustrated by 100 figures in the text. One improvement 
might be made — namely, a full bibliographical reference 
to the works of other authors quoted. 



A Plea for the Thorough and Unbiased Investigation of 
Christian Science. By an Enquirer. London : J. M. 
Dent & Sons. 1913. 8vo. Pp. xi + 208. 

The modest author of this booklet had " a somewhat re- 
markable experience " about five years ago — which would 
seem to have set him furiously to think on the subject 
of his present publication. In days of yore some people 
would probably have regarded the result of his experi- 
mental cogitation as a " revelation ' ' from the only illu- 
minating source. And it would appear that in our own day 
this work will be credited to inspiration (at least second- 
hand, per the spirit of Mary Baker Eddy) by the evan- 
gelists of, and converts to, the new knowledge of the 
mysterious manifestations of the divine and the super- 
natural ; in a generation — not necessarily viperous — of 
materialists and Philistines. However the present re- 
port may be received by the members of the latter tribe, 
we have it from the author's own pen that '* later ex- 
periences . . . have proved to my own satisfac- 
tion " that Christian Science is " more reliable and 
satisfactory in every way than ordinary medical 
methods." And we must here admit, at the dictation of 
scientific candour, that : having regard to the present state 
of medical education ; and the subsequent practice inspired 
thereby — well, that some foundation has been laid (and 



260 Reviews and Bibliographical Notices. 

is now being tested) for the opinion that we once heard 
enunciated by a cynical medical student, to the effect that if 
one of his own limbs happened to be badly damaged, he 
would prefer the soothing advice and attention of Mrs. Eddy 
to the possible surgical performances of chirurgical acrobats 
of the Sir Baboo and Sir Blunderboar type. This was, 
of course, in the past generation ; and the recent passing 
of practitioners of that ilk has left us breathing a healthier 
atmosphere. 

Our author himself attributes the antagonistic attitude 
of the clerical and medical professions " to the mislead- 
ing influence of prominent members of both profes- 
sions " — which was adopted "without having grasped 
even the basis of its philosophy." We feel constrained 
to recognise the presence of a grain of truth in this state- 
ment of view-point. In the present generation of hurry 
and worry, the average member of one profession does 
not, as a rule, indulge in any acrobatic endeavours to *' put 
himself in the other fellow's place." And among the vast 
majority of things which are never (mentally) discerned 
by the average man are those which are always before 
his eyes. Those who would deny all clinical results to 
suggestion, and faith-cure, and Christian Science, and 
other applications of psycho-therapeusis, must be bliss- 
fully unaware of the facts of their own hourly existence — 
of the influence of hope and oifear on the circulation, nutri- 
tion, appetite, and digestion ; of the fact that the greatest 
results hitherto recorded to the credit of humanity owed 
their mainspring to the influence of the emotions ; that is to 
say, of the factor which most broadly marks off man from 
beast. And here we would point out that the author 
seems to have dro]i])ed his cue when stating that ** ques- 
tions of ])hilosoiihy and religion . . . must ulti- 
mately be resolved into questions of fact which either are 
or are not logically provable." Experts have often 
])()inted out that the believer may safel)/ Imigk at his 
faith, but should iiever be encouraged to reason about it. 
Our author opens his Introduction by observing that 
" When a business man undertakes for the first time 



RosENAU — The Milk Question. 261 

the somewhat arduous task of writing a book, it may 
fairly be assumed that he feels that such a book is 
needed." We quite agree — while pointing out that it 
may as " fairly be assumed " that in case of a subject 
requiring, as this does, the most expert skill, he should 
try to get somebody else to write it. K. 

The Difficulties and Emergencies of Obstetric Practice. 
By CoMYNS Berkeley, M.A., M.D., B.C. Cantab., 
F.R.C.P. Lond., M.R.C.S. Eng., Obstetrical and Gynae- 
cological Surgeon to the Middlesex Hospital, Lecturer 
on Obstetrics and Gynaicology, Middlesex Hospital 
Medical School, Examiner in Obstetrics and Gynae- 
cology to the University of Oxford and the Conjoint 
Board of England; and Victor Bonnby, M.S., M.D., 
B.Sc. Lond., F.R.C.S. Eng., M.R.C.P. Lond., 
Assistant Obstetrical and Gynaecological Surgeon to the 
Middlesex Hosjntal, &c. With 287 Illustrations. 
London : J. & A. Churchill. 1913. Large 8vo. Pp. 
xii + 787. 
This book is intended to afford practical guidance to the 
practitioner when he is called upon to deal with the diffi- 
culties and emergencies of obstetrical practice. The 
physiology and management of normal pregnancy and 
labour have been omitted. The authors are to be con- 
gratulated on the production of a most readable and 
reliable work which may fairly be regarded as descriptive 
of the best modern practice. Other times, other customs. 
What would the conservative London obstetrician of 
even ten years ago have said of its teachings ! 



The Milk Question. By M. J. Kosenau, Professor of 
Preventive Medicine and Hygiene, Harvard Medical 
School ; formerly Director of the Hygienic Laboratory, 
United States Public Health and Marine-Hospital 
Service, Washington, D.C. London : Constable & Co., 
Ltd. 1913. Bvo. Pp. xiv + 309. 
The importance of the milk question is now so generally 
recognised that it may be regarded as one of the most 



^^2 Reviews and Bibliographical Notices. 

pressing problems of the day. The more one studies it 
the more comj^lex and far-reaching it appears to be. We 
find variations of administrative methods in different 
municipalities, all aiming at the provision of a relatively 
clean milk su[)ply to the population. In Great Britain 
the work of Hope in Liverpool and of Niven in Man- 
chester may be taken as types of systematic effort in this 
direction. 

The book before us forms one? of the series of '* N. W. 
Harris Lectures," founded by a Chicago citizen 
" to stimulate scientific research of the highest type 
and to bring the results of such research before the 
students and friends of Northwestern University, and 
through them to the world." Though primarily 
American, European investigations and experience have 
been availed of largely in its preparation. It is more 
than a text-book ; it deals with the milk problem from the 
public health and administrative points of view. Much 
of the work is of the ** popular " type — in the best sense ; 
this may be said more especially of the cartoons, most 
of which are excellent. One, published by the American 
Medical Association (a prize winner !) is inserted as an 
exam])le of what such productions should not be, and we 
emphatically agree with the author's comment that such 
sensational ])ictiires probably do more harm than good. 
It is dreadful ]irint, containing a germ of truth and 
implying a whole falsehood which might, when placed 
before uneducated people, cause a disuse of a necessary 
article of diet. 

The chapter on diseases caused by infected milk is an 
eminently fair statement of the case, and the author's 
moderation in dealing with the subject enhances its value. 
This is notably tnie in regard to tubercle and the 
deductions which are made from the results of bacterial 
examinations of milk siimples. In this connection the 
consideration of the relation of bovine to human tuber- 
culosis, and the relative incidence of infection in man of 
tuberculosis of the bovine and the human type, may be 
referred to. The results of researches carried out in the 
laboratories of the Department of Health of New York 



Lister — Dr. Chavasse's Advice to a Mother. 263 

City have yielded results so suggestive that they call for 
further investigation in this field. 

The recommendations regarding receptacles for milk 
during collection, transit, and storage are extremely prac- 
tical, and would well repay the attention of all w^ho have 
to do with milk during its progress from the cow to the 
consumer : but however much may be effected by clean 
vessels and clean handling we can never attain to a clean 
milk supply so long as the milking of cows is left in the 
charge of the most ignorant and least cleanly portion of 
the community. Keform should begin in the dairy yard 
amongst the workers. 

In regard to Pasteurisation we would state merely that 
were the rules given in this book strictly adhered to, the 
objections to the process held by many consumers would 
vanish. We have read the w^ork with pleasure and profit. 

Dr. Chavasse's Advice to a Mother on the Management 
of her Children. Illustrated. Eevised by T. D. 
Lister, M.D. ; Physician to the Eoyal Waterloo Hos- 
pital fol" Children and Women. Seventeenth authorised 
Edition. 340th thousand. London : J. & A. 
Churchill. 1913. Cr. 8vo. Pp. xii + 338. 

The phenomenal success which has all along attended 
the production, and reproduction, of Dr. Chavasse's well- 
known little volume has made it a land-mark in the history 
of professional literature ;. while demonstrating, to a 
degree of logical certitude, that the subject and its treat- 
ment have reached, and been based upon, one of the 
specialised areas of the bedrock of human sympathies. 
The fact that it offers points of emotional and scientific 
contact to every household, to every parent, and indeed 
to every human being, goes to account for the collateral fact, 
which has recently been stated in our presence, that the work 
has been oftener bought, oftener borrowed, and oftener 
stolen than any other medical work of the past century. 
Our own copy has already vanished ! It need hardly be 
added that a volume of quality so magnetic requires no 
recommendation from the reviewer. K. 



264 Reviews and Bibliographical Notices. 

The Surgical Diseases of Children. By William 
Francis Campbell, A.B., M.D., and Le Grand Kerr, 
M.D. New York and London : D. Appleton & Co. 
1912. Koyal 8vo. Pp. xxviii + 693. 

We must congratulate the authors in having put at our 
disposal a really good book on the surgical diseases of 
children. Through every chapter a thoroughly practical 
strain can be detected, and theories are discounted. 
Further, the book, unlike many similar publications, 
makes one feel that it is worth reading. 

The chaj^ters which especially attract attention are those 
on congenital syphilis, hernia, and fractures. 

The illustrations are instructive and well chosen. 

The authors dedicate the book to the " Family Physi- 
cian," yet it is one wiiich will be of still greater use to 
the general surgeon, by whom it will certainly be appre- 
ciated. 



The Healthy Marriage. A Medical and Psychological Guide 
for Wives. By G. T. Wrench, M.D., B.S. (Lond.) ; 
Past Assistant Master of the Rotunda Hospital, Dublin, 
&c. London : J. & A. Churchill. 1913. Cr. 8vo. Pp. 
viii + 300. 

The chief subject which engrossed the attention of this 
year's International Medical Congress was Syphilis. The 
daily papers all speak openly of the " Hidden Plague." 
A Royal Commission is to be appointed to inquire into 
the matter. In the English Review for July there is an 
excellent article on the difficulties and dangers of marriage 
in Africa. In fact, marriage with its pros and cons is the 
niost discussed question of the present time. We are glad 
to have had an opportunity of reading and reviewing Dr. 
Wrench's splendid work, and trust that the publishers will 
send it for review not only to the medical press, but also 
to the diiTerent lay papers. 

Ignorance of the rites of mfvtrimony often brings deep 
sorrow, and we know of no more suitable work to be placed 
in tlic hand of the bride or bridegroom than " The Healthy 



FiTzWiLLiAMS — A Manual of Operative Surgery. 265 

Marriage." There is so much information to be gleaned 
from its pages that in the space at our disposal we can but 
touch on the fringe of the contents and recommend our 
readers to go further and buy the book. 

Marriage is dealt with from every point of view : the 
best age to marry, with the advantages and disadvantages 
of early and late marriage, and the economic side of 
matrimony are carefull}' treated. Dr. Wrench gives 
statistics to prove that mortality is greater in the married 
than in the unmarried state. We should much like to 
know his reasons for thinking that the emancipated 
woman should not marry : such dogmatic assertions are 
useless without reliable statistics. 

Women are advised to abstain from alcohol. Professors 
Forel and Kraepelin are quoted : they consider that 
children are degenerate who are conceived while alcohol is 
circulating in the parent's blood. The author is not 
inclined to agree with all the views of these learned 
professors. A woman's life from the onset of menstruation 
to the menopause, with many useful hints on pregnancy, 
labour, the puerperium and lactation, occupy the second 
half of the book. 

The world will be indebted to the Eugenic Society and 
to thinkers such as Dr. Wrench when parents have been 
educated to pay more attention to the health bill of the 
prospective bridegroom and less to his bank account. 



A Manual of Operative Surgery, with Surgical Anatomy and 
Surface Markings. By Duncan C. L. FitzWilliams, 
M.D., Ch.M., F.R.C.S. Eng., F.R.C.S. Edin. ; Surgeon 
in Charge of Out-patients, St. Mary's Hospital, &c. 
London : Bailliere, Tindall & Cox. 1913. Demy 8vo. 
Pp. viii + 450. 

In the preface the author states that this text-book is 
written for the instruction of the apprentice and to help 
the journeyman craftsmar of our profession, but that it 
is not written to be read by surgeons. 

There are two obvious objections to the fulfilment of 
this intention — namely, that the price, viz., 10s. 6d., is 



266 Reviews and Bibliographical Notices. 

too high for the average stuc'ent ; and secondly, that many 
of the operations are too advanced to be of use to the 
student. If all out-of-date operations and all rare opera- 
tions were omitted from all text-books written for students 
we should soon have a far better standard. Among such 
operations many am|)utations and the ligature of most 
arteries might be classed. Further, there is, as is usual 
in these books, no reference to some common operations 
such as those for varicose veins, hydrocele and to intra- 
venous injections. 

Apart from the above points the book is deserving of 
praise. It is very well turned out ; the general arrange- 
ment and clearness of illustration and descriptio i deserve 
every praise. We can strongly recommend the book to 
anyone seeking a book written on the usual lines. 



RECENT WORKS ON MEDICAL CLIMATOLOGY. 

1. Health Resorts of the British Islands. Edited by Neville 
Wood, M.D. ; Member of the Council of the Section of 
Balneology and Climatology of the Royal Society of 
Medicine. With the assistance of an Advisory Com- 
mittee. With 40 Illustrations and 3 Ma])s. London : 
University of London Press. Published for the Uni- 
versity of London Press, Ltd., by Hodder & Stoughton, 
Warwick Square, E.G. 1912. Demy 8vo. Pp. xii -f- 
253. 

2. The Principles and Practice of Medical IlydroUniy: 
Being the Science of Treatment by Waters and Baths. 
By R. FORTESCUE Fox, M.D. ; late Hyde Lecturer on 
Hydrology, Royal Society of Medicine. London 
Medical Publications. London : University of London 
Press. 1913. Demy 8vo. Pp. xiv + 296^ 

1. This book, which has been edited by Dr. Neville Wood, 
and whi(di largely owes its appearance to his energ}', should 
prove of distinct value not only to the jnedical ])rofession 
at home and abroad, l)ut also to the gi^neral pu}>lic. 
After a brief account of the natural niiueral woters of the 



Recent Works on Medical Climatology. 267 

British Isles, the chief inland spas are dealt with in 
alphabetical order, the account in almost every case being 
furnished by medical men or others actually resident in 
the place described. In this way accurate up-to-date 
irformation is provided, concise and to the point. We 
regret that the Irish spas — Lucan and Lisdoonvama — are 
not included in this list. Both spas indeed receive 
mention in the introductory chapter of the book, but we 
think they are both worthy of more extended notice, 
even if they are not fitted out in a modern luxurious style. 
Many Irish patients, either from motives of economy or 
from choice, frequent these spas and derive much benefit 
from the treatment and waters. 

The second half of the book is devoted to a description 
of the seaside resorts of Great Britain. These are dealt 
with systematically in much the same way as the inland 
spas. The chapter on Irish seaside resorts is from the pen 
of Professor Lindsay, of Belfast, and is fairly complete, 
although there are some omissions. Tramore, for example, 
is unmentioned. 

An important object of this book is to provide for 
European physicians a manual, similar to those published 
in the Continent, in which British health resorts are 
exclusively dealt with. To facilitate the familiarisation 
abroad of the information now compiled a French edition 
is contemplated, and will, we feel sure, be of value in 
spreading information concerning the health-giving 
properties of many of our British spas and watering places. 

The book should be in the study of every physician 
who is called upon to advise his patients either with 
regard to their annual holiday or as to what balneological 
treatment is required for their particular ailment. It will 
well repay perusal, and will be useful for reference. 

2. Dr. Fortescue Fox has written an informing work 
on a subject concerning w^hich the information of the 
average medical man is apt to be unsystematised and 
hazy. He attacks his subject at the beginning and brings 
the reader in successive stages to the discussion of the 
indication for hydrological treatment. Preliminary to 



268 Reviews and Bibliographical Notices. 

this he deals with the physiology of the skin, the way in 
which the body generally reacts to baths, the different 
methods of apj^lying hydrotherapy, and the various 
mineral springs that are in use for therapeutical pur- 
poses. The book is written in an easy style, and is de- 
cidedly practical. The chapter entitled " The Province 
of the Spa Physician " alone demonstrates that the 
author is acquainted with the difficulties that doctors 
practising at spa resorts have to deal with. Incidentally he 
liints that a thorough knowledge of the effects of hydro- 
logical treatment, and of the springs in their own locality 
in particular, will do much to minimise these difficulties, 
and with this view we are in hearty agreement. The 
mere settling at a spa and prescribing routine baths does 
not constitute a spa physician in whom confidence can ])e 
placed. The subject of hydrology requires special study, 
and the present volume should prove of aid to those who 
wish to pursue that study. 

Part IV. of the book, which deals with the indications 
for hydrological treatment, and which also contains an 
index of spas, should prove of s])ecial utility for reference 
by the general practitioner who is called u])on to advise 
concerning a course of baths and waters at home and 
abroad. 



The Practical Medicine Series, comjirising Ten Volumes 
on the Year's Progress in Medicine and Surgery. Under 
the General Editorial charge of Charles L. Mix, M.D. 
Volume IV. GyncTCology. Edited by Emilius C. 
Dudley, M.D., and Herbert M. Stowe, M.D. 
Chicago: The Year Book Publishers. 1013. 8vo. Pp.230. 

The custom of pul)lishing year books has become very 
common. The series issued by the Chicago Year Book 
Publishers lias the marked advantage over other such 
pu])]ications that the general practitioner is able for a 
jnoderatc sum to liave a r<''SU7nr of the whole of the annual 
medical news whilst the specialist need only secure the 
volume or volumes on the subject interesting to him. 



SwaYne — Obstetric Aphorisms. 269 

There has been very little original gynaecology during 
the past year. The treatment of tumours by x-rays is 
the most notable. Professor Doderlein said at this year's 
International Medical Congress that operation for tumour 
would be soon a thing of the past. We doubt greatly if 
hysterectomy and myomectomy will be abolished in our 
time. 

In the present volume there is a great deal concerning 
gynaecological disease in the insane. It is a difficult matter 
for the gynaecologist who encounters such conditions and 
who is exercised as to whether the operation to cure the 
disease will cure the insanity or will aggravate it. We are 
still far from a solution of this difficult problem. 

Amongst other interesting articles are : — The technique 
of removing adipose deposits in the abdominal wall, the 
premonitory symptoms of embolism, and the formation of 
artificial vaginae. 

The importance of blood loss in gynaecological operations 
cannot be too strongly urged. Many a Wertheim opera- 
tion has had a fatal result from this cause, when a little 
care in avoiding haemorrhage might have turned failure 
into success. 

There are some beautifully drawn illustrations. Those 
describing a new perinaeorrhaphy by Dorsett and an 
operation for uterine displacements modified by Willis 
are most instructive. 



Obstetric Aphorisms for the Use of Students commencing 
Midwifery Practice. By Joseph Griffiths Swayne, 
M.D. Eleventh Edition, revised and edited by Walter 
Carless Swayne, M.D., B.S. Lond., &c. ; Professor of 
Obstetrics in the University of Bristol, &c. London : 
J. & A. Churchill. 1913. Cr. 8vo. Pp. xiv + 21G. 

Swayne's " Obstetric Aphorisms," as evidenced by the 
publication of an eleventh edition, has enjoyed much 
favour, and this last edition should prove to be as popular 
as its predecessors. There is no intention to delve deeply 
into obstetrics. The work is divided into three parts, the 



270 Reviews and Bibliographical Notices. 

first embracing " The Management of Normal Labour ; '* 
the second, " Cases which the Student may undertake 
without Assistance ; " the third, " Cases in which the 
Student ought to send for Assistance." 

Before the twelfth edition appears we would make the 
following suggestions : — (1) That explanatory text should 
be given under each illustration. (2) That in illustrating 
any operative procedure the obstetrician should not be 
seen wearing an ordinary coat and cuffs extending to the 
wrist. (3) That palpation of the abdomen should be 
illustrated with the physician sitting to the right side of 
the patient. It is a pity that this is not a universal 
teaching. (4) That ante-partum haemorrhage should be 
dealt with more thoroughly. 

We offer these criticisms of an excellent work, which we 
can confidently recommend to the busy practitioner and 
student. 



Diseases of Children. A Practical Treatise on Diagnosis 
and Treatment for the Use of Students and l^racti- 
tioners of Medicine. By Benjamin Knox Raciiford. 
New York and London : D. Applet on & Co. 1912. 
Royal 8vo. Pp. xvii + 783. 

Though we are fortunate in the possession of several 
standard works on this subject, we are always glad to 
welcome another, provided it can add to our resources in 
dealing with a difficult department of practice. 

The fundamental ijnportance of the health of the child 
is receiving thorough if tardy recognition, and the autlior 
of the work before us occupies a projninent position 
amongst those who are striving to attain this end. A 
former President of the American Pediatric Society and 
physician to several panlintric institutions, he lirs made 
a very s])ecial study of tlie chikl iji liealth and disease, 
and tlie results are eml)odied iji the present volume. 

The work purports to be a " practical clinical treatise '* 
in which theoretical discussions fire omitted in order to 
find more space " to (clearly outline the differential 



Malins — Surgical Experiences in South Africa. 271 

diagnosis and give in full the treatment of these diseases." 
This object has been well achieved, and we have an 
account of the disorders of infancy and childhood, the 
complete and useful character of which only extended 
acquaintance can appreciate. 

The care of the normal child is not neglected — in fact 
the chapters dealing with this subject form perhaps the 
most original and readable in the book. Put in the 
author's words " the giving of medicine is a comparatively 
small part of the physician's duty." We are glad to see 
the scientific methods advocated for the preparation of 
milk and infant foods, the acme of which is probably, the 
" Rotch " method of milk laboratories from which milk 
may be ordered by prescription according to the strength 
desired — e.g., I^. Fats, 3 per cent. ; milk sugar, 6 per cent. ; 
protein, 1 per cent, (whey, 0.75 per cent. ; casein, 0.25 
per cent.). 

It is difficult to particularise in the case of such a work 
as this, as the entire is excellent, but we have no hesitation 
in recommending the book to those who seek a reliable 
guide in a subject which few, in one capacity or other, can 
escape. 

Surgical Experiences in South Africa, 1899-1900. Being 
mainly a Clinical Study of the Nature and Effects ot 
Injuries produced by Ballets ot Small Caliber. By 
George Henry Maijns. C.B., F.R.C.S. Second Edition. 
London : Henry Frowde, Oxford University Press, 
Hodder & St ought on. 1913. Demy 8vo. Pp. xvi + 
504. 

The title and above explanation are a sufficient description 
ot this well-known book. The fact that a second edition 
has been brought out is the best practical argument in its 
favour, and to our mind it is very remarkable that a book 
which can only appeal to a very small section of the 
profession should be in demand twelve years after its 
first appearance. However, all wonder disappears once 
a reader begins to master the contents, for there is some- 



272 Reviews and Bibliographical Notices. 

thing which appeals to the reader in spite of the fact 
that he may never have seen an injury inflicted by a 
modern weapon. Writing without definite knowledge one 
feels that this book must be used as a text-book by all 
who may be called upon to treat wounds received in 
warfare, and that it will continue to be so used, until the 
present day type of projectile is changed, is beyond doubt. 



RECENT WORKS ON DISEASES OF THE EYE. 

1. Diseases of the Eye. A Handbook of Ophthalmic 
Practice for Students and Practitioners. By G. E. de 
SCHWEINITZ, A.M., M.D. ; Professor of Ophthalmology 
in University of Pennsylvania and Ophthalmic Surgeon 
to the University Hospital ; Consulting Ophthalmic 
Surgeon to the Philadelphia Polyclinic ; Ophthalmic 
Surgeon to the Philadelphia Hospital ; Ophthalmologist 
to the Orthopaedic Hospital and Infirmary for Nervous 
Diseases. Seventh Edition, thoroughly revised. Phila- 
delphia and London : W. B. Saunders Company. 1913. 
8vo. Pp. 979. 360 Illustrations and 7 Chromo- 
lithographic Plates. 

2. Diseases and Injuries of the Eye. A Text-book for 
Students and Practitioners. By William George 
Sym, M.D., F.R.C.S.E. ; Ophthalmic Surgeon, Edin- 
])urgh Royal Infinnary ; Lecturer on Diseases of the 
Eye in the University of Edinburgh. London : Adam & 
Charles Black. 1913. Crown 8vo. Pp. xvi + 493. 
75 full-p:i.ge illustrations, IG of them in colour and 88 
figures in the text ; also a type test-card at end of 
volume. 

1. In reviewing any medical text-book which lias reached its 
seventh edition the reviewer is tem])te(l to think out what 
recent discoveries, methods of treatment, or operations he 
himself has knowledge of, and then to see which of these 
have been omitted trom tlie book he is reviewing. Working 
from this basis we can very heartily congratulate Dr. de 



Recent Works on Diseases of the Eye. 273 

Schweinitz on having incorporated in this present edition 
of his book on diseases of the eye certainly all the important 
novelties that have been introduced to ophthalmic surgeons 
in later years. We think, however, that in the sections 
treating of colour-vision and colour-blindness more atten- 
tion should have been paid to the work of Dr. Edridge- 
Green than the mere statement that he (amongst others) 
has designed a useful lantern for testing colour-blindness. 

The first four chapters are devoted to general optical 
principles, examination of the patient, the ophthalmoscope, 
normal and abnormal refraction. In these chapters the 
author has had valuable assistance from Dr. Edward 
Jackson, of Philadelphia. Following these preliminary 
chapters the diseases of the various regions of the eye and 
its appendages are carefully and fully explained, though 
(as the book is intended largely for students) we think a 
short paragraph at the beginning of each chapter treating 
of the anatomy of the region under discussion would be of 
use. The excellent chapter on operations is followed by 
an appendix on the use o^ the ophthalmometer and 
tropometer — the latter being an instrument not generally 
used in this country. The index is quite good, misprints 
are few and far between, though we fancy that the word 
" aural " on page 418 must be an error for " oral." 

The general get up of the book is excellent, and the 
illustrations are good. 

This is a book — rather too large for the average medical 
student, we think — to be thoroughly recommended to 
practitioners as presenting a clear, unbiased and definite 
view of diseases of the eye and their treatment. 

2. We can very heartily congratulate Dr. W. G. Sym upon 
the appearance of this his book. There are, and we may 
suppose there will be, many books of this kind, and there 
will always be a demand for them if they are as excellent 
as this present specimen. We may at the outset describe 
it as a " clinical " book — the author so calls it in his 
preface — which gives a very clear exposition of the 
generally accepted views of ophthalmic surgeons and a 

S 



274 Reviews and Bibliographical Notices. 

(perhaps) clearer exposition oi the views oi the author of 
the book. Now, the present reviewer ap])roves highly of 
this method of treating the subject for students. Take, 
for example, Dr. Sym on advancement in squint opera- 
tions : — " The variations in detail in the manner of 
operating are legion, each surgeon being prone to the 
opinion that the secret of success lies in some trifling 
modification or unimportant variation which he has 
invented, and which has no real significance whatever." 

He then proceeds to give a clear description of a " useful 
method," which we have no doubt he has frequently 
performed with success. This is the keynote of the book. 
Another ophthalmic surgeon reading the book may 
consider that the author is too dogmatic, but this view is 
not correct. What the student — and we may add the 
practitioner — wants in a book of this size and aim is a 
clear and definite method ot treating more or less definite 
conditions. The enunciation, in an abridged form, of the 
views of numerous ophthalmic surgeons on specific points 
may be interesting to specialists, but can be of little 
benefit to students. The adequate presentation of such 
differing views necessitates an encyclopaedia of ophthal- 
mology. 

There are three new features — at least new to the present 
reviewer in a book of this size — which we can heartily 
recommend — viz., the chapters on medico-legal questions, 
the points in general diagnosis (('ha])ter XXII.), and the 
bri(d' but excellent cha])ter on nursing (written by Sister 
Douglas, in charge of Dr. Sym's wards in the Royal 
Infirmary, Edinburgh). 

There is one point in the treatment of the eye after 
cataract extraction has been performed on which we hold 
an opinion differing from that of Dr. Sym — we do not put 
a '' so-called antiseptic dressing " on such an eye as an 
antiseptic for the eye, but as a method of limiting the 
movements of the eye and as a protection to the eye. We 
have tried the open method of treatment on upwards of 
100 patients— the Irish may differ from the Scotch — and 
we have found it unsatisfactory. 



MuiR — Ritchie — Manual of Bacteriology. 275 

We can thoroughly recommend this book to all students 
and practitioners ; and we are sure that there are very 
few specialists who will not derive much pleasure and 
profit from reading it. 



Manual of Bacteriology. By Robert Muir, M.A., M.D., 
Sc.D., F.R.S., Professor of Pathology, University of 
Glasgow ; and James Ritchie, M.A., M.D., F.R.C.P. 
(Ed.), Superintendent of the Royal College of Physicians' 
Laboratory, Edinburgh, formerly Professor of Pathology 
in the University of Oxford. Sixth Edition. With one 
hundred and ninety-two Illustrations in the text and 
six Coloured Plates. London : Henry Frowde, Oxford 
University Press, and Hodder & St ought or. 1913. 
Cr. 8vo. Pp. xxiv + 736. 

So recently as May, 1911, this manual was reviewed in the 
pages of this Journal. Little need be added to the 
favourable notice of the work which was then published. 
Well within three years another — the sixth — edition has 
been called for. 

The general form and size of the book remain unaltered, 
but its pages have undergone careful revision, and two 
noteworthy additions to its contents have been made. 
A chapter — the twenty-first — on Pathogenic Fungi has 
been added, and for assistance in its preparation the 
authors record in the preface their indebtedness to 
Professor Percy Groom, of the Imperial College of Science, 
London, and to Dr. Cranstoun Low, of Edinburgh. In 
this chapter the following examples of common non- 
pathogenic types of fungi are given and described — 
Zygomycetes : Mucor Mucedo (and other species of 
Mucor) ; Ascomycetes : Aspergillus herbariorum ( = A. 
niger), Penicillium crustaceum ( = P. glaucum), Saccharo- 
myces or Yeasts (Torula, Mycoderma) ; Fungi imperfecti : 
Oospora lactis (Fres.) ( = Oidium lactis). The common 
fungoid infections of the skin are then described — namely, 
tinea, favus, thrush, aspergillosis, vsporotrichosis and 
blastomycosis. The chapter ends with a brief note on 



276 Reviews and Bihliographical Notices. 

Micros j)oron furfur, the organism associated with 
pityriasis versicolor. 

In chapter V., on the methods employed in sanitary 
work for the bacteriological examination of the air, soil, 
water and milk, the section on the bacteriology of milk 
is new. The following sentence (page 1G7) is startling : — 
" Before the milk reaches the consumer, especially in city 
supplies, the bacterial content of apparently fresh milk 
may rise to several hundred thousands or even millions 
of bacteria per c.c." The organisms present belong 
chiefly to the group of milk-souring bacteria so wide- 
spread in nature, but to this group, unfortunately, the 
Bacillus coli and its congenors also belong. So too does 
the Bacillus enteritidis sporogenes, which plays an 
important causal part in infantile diarrhoea and summer 
diarrhoea. 

The volume contains twenty-two chapters so-called, 
and then follow nine appendices, and a very useful biblio- 
graphy. We are at a loss to understand why the word 
" Appendix " is used instead of " Chapter." Certainly 
the subject-matter is sufficiently important to justify the 
latter word — Small-pox and Vaccination, Hydrophobia, 
Malarial Fever, Amoebic Dysentery, Trypanosomiasis, 
Leishmaniosis, Piroplasmosis, Yellow Fever, Epidemic 
Poliomyelitis, Phlebotomus Fever, and Typhus Fever — 
such are the headings of the Appendices. 

The work can be recommended to both students and 
practitioners with confidence. 



LITERARY NOTE. 

A FIFTH edition of Dr. Burncy Yoo's " Manual of Medical 
Troatjucnt " is auuounctxl l)y Messrs. Cassoll & Co. Tlio 
revision has boon iairicH.1 out l)y Dr. Kaynioud Crawfurd and 
Dr. E. Faiquhar iJuzzaril, who collaborated with the author 
ill the fourth edition. 



PART III. 
MEDICAL MISCELLANY. 



SANITARY AND METEOP.OLOGICAL NOTES. 

Vital Statistics. 
For jour weeks ending Saturday, September 6, 1913. 

IRELAND. 

The average annual death-rate represented by the deaths — 
exchisive of deaths of persons admitted into public institutions 
from without the respective districts — registered in the week 
ended September 6, 1913, in the Dublin Registration Area and 
the twenty-six principal provincial Urban Districts of Ireland 
was 19.9 per 1,000 of their aggregate population, which for the 
purposes of these returns is estimated at 1,199,180. The 
deaths registered in each of the four weeks of the period 
ending on Saturday, September 6, and during the whole of that 
period in certain of the districts, alphabetically arranged, 
correspond to the following annual rates per 1,000 : — 



County Boroughs, &c. 


Week ending 


Average 
Rate 
for 4 
weeks 


Aug. 
16 


Aug. 
23 


Aug. 
30 


Sept. 
6 


27 Town Districts 


19.2 


18.7 


20.7 


19.9 


19.6 


Dublin Reg. Area 


18.6 


19.5 


20.4 


19.8 


19.6 


Dublin City 


21.0 


20.0 


21.1 


21.1 


20.8 


Belfast 


20.9 


18.7 


23.0 


20.7 


20.8 


Cork 


25.2 


24.5 


24.5 


19.7 


23.5 


Londonderry 


17.8 


21.6 


24.2 


15.3 


19.7 


Limerick 


16.2 


8.1 


10.8 


19.0 


13.5 


Waterford 


20.9 


13.3 


24.7 


34.2 


23.3 



The deaths (excluding those of persons admitted into public 
institutions from without the respective districts) from certain 



278 Sanitary and Meteorological Notes. 

epidemic diseases registered in the 27 districts during the week 
ended Saturday, September 6, 1913, were equal to an annual 
rate of 5.4 per 1,000. Among the 157 deaths from all causes in 
Belfast were ] from each of scarlet fever, measles and whooping- 
cough, and 30 from diarrhoea and enteritis of children under 
2 years. Included in the 29 deaths from all causes for Cork 
were 15 from diarrhceal diseases. Three of the 14 deaths from 
all causes for Limerick were from diarrhoea and enteritis of 
children under 2 years. Among the 18 deaths from all causes 
for Waterford were 3 from measles and 4 from diarrhoeal 
diseases. The 10 deaths from all causes for Galway included 
4 from measles and 3 from whoojiing-cough. Included in the 
10 deaths from all causes for Lisburn were one from each of 
measles and whooping-cough, and 4 from diarrhoeal diseases. 
Two of the 4 deaths recorded for Wexfoid were from diarrhoea 
and enteritis of cliildren under 2 years ; and 2 of the 3 deaths 
from all causes for Bally mena were from diarrha^a and enteritis 
of children under 2 years. Included iii the 4 deaths from all 
causes for Traleo were 2 from diarrhoea and enteritis of children 
under 2 years. Two of the 4 deaths for Newtownards were 
from diarrhoea and enteritis of children under 2 years of ago ; 
and 3 of the 7 deaths from all causes for Queenstown were 
from diarrhoeal diseases. 

DUBLIN REGISTRATION AREA. 

The Dublin Registration Area consists of the City of Dul)lin, 
as extended by the Dublin Corporation Act, 1900, together 
with the Urbaii Districts of Rathmines, Pembroke, BhK^knx^k, 
and Kingstown. The ])opulation of tliis area is 403,000 ; 
that of the City being 308,187, Rathmines 38,769, Pembroke 
29,942, Blackrock 9,161, and Kingstown 16,941. 

In the Dublin Registration Area the births registered 
during the week ended Septeml)er 6 amounted to 239 — 1 18 Imys 
and 121 girls, and the deaths to 157 — 74 males and 83 females. 

DEATHS. 

The deaths registered, omitting the deaths (numbering 4) 
of persons admitted into jnibUc institutions from locaUties 
outside the Area, represent nn annual rate of mortality of 
19.8 per LOOO of the pojnilation. During the thirty -six weeks 
ending with Satui'day, September 6, the death-rate averaged 
20.5, and was l.() below the mean rate for the corresponding 
portions of the ten years, 1903-1912. 



Sanitary and Meteorological Notes. 279 

The total deaths registered, numbering 157, represent an 
annual rate of 20.3 per 1,000. The annual rate for the past 
thirty-six weeks was 21.9 per 1,000, and the average annual 
rate for the corresponding period of the past ten years 
was 23.2 per 1,000 of the mean population for all deaths 
registered. 

The deaths included one from each of measles, whooping- 
cough, diphtheria and influenza, 2 from enteric fever, and 
31 deaths from diarrhoea and enteritis of children under 2 
years. In each of the 3 preceding weeks deaths from measles 
had been one, 0, and one ; deaths from enteric fever had been 
0, 0, and ; deaths from diphtheria had been 0, 0, and ; 
deaths from whooping-cough had been 3, 0, and ; deaths 
from influenza had been 0, one, and ; and deaths from 
diarrhoea and enteritis of children under 2 years had been 
27, 21, and 29. 

Of 28 deaths from tuberculosis (all forms) 20 were attributed 
to pulmonary tuberculosis, 2 to tubercular meningitis, 2 to 
abdominal tuberculosis, and 4 to other forms of the disease. 
In each of the 3 preceding weeks, deaths from all forms of 
tuberculosis had been 27, 30, and 26. 
There were 14 deaths from cancer. 

The deaths of 5 children were caused by convulsions, 3 being 
infants under one year of age. There was one death of one 
infant from congenital defects, and there were 5 deaths from 
congenital debility, and 4 deaths from premature birth. 

The deaths from pneumonia included one from broncho- 
pneumonia, and one from pneumonia (type not distinguished). 
Six deaths were caused by organic diseases of the heart. 
There were 7 deaths from bronchitis. 

The deaths from accidental causes or negligence, 4 in number, 
included the death of one child aged 2 years and 5 months from 
burns. There was one death by suicide. 

In two instances the cause of death was "uncertified," 
there having been no medical attendant during the last illness. 
These cases comprise the death of one infant under one year 
of age, and the death of one person aged 65 years. 

Sixty-six of the persons whose deaths were registered during 
the week were under 5 years of age (53 being infants under 
one year, of whom 7 were under one month old), and 22 were 
aged 65 years and upwards, including 17 persons aged 70 and 
upwards ; among the latter were 5 aged 75 and upwards. 



280 



Sanitary and Meteorological Notes. 



STATE OF INFECTIOUS DISEASE IN THE DUBLIN 
REGISTRATION AREA AND IN BELFAST. 

The usual returns of the number of cases of infectious 

diseases notified under the " Infectious Diseases (Notification) 

Act, 1889," and the " Tuberculosis Prevention (Ireland) Act, 

1908," as set forth in the following table, have been furnished 

by Sir Charles A. Cameron, C.B., M.D., Medical Superintendent 

Officer of Health for the City of Dul)lin ; by Mr. Fawcett, 

Executive Sanitary Officer for Rathmines and Rathgar Urban 

District ; by Mr. Manly, Executive Sanitary Officer for 

Pembroke Urban District ; by Mr. Heron, Executive Sanitary 

Officer for Blackrock Urban District ; by the Executive 

Sanitary Officer for ICingstown Urban District ; and by 

Dr. Bailie, Medical Superintendent Officer of Health for the 

City of Belfast. 

Table showing the Ndmbeu of Cases of Infectious Diseases notified in the Dublin 
Registration Area (viz. — the City of Dublin and the Urban Districts of liathmiiiea 
and llatligar, Pembroke, Blackrock, and Kingstown), and in the City of Belfast, 
during the week ended September 0, 1913, and during each of the preceding three 
weeks. An asterisk (*) denotes that the disease in question is not notifiable in the 
District. 



Cities a^u 
UiiHAN Districts 


Week 
ending 


en 

3 


O 93 

c 


9 

V 

0) 

<A 
u 
V2 




f 

Ci. 

a 
'3 


« 

"a. 


09 

9 
O 

u — 

- £ 
So 


O 

a ^ 


u 
> 

kl "C 

°c 

u C. 
1) >. 

i3 


a 

"3 

'5: 


e 

o 

u 

o 

3 

a. 


s 
o 
y 

bc 

c 

'E. 
o 
o 

.c 


13 

Q 
3 


3 3 

Ui ^' 

a> cc 

11 

&4 


01 

2 

3 
o 

< 


1 

c 
H 


City of Dublin 

KatliinineH Rnd f 
KatliKar 1 
IJrhan \ 
Dislrict { 

Puiiil>roke 
Urliiiii 
DiHtTict 

IMiiokrock j 
llrltan I 
DiHlrict 1 

KiiiftNlowii 1 
Url)an 
DiHlrict 

City of KeHaHt 

V 


Ang 16 

A.iK. 23 
Auk. ;iO 
Sept. G 

Autr. ifi 
AuR. 2;i 
AiiL'. ;!0 

Sept. (J 

Auff. 1« 
Auk, 2:i 
Auk. 30 
Sept. 6 

Aiisr. 10 
Aug. i>;t 
Anil. 30 
Sci)t. G 

Aug. 10 
Aug. 23 
An^. <)0 
Sept. G 

Aug. if. 
A Tig. '2-A 
Auk'. 30 
Sept. r. 


- 




12 
6 

15 
10 

1 

1 

23 
\i 
30 
44 


1 
'1 
1 
I 


: 


2 

ii 
1 

3 

1 

2 

1 

1 
1 

8 

11 

12 

5 

7 


1 


1 
1 


8 

7 
11 

3 

1 

2 
2 
2 
3 


4 

7 
3 
3 

I 

2 

2 
8 

1 
8 


2 


1 
1 


- 


7 

17 



8 

• 
• 
• 
• 

1 

• 
• 
• 
« 

V 
7 
7 




8r> 
•,\u 
36 
36 

3 

4 
1 

1 
2 
2 
1 

3 

1 

2 

66 
65 

^:^ 

65 



a Continued Fever 



Sanitary and Meteorological Notes. 281 

Cases of Infectious Diseases under Treatment in Dublin 

Hospitals. 

During the week ended September 6, 1913, 3 cases of enteric 
fever were admitted to hospital, 6 were discharged, there was 
1 death, and 34 cases remained under treatment in hospital 
at the close of the week, the respective numbers in hospital 
at the close of the three preceding weeks having been 43, 37, 
and 38. 

Four cases of typhus remained under treatment in hospital 
at the close of the week. At the close of the 3 previous weeks 
the cases in hospital had been 12, 6, and 4 respectively. 

One case of measles was admitted to hospital, one was 
discharged, and one case remained under treatment at the close 
of the week. At the end of the 3 preceding weeks such cases 
were 2, 2, and one respectively. 

Thirteen cases of scarlet fever were admitted to hospital, 
15 were discharged, and 57 cases remained under treatment 
at the close of the week. This number is exclusive of 13 
patients under treatment at Beneavin, Glasnevin, the Con- 
valescent Home of Cork Street Fever Hospital. At the close 
of the 3 preceding weeks the cases in hospital had been 59, 57, 
and 59. 

Eight cases of diphtheria were admitted to hospital, one was 
discharged, and there was one death. The cases in hospital, 
which at the close of the 3 preceding weeks had numbered 21, 
19, and 21 respectively, were 27 at the close of the week under 
review. 

In addition to the above-named diseases, 5 cases of pneu- 
monia were admitted to hospital, 7 were discharged, there 
was one death, and 15 cases remained under treatment at the 
end of the week. 

ENGLAND AND SCOTLAND. 

The mortality in the week ended Saturday, September 6, in 
96 large English towns (including London, in which the rate 
was 12.4) was equal to an average annual death-rate of 13.8 
per 1,000 persons living. The average rate for 16 principal 
towns of Scotland was 16.7 per 1,000, the rate for Glasgow 
being 19.1, and that for Edinburgh, 13.5. 



282 Sanitary and Meteorological Notes. 

INFECTIOUS DISEASE IN EDINBURGH. 

The Registrar-General has been favoured by A. Maxwell 
Williamson, M.D., B.Sc, Medical Officer of Health for Edin- 
burgh, with a copy of his Return of Infectious Diseases notified 
during the week ended September 6. From this Rejiort it 
aj)pears that of a total of 32 cases notified, 8 were of scarlet 
fever, 13 of phthisis, 8 of diphtheria, 2 of erysipelas, and one 
of i)ueri:)eral fever. Among the 308 cases of infectious diseases 
in hosjiital at the close of the week were 127 cases of scarlet 
fever, 93 of phtliisis, 33 of diphtheria, 33 of measles, 4 of 
whooping-cough, G of enteric fever, 6 of erysipelas, and 4 of 
chic ken "1)0 X. 



Meteorology. 
Abstract of Observations made in the City of Dublin, Lai. 53° 20' 

N., Long, 6° 15' W., for the month of August, 1913. 
Mean Height of Barometer, - - - 30.092 inches. 

Maximal Height of Barometer (27th, at 9 a.m), 30.332 ,, 
Minimal Height of Barometer (29tli, at 9 p.m.), 29.749 „ 
Mean Dry -bulb Temperature, - - 59.1°. 

Mean Wet-bulb Temperature, - - 5G.1°. 

Mean Dew-point Tem])eraturc, - - 53.4°. 

Mean Elastic Force (Tension) of Aqueous Vai)Our, .413 inch. 
Mean Humidity, - - -. - 81.8 per cent. 

Highest Temperature in Shade (on 14th), - 75.3°. 
Lowest Temperature in Shade (on 12th), - 46.8°. 
Lowest Temi)eraturc on Grass (Radiation) (12th 

and 19th), 44.8°. 

Mean Amount of Cloud, - - - 54.4 per cent. 

Rainfall (on 10 days), - - - - .941 inch. 

Greatest Daily Rainfall (on 9th), - - .295 „ 

General Directions of Wind, - - W., N.W., N.E. 

Remarks. 

The si)lcndid summer-like August of 1911 was followed by 
the dull, cold, wet, and generally inclement August of 1912 ; 
aud this has now been followed by an extremely fine, dry, 
bright and warm August in 1913. 

As regards atmosi)heric pressure, the outstanding feature 



Sanitary and Meteorological Notes. 283 

was the tendency to a high barometer reading over Ireland 
and the adjoining portions of the Atlantic. This led to a 
remarkable prevalence of northerly (between N.W. and N.E.) 
winds, which blew gently in Ireland but more strongly over 
Great Britain. As was to be expected from this, the weather 
was finer in Ireland than in the sister island. On three 
occasions, however, the weather broke — ^first, from the 8th to 
the 11th, when the secondary systems of a large but shallow 
depression centred in Scandinavia and the Baltic passed south- 
wards across the British Isles. In that interval DubUn City 
received .587 inch of rain in heavy showers. The second 
disturbed period began on the 21st, lasting to the 23rd. It was 
related to a depression, in which the barometer fell below 
29.2 inches in the South of Iceland. Strong S.W. winds and 
showers resulted, the rainfall being heaviest round the S., 
W., and N. shores of Ireland. Lastly, a shallow thunderstorm 
depression, which moved slowly northwards from Morocco to 
the English Channel, caused severe thunderstorms in many 
parts of the United Kingdom, and torrential rains in the South 
and South-east of England on Sunday, the 31st. Dublin 
escaped this visitation, and the 31st was a beautiful summer's 
day in and near the Irish capital. Special mention should 
be made of a magnificent meteor which passed over the South 
of Ireland at 10 55 p.m. of the 3rd. It was seen also from 
Greystones, Co. Wicklow, and from St. George's Channel near 
Holyhead. 

In Dublin the arithmetical mean temperature (59.7°) was 
exactly equal to the average (59.7°). The mean of the dry- 
bulb readmgs at 9 a.m. and 9 p.m. was 59.1°. The mean 
maximum temperature was 66.2° ; the mean minimum w^as 
53.2°. In the forty-nine j^ears ending with 1913, August was 
coldest in 1912 (M. T. = 54.4°) and in 1881 (M. T. = 57.0°), 
and warmest in 1899 (M. T. = 63.4°). In 1911 the M. T. 
was 63.2°. 

The mean height of the barometer was 30.092 inches, or 
0.195 inch above the corrected average value for August — 
namely, 29.897 inches. The mercury rose to 30.332 inches 
at 9 a.m. of the 27th, and fell to 29.749 inches at 9 p.m. of the 
29th. The observed range of atmospheric pressure was, 
therefore, 0.583 inch. 

The mean temperature deduced from daily readings of the 



284 Sanitary and Meteorological Notes. 

dry-bulb thermometer at 9 a.m. and 9. p.m. was 59.1°. It was 
0.6° above the value for July, 1913. Using the formula, Mean 
Temp. = Min. + {Max. — Min.) x .47, the mean temj^era- 
ture was 59.3°, or equal to the average mean temperature for 
August, calculated in the same way, in the thirty-five years 
1871-1905 inclusive (59.3°). The arithmetical mean of the 
maximal and minimal readings was 59.7°, compared with a 
thirty-five years' average of 59.7°. On the 14th the ther- 
mometer in the screen rose to 75.3° — wind, W. ; on the 12th, 
the temperature fell to 46.8° — wind, N.N.W. The minimum 
on the grass was 44.8° on the 12th, and again on the 19th. 
August, 1912, established a record for low temperatures. 

The rainfall was .941 inch on 10 days. The average rainfall 
for August in the thirty-five years, 1871-1905 inclusive, was 
3.240 inches, and the average number of rain-da3^s was 18. 
The rainfall, therefore, and the rain-days were much below 
the average. In 1900 the rainfall in August was very large — 
5.871 inches on 17 days ; in 1889, also, 5.747 inches were regip- 
tered on 22 days. On the other hand, in 1884, only .777 inch 
was measured on 8 days. August, 1905, established a record 
for rainfall in this month in Du])Un, for the measurement was 
7.019 inchet^ on 22 daya, 3.436 inches having fallen on the 25th. 
In 1912 the rainfall was as much as 5.277 inches on 23 days. 

Fresh winds were noted on 4 days, but never attained the 
force of a gale (8). Temi^crature reached or exceeded 70° in 
the screen on 6 days, and on 8 days fell below 50°. A solar 
halo was seen on the 12th. Lightning was seen on the 3rd, 
28th and 29th. 

The rainfall in Dublin during the eight months ending 
August 3 1st amounted to 16.()72 inches on 127 days, compared 
with 22.088 inches on 150 days in 1912, 11.592 inches on 
10!) days in 1911, 24.382 inches on 149 days in 1910, 16.677 
inches on 119 days in 1909, 17.244 inches on 135 days in 1908, 
1().5SS inches on 14(> days in 1907, 15.425 inches on 139 days 
in 1906, only 9.455 inches on 96 days during the same ])eriod 
in 1887, and a thirty-five years' average (1871-1905) of 
17.950 inches on 131 da vs. 



At the Normal Oliniatological Station in Trinity College, 
Dublin, the observer, Mr. 0. D. Clark, re])orts (hat the mean 
value of the readings of the dry-l)ulb thermometer at 9 a.m. 



Sanitary and Meteorological Notes. 285 

and 9 p.m. was 60.3°. The arithmetical mean of the daily- 
maximal and minimal temperatures was 60.3°, the mean 
maximum being 67.5°, and the mean minimum 53.1°. The 
screened thermometers rose to 77° on the 14th, and fell to 46° 
on the 12th. On the 12th, 19th, 20th, and 25th the grass 
minimum was 42°. Rain fell on 8 days to the amount of .94 
inch, the greatest fall in 24 hours being .37 inch on the 9th. 
The duration of bright sunshine, according to the Campbell- 
Stokes recorder, was 167.4 hours, of which 10. G hours occurred 
on the I7th and again on the 31st. The mean daily duration 
was 5.4 hours. The mean sub-soil temperatures at 9 a.m. 
were— at 1 ft., 61.6° ; at 4 ft., 58.6°. 



At Ardgillan, Balbriggan, Captain Edward Taylor, D.L., 
registered only .41 inch of rain on 9 days, the greatest fall in 
24 hours being .14 inch on the 8th. The rainfall was 3.24 
inches below the average, and the rain-days were 9 in defect. 
Since January 1, 1913, 16.99 inches of rain have fallen on 122 
days, the measurement being 1.91 inches and the rain-days 
3 less than the average. The thermometer in the screen rose 
to 75.8° on the 14th, and fell to 44.0° on the 12th. The present 
was the driest August experienced at Ai'dgillan within the past 
twenty years. In August, 1905, the rainfall was 6.89 inches. 

Mr. T. Bateman reports that the rainfall at The Green, 
Malahide, Co. Dublin, was only .525 inch on 7 days ; the 
heaviest fall in 24 hours was .300 inch on the 10th. The 
mean shade temperature was 58.1°, the extremes being — 
highest, 75.0° on the 14th ; lowest, 40.5° on the 7th. 

At the Ordnance Survey Office, Phoenix Park, rain fell on 

10 days to the amount of .735 inch, the greatest rainfall in 
24 hours being .270 inch on the 10th. The total duration 
of bright sunshine was 168.9 hours, the greatest daily sunshine 
being 12.5 hours on the 25th. The thermometer rose to 76.0° 
in the screen on the 14th, and fell to 37.0° on the 19th. 

Miss C. Violet Kirkpatrick measured 1.14 inches of rain on 

11 days at Cheeverstowii Convalescent Home, Clondalkin, Co. 
Dublin, the largest record in 24 hours being .27 inch on the 
9th. 

Dr. Christopher JojTit, F.R.C.P.I., recorded a rainfall of 
.838 inch on 9 days at 21 Leeson Park, Dublin. The 
greatest fall in 24 hours was .310 inch, which occurred on 



286 Sanitarij and Meteorological Notes. 

the 9th. In July Dr Joyiit measured .511 inch of rain on 
10 days, the maximum in 24 hours being .145 inch on the 
18th. 

Mr. George B. Edmondson reports that at Manor Mil Lodge, 
Dundrum, Co. Dublin, the rainfall was .69 inch on 10 days. 
The maximal fall in 24 hours was .22 inch on the 9th. 
The mean shade temi)erature was 60.1°, the range being from 
77° on the 2nd, 14th and 16th to 46° on the 20th and 21st. 

Dr. Arthur S. Goff reports that at Belfort House, Dundrum, 
Co. Dublin, rain fell on 9 days to the amount of .79 inch, the 
greatest daily fall being .20 inch on the 9th. The shade 
temperature ranged from 77° on the 2nd, 14th and 16th to 
48° on the 6th and 12th. The mean temperature in the shade 
was 61.2°. 

According to Mr. W. J. M'Cabe, the Observer for the Right 
Hon. Laurence Waldron, at Marino, Killiney, Co. Dublin, 
only .41 inch of rain fell on 7 daj^s. The maximal fall in 
24 hours was .20 inch on the 10th. The average rainfall at 
Clonccvin, Killiney, in August of the twenty-four years, 
1884-1907, was 3.212 inches on 16.8 days. 

Dr. A. J. Blake, Resident Medical Superintendent of the 
Sanatorium of the Dublin Joint Hosi)ital Board, Crooksling, 
Brittas, Co. Dublin, recorded a rainfall of l.()l inches on 11 
days. The heaviest fall in 24 hours occurred on the 10th 
and measured .63 inch in the gauge. In July, the rainfall 
at Crooksling was 1.21 inches on 12 daj^s, the largest measure- 
ment in 24 hours being -31 inch on the 18th. 

According to Dr. J. H. M. Armstrong, at Coolagad, Grey- 
stones, Co. Wicklow, the rainfall for August was .93 inch on 
8 days. The heaviest fall in 24 hours was .31 inch on the 10th. 
The total fall since January 1 amounts to 24.20 inches on 128 
days. A brilliant meteor was seen in the west at 10 15 p.m. 
of the 5th. 

At Auburn, (Jreystones, Co. Wicklow, Mrs. Sj'dney 
O'SuUivan recorded a rainfall of .75 inch on 8 days. The 
greatest measurements in 24 hours were .22 inch on the 9th 
and .21 inch on the 10th. On the 22nd also .20 inch was 
recorded. 

At the Royal National Hos]ut<al for CoiLsumption for 
Ireland, Newcastle, Co. Wicklow, Dr. F. Crosbie, M.D., 
Assistant Resident Medical Ollicer, reports that rain fell to the 



Sanitary and Meteorological Notes. 287 

amount of 1.29 inches on 5 days, the greatest daily rainfall 
being .44 inch on the 9th. The screened thermometers rose 
to 75° on the 14th, and fell to 47° on the 2nd. The mean 
maximum temperature was 65.1°, the mean minimum tem- 
perature was 52.8°, and the mean temperature was 59.0°. 

The Rev. Arthur Wilson, M.A., returns the rainfall at the 
Rectory, Dunmanway, Co. Cork, as 1.37 inches on 12 days. 
This rainfall was 3.20 inches below the average. The largest 
measurements in 24 hours were .29 inch on the 21st, and again 
on the 22nd. At Dunmanway the month was very warm, 
especially from the 1st to the 6th, the 13th to the 17th, and 
the 24th to the 28th. The last 3 days were dull and cool. 
From June 23rd to August 19th inclusive the rainfall was only 
.69 inch, following a fall of .70 inch on the night of June 22nd. 
Thunder and heavy showers occurred on the afternoon of 
August 11th. The average rainfall in August, based on the 
returns for the last eight years, is 4.67 inches. In 1911, the 
rainfall to August 31 equalled 33.35 inches ; in 1912 it 
amounted to 41.54 inches. In 1913 it has been 41.00 inches, 
or 6.02 inches above the average (34.98 inches). 



THE ROLE OF THE THYMUS IN EXOPHTHALMIC GOITRE. 

Dr. M. G. Seelig, in an elaborate article on the role of the 
thymus in Graves's disease, concludes: — In Graves's 
disease an enlarged thymus occurs in 80 to 90 per cent, of 
the cases in which operation on the thyroid was followed 
by death. There is no statistical evidence on which to base 
the statement that the existence of an enlarged thymus 
contra-indicates thyroidectomy for Graves's disease. Further- 
more, there is no proof that an enlarged thymus adds an 
independent source of toxic danger in cases of Graves's 
disease. It is impossible to ascertain whether the enlarged 
thymus is a congenital or an acquired condition; but it 
cannot be denied that the status thymicolymphaticus may 
be a general tissue reaction brought about by hyper- 
thyroidism. It may be possible, therefore, that a primary 
hyperplastic thymus may share secondarily in the general 
atrophy that occurs as the result of a Graves's cachexia. — 
Interstate Medical Journal, Vol. XX., No. 7. July, 1913. 



PERISCOPE. 

SANATORIUM SCAREMONGERS IN DUBLIN. 

It is tlio fashion at the present time to say that an intelhgent 
Enf^disliman always turns out on examination to be an Irish- 
man, a Gennan, or a Jew. Certainly exceptionally clever 
individuals of these races seem easier to name offhand than 
men of our own. Perhaps they advertise themselves better. 
But in any case the truth is that the greatest common 
measure of each nation shows the same number of wise men 
and fools. Look at the panic in Ireland about the infective 
dangers of consumption which is still making the United 
Kingdom laugh at such a shameless combination of cowardice 
and folly. A modern sanatorium for consumption, as we 
have often repeated, is not only no danger to a locality, it 
even tends to raise the rents. But the stupidity which 
cannot grasp the first of these facts is accompanied by a 
paralysis of the business faculties which cannot grasp the 
second, for folly is justified of her children on commercial as 
well as on other grounds. Thus last week the Dublin news- 
papers were reporting, under the suggestive title of " Another 
Peamount? " the terrible discovery that T^ady Aberdeen had 
purchased a house and grounds seven miles from Dublin (a 
dn>adful proximity, is it not?) with a view to establishing a 
large consumptive hospital, and the locality was urged to 
bestir itself to prevent her from doing so. Happily, the 
bubble colla])sed after a free incision on the part of Sir 
Tjambert Ornisby, Senior Surgeon to the National Children's 
Hosi)ital, Dublin, and of Dr. E. J. McWeeney, Professor of 
Pathology and Bacteriology at University College, Dublin, 
who pointed out that the sanatorium is intended for cases 
of tubercular bones and joints requiring surgical treatment. 
Unable, of course, to grasp the difference between the 
pulmonary and non-pulmonary tuberculosis from the point 
of view of infection, the protesting Irishmen are feeling very 
much ashamed of themselves. Since, however, the hospital 
world cannot permit itself so cheap a victory over a few 
terrified laymen, we cannot forbear to iK)int out that, the 
object of the sanatorium once known, " non-infectious " is 
an adjective likely to be used as recklessly as its opposite. 



Periscope, 289 

The point to make, again, is not that one type of sanatorium 
is less "a danger" to the community than another, but 
that neither, under proper control, is a danger at all. Sea- 
sickness is not at present believed to be infectious. But 
why should we set limits to the beneficent discoveries of 
science? If it is considered infectious in the future, that 
will be no reason for preventing people from going on the 
sea. It will be a reason for providing proper isolation 
arrangements on every vessel, which is exactly what the 
sanatorium provides for infectious consumptives on land. — 
The Hospital, Saturday, September 13, 1913. 

DEATH FROM THE INTRAVENOUS INJECTION OF SALVARSAN. 

Dr. S. Gordon Fleming, Adelaide, reports a case of death 
from salvarsan. The patient, a robust man of nineteen,, was 
given 0.6 grm. of salvarsan a short time after the appear- 
ance of a hard chancre, and before any secondary manifes- 
tations ; and two weeks later a second injection of 0.6 grm. 
was given. He had only a slight reacc^on, was detained in 
hospital over night, and next morning was allowed to 
return home. Dr. Fleming saw him the following day — 
March 14th — about forty-eight hours after the second in- 
jection. He was then complaining of a general feeling of 
being ill, of epigastric pain, and sensitiveness to noises — all 
noises sounding like the beat of a drum. On the way home 
he had been compelled to lie down in the gutter for fifteen 
minutes owing to giddiness. He was flushed and sweating. 
Temperature 101°, pulse 90, knee-jerks slightly exaggerated. 
About eight hours later he became irrational, and was very 
frightened over his condition. Eigors were frequent; pupils 
equal and active. Bowels opened by an enema. The next 
morning he was stuporous. He made no response to ques- 
tions, but reacted to painful stimuli; Babinski's sign 
present ; knee-jerks exaggerated ; had eighteen fits during 
the following twenty-four hours. He vomited four or five 
times. He was seen in two convulsions ; one was gen- 
eralised, the other was definitely left-sided. By a lumbar 
puncture an ounce and a half of clear fluid was withdrawn 
under pressure. The fluid contained blood, excess of cells, 
no micro-organisms. The patient gradually subsided into a 
deeper coma, and died ninety-six hours after the injection, 
or forty-eight hours from the onset of symptoms. His urine 



290 Periscope. 

was not obtained, and no post-7nortcm was allowed. The 
author gives a summary of eight fatal cases following on the 
use of salvarsan. Of these, seven cases followed on the 
administration of the second injection of the drug, and in 
one instance death resulted from one injection. In all these 
cases meningo-cncophalitis with more or less htemorrhage 
was found. — The Australian tlcdical Gazette, Vol. 
XXXIII., No. 24. Sydney, June 14th, 1913. 

DR. LOUIS MERCK. 

The death is announced from Darmstadt of Geheimer Kom- 
mcrzienrat Dr. Louis Merck, in his 59th year. Dr. Merck. 
whose death occurred on Monday, September 15th, was head of 
what is probably the oldest established chemical factory in the 
world — namely, that of E. Merck, of Darmstadt. The busi- 
ness was founded in 1668 by Friedrich Johann Merck, and 
has since remained in the uninterrupted possession of the 
family. Dr. Louis Merck entered the firm thirty years ago, 
and in addition to directing the business generally, he was 
the active head of the scientific department, in which scores 
of trained chemists are engaged in research work. He was a 
life member of the Hessian Upper Chamber, but took no 
active interest in politics ; he was also a \dce-president for 
many years of the Grand Ducal Chamber of Commerce. Dr. 
Merck was deeply interested in " welfare " work, and himself 
superintended the organising and devel()]iment of the social 
institutions connected with the chemical works. It is an 
interesting fact that Dr. Merck's firm was one of the earliest 
pioneers in the production of alkaloids, and a])out thirty years 
ago practically held the monopoly in the manufacture of san- 
tonin ; this drug has lately attracted niuch attontioii owing to 
the fact that, as a consequence of the establishment by the 
Ilussian Government of a monopoly in the control of the raw 
material (from which santonin is produced), which grows on 
the Turkestan Steppes, the price of the drug has within a few 
years advanced from 4s. per lb. to £5. Tlie firm was also the 
first to sup]ily cocain on a commercial scale, and in fact was 
the only house able to su])])ly this alkaloid when, nearly thirty 
years ago, at the time when Dr. Louis Merck entered the busi- 
ness, the attention of medical men was drawn to the drug ; 
at that time the value of cocain was Is. 6d. a grain, or some- 



Periscope. 2^1 

thing like a hundred times its present price. The works cover 
an area of 75 acres, and consist of over 200 separate buildings 
intersected by miles of railway lines. — The Times, Sept. 20, 
1913. 

TROPICAL NORTH QUEENSLAND. 

The other day Sir W. MacGregor, Governor of Queensland, 
opened the new buildings of the Institute of Tropical Medicine 
at Townsville, North Queensland. The Institute owes its 
origin to the pioneer work of Dr. Frodsham, then Bishop of 
North Queensland, and Professor Anderson Stuart, Dean of 
the Faculty of Medicine at the University of Sydney. These 
gentlemen had separate schemes which were amalgamated. 
And now the combined scheme has first borne fruit by Sir 
William MacGregor — himself a distinguished medical man — 
presiding at the function above referred to. The Imperial 
Colonial Office gave £400 to help at the start, Mr. W. K. 
D'Arcy, a wealthy Queenslander resident in this country, 
contributed £1,000, and the Universities of Sydney, Melbourne, 
and Adelaide subscribed. Dr. Anton Breinl, who has been 
absorbed in tropical research work for the past ten years, and 
wa? associated with the Liverpool School of Tropical Medicine, 
was appointed Dkector, and temporary premises were secured 
at the Townsville (North Queensland) hospital. The com- 
pelling necessities of finance have been surmounted by the 
Federal Government of Australia subscribing £4,000 a year 
and the Government of Queensland £400 a year. With this 
backing the Committee of Management set to work, and now 
the Institute has under Dr. Breinl's charge a competent staff 
of scientific men : Dr. Nicol, late of the Lister Institute, 
engaged on Ankylostomiasis and Intestinal Parasites ; Dr. 
Priestley (Lister Institute), studying the Mutations of Bacteria 
and Pathology of the Great White Races ; Dr. Taylor, Ento- 
mologist ; and Dr. Young (Lister Institute), who will study 
*' Food and Nutrition." Beyond the research which gathers 
roimd the " Ro^sa Cycle " in Malaria, &g., the Institute has a 
great work in hand, which is really its mainspring, no less a 
work than that of solving the great question of the White 
Race in Tropical Australia — what is its future ? As the home 
of a great White Race, Tropical Australia is on its trial, and 
this is one of the greatest and most interesting of modern 



292 New Preparations and Scieyitific Inventions. 

questions of statesmanship. Science, through Dr. Breinl's 
work and that of his staff, alone can give a repl} , and the 
North Queensland Inf-titute is now hard at work gathering 
material for coi^sideration of this weighty problem, upon the 
solution ot which the thorough settlement of Australia as a 
whole depends. If the policy succeeds (and see what has been 
done at Panama) there will be room and work for millions of 
Britons in the fertile regions skirting north and north-eastern 
Queensland. The problem, in a word, which has to be tackled 
is how to regulate life in the troi)ics so that white people may 
letain the characteristics of a fine white race, and that was 
the text of Sir William MacGregor's address, and will be the 
watchword of the Tropical Institute now at work in Northern 
Queensland. 



NEW PREPARATIONS AND SCIENTIFIC INVENTIONS. 

Transparent Zoological and Anatomical Specimens. 

Among the many remarkable exhibits in the wonderful 
Museum of the XVIIth International Congress Of Medicine 
held in London in August last, one of the most novel and 
interesting was that of Prof. Dr. Werner Spalteholz, ot 
Leipzig, demonstrating his method of rendering organs and 
tissues transijarent, and of illustrating the vascular su])])ly 
of bones, &c. The Professor's exhibit (Nos. 3375 to 331)0 in 
the Catalogue of the Museum) included a number of bones 
stained with alizarin — a red, cr>:stallhie ])rinciple, C14 H« O4, 
obtained synthetically from coal-tar and from madder {Rubin, 
tinctoria) — decalcified, and rendered maximally tran.s])arent b\ 
means of a mixture of oil of winter-green and benzyl-l)enzoate. 
This method enables the observer to see the skeleton, the 
muscles, the thoracic and abdominal viscera through the skin 
as in a good skiagra])h. The epii)hyseal lines can be demon- 
strated in a young human being, and the gradual ossilieation 
of the skeleton may ))e studied with ease by this marvellous 
process, the patent of which, we understand, has been recently 
accpiired l)y the Chemical Works, 59-63 Park Street, South- 
wark, London, S.E. Within a short tinu^ the Firm in (piestion 
will be in a ])ositi(>n to su])])ly almost any ()i)jeet desired after 
treatnuMit by Dr. S2)altehol//s process. 



PART IV. 



MEDICAL EDUCATION AND EXAMINATIONS 

IN IRELAND. 

1913-1914. 

Medical students in Ireland, as elsewhere, have in the first 
instance to choose between University Degrees and Non- 
University Qualifications or Diplomas. Should they elect 
to try for a University Degree, their choice must lie 
between the University of Dnblin, which requires a Degree 
in Arts before registrable Degrees in Medicine, Surgery, and 
Midwifery are conferred; the National University of Ireland? 
which — while not requiring an Arts Degree — requires all 
students to pass a Matriculation Examination in Arts, before 
a candidate enters upon the curriculum in the three branches 
of medicine already mentioned — Medicine, Surgery, and 
Midwifery ; and the Queen's University of Belfast, in wdiich 
also a Matriculation Examination in Arts is required. 
Under the Regulations of the School of Physic in Ireland 
considerable Professional Privileges are afforded to medical 
students in regard to the Arts Curriculum of the University 
of Dublin. 

Outside the Universities, the chief Licensing Bodies are 
the Royal Colleges of Physicians and Surgeons. The 
position of the Apothecaries' Hall of Dublin as a Licensing 
Corporation under the Medical Act of 1886 has been defined 
by the appointment of Examiners in Surgery by the General 
Medical Council at the bidding of His Majesty's Privy 
Council. 

The Royal Colleges of Physicians and Surgeons are in a 
position to give a first-class working qualification in Medicine, 
Surgery, and Midwifery — a qualification which is registrable 
under the Medical Acts, which is universally recognised as one 
of high merit, and the possession of which is attended by no 
disabilities, such as preventing its possessor from dispensing 
medicines or keeping open shop for the sale of medicines, if 
he is legally qualified to do so. 



204 Medical Education and Examinations in Ireland. 

The Medical Schools in Ireland are — (1.) The School of 
Physic in Ireland, Trinity College, Dublin; (2.) Tlie Schools 
of Surgery of the Royal College of Surgeons in Ireland 
(including the Carmichael College of Medicine and the 
Ledwich School of Medicine) ; (3.) The University College 
Medical School, Cecilia-street, Dublin ; (4.) The Faculty of 
Medicine, Queen's University of Belfast; (5.) The School of 
Mediciue, University College, Cork; and (6.) The School 
of Medicine, University CoUege, Galway. 

Facilities for Clinical Instruction in fully-ecjuipped Medico- 
Chirurgical Hospitals exist in Dublin, Belfast, Cork, and 
Galway; but, as a rule, the Schools of Medicine in Ireland 
are not attached to a given hospital, or vice versa, as is the 
case in London and other large centres of medical education. 
The student will, however, have little difficulty in selecting 
a lios})ital, in the wards of which he will receive excellent 
bedside teaching and have ample opportunity of making 
himself familiar with the aspect and treatment of disease. 

The detailed information which follows is authentic, being 
taken directly from the published calendars of the respective 
licensing bodies. 



REGULATIONS PRESCRIBED BY THE GENERAL 
MEDICAL COUNCIL. 

With regard to the course of Study and Examinations which 
persons desirous of qualifying for the Medical Profession shall go 
through in order that they may become possessed of the requisite 
knowledge and skill for the efficient practice of the Profession, 
the General Medical Council have resolved that the following con- 
ditions ought to be enforced without exception on all who com- 
mence their Medical Studies at any time after Jan. 1, 1802: — 

(a.) The period of Professional Studies, between the date of 
Kegistration as a Medical Student and the date of Final Examina- 
tion for any Diploma which entitles its bearer to be registered 
under the Medical Acts, must be a period of bond fide study 
during not less than five years. For the purpose of this require- 
ment the close of the fifth year may be reckoned as occurring 
at the expiration of iifty-sevcn months from the date of regis- 
tration. 



Medical Education and Examination.^ in Ireland. 295 

(b.) In every course of Professional study and Examinations, 
the following subjects must be contained: — 

I.) Physics, including the Elementary Mechanics of Solids and 
Fluids, and the Rudiments of Heat, Light, and Elec- 
tricity. 
(II.) Chemistry, including the principles of the Science, and the 

details which bear on the study of Medicine. 
(III.) Elementary Biology. 
(IV.) Anatomy. 
(V.) Physiology. 
(VI.) Materia Medica and Pharmacy. 
(VII.) Pathology. 
(VIII.) Pharmacology and Therapeutics. 

(IX.) Medicine, including Medical Anatomy and Clinical Medicine. 
(X.) Surgery, including Surgical Anatomy and Clinical Surgery. 
(XI.) Midwifery, including Diseases peculiar to Women and to 
New-born Children. [By a recent decision of the General 
Medical Council the study of (XI.) must not commence 
till the student has held the posts of Clinical Clerk and 
Surgical Dresser.] 
(XII.) Theory and Practice of Vaccination. 
(XIII.) Forensic Medicine. 
(XIV.) Hygiene. 
(XV.) Mental Disease. 
(XVI.) Anaesthetics. 

The General Medical Council considers that the Regulations of 
the Examining Bodies should be so framed as to ensure that the 
study of the Final Group of Subjects (VII. to X VI. above) shall 
extend over a period of not less than twenty-four months after the 
passing of the Examination in Anatomy and Physiology. 

The first four of the five years of Medical Study should be 
passed at a School or Schools of Medicine recognised by any of 
the Licensing Bodies, provided that the First Year may be passed 
at a University, or Teaching Institution, recognised by any of 
the Licensing Bodies and approved by the Council, where the 
subjects of Physics, Chemistry, and Biology are taught. 

A student who has, previous to registration, attended a course 
or courses of study in one or all of the subjects, Physics, Chemistry, 
or Biology, in any University, School of Medicine, or Teaching 
Institution recognised by any of the Licensing Bodies, may without 
further attendance be admitted to examination in these subjects. 

A graduate in Arts or Science of any University recognised by 
the General Medical Council, who has spent a year in the study of 
Physjp9, Chemistry and Biology, and has passed an examination 



296 Medical luhicdfiou and /'J.raniinatiofis in Itr/and. 

in these subjects for the degrees in question, is held to luive com- 
pleted the first of the five years of medical study. 

Six months instruction or more in the Preliminary Sciences at a 
Teaching Institution (other than a Medical School) recognised by 
one of the Licensing Bodies and approved by the Council may 
count as six months, and no more, of tlie Curriculum of Professional 
Study, provided such instruction is subsequent to the date of 
passing the required Prelitninary Examination in general education. 

Tlie Examinations in tlie Elements of Pliysics, Cliemistry, and 
Biology should be passed before the beginning of the Second 
Winter Session. 

Tlie General Medical Council considers that no Qualification in 
Medicine ought to be granted without evidence of Clinical 
Instruction in Infectious Diseases. 



I. 

University of Dublin. 



DEGREES AND DIPLOMAS IN MEDICINE, SURGERY, AND 
MIDWIFERY ; AND IN DENTISTRY. 

The Medical School of the University of Dublin has for its 
ofTicial title the name of The School of Physic in Irelatid. It is 
officered by University Professors and Examiners and by four 
King's Professors appointed by the President and Follows of the 
Royal College of Physicians of Ireland, acting as Trustees of the 
Estate of Sir Patrick Dun. 

Matriculation. 
Students cannot be permitted to attend any of the Courses of 
Instruction in the School of Physic in Ireland until they have 
Matriculated. There is no special Examination ; the Public 
Entrance and Term Examinations of Trinity College, or any other 
of the Preliminary Examinations recognised by the General Medical 
Council, IxMug accepted as equivalent. The Matriculation Fee 
is Five Shillings. It is not necessary for Students to have their 
names on the College Books, or to attend any of the Academical 
duties of the University, unconnected with the School of Physic, 
unless they desire to obtain a Diploma or Degree in Medicine, 
Surgery, and Midwifery. Students may matriculate at the 
commencement of either the Winter or the Summer Session. 
The I7th of November is the last day of admission to the Winter 



\ 



Medical Edacatlon and Examinations in Ireland. 297 

Session. In the Summer Session the day varies a good deal 
according to the time at which Easter occurs, and the Courses of 
Lectures for which the Student proposes to enter. 

WOMEN STUDENTS. 

Women Students are now admitted to the Degrees and Diplomas 
in Medicine, Surgery, and Midwifery, on the same conditions as 
men. A special Anatomical Department, with separate entrance, 
dissecting-room, and reading-room, has been erected by the 
Board of Trinity College for their accommodation. 

Qualifications. 
The Qualifications in Medicine, Surgery, and Midwifery, and in 
Dental Science, granted by the University are as follow : — 

The Degrees are : — 

1. Bachelor in Medicine. 

2. Bachelor in Surgery. 

3. Bachelor in Obstetric Science. 

4. Doctor in Medicine. 

5. Master in Surgery. 

6. Master in Obstetric Science. 

7. Bachelor in Dental Science. 

8. Master in Dental Science. 

The Diplomas are : — 

1. Diploma in Public Health (formerly Qualifica- 

tion in State Medicine). 

2. Diploma in Medicine. 

3. Diploma in Surgery. 

4. Diploma in Obstetric Science. 

Final Medical Examination. — ^Part L 

The subjects are — Pathology, Materia Medica and Therapeutics, 
Medical Jurisprudence and Hygiene. 

Before they are admitted to the Examination, Students must 
have attended the prescribed Courses of Study, passed the Inter- 
mediate Medical Examination, Part II., and paid the Liceat 
Fee (£5). 

Vaccination (Fee, £1 Is.) should be taken out in the fourth 
year. 

Final Medical Examination. — ^Part II. 

The subjects are— (a) Medicine, Clinical Medicine, and Mental 
Disease ; (6) Surgery, Clinical Surgery, Surgical Operations, and 



298 Medical Education and Examinations in Ireland. 

Ophtlialmio Surgery ; (c) Midwifery and Gynjecology (clinical, 
papers, and viva voce). 

Candidates for the Final in Surgery will be required to produce 
a certificate of instruction and practice in the adniiuistration of 
general x\na'Sthetics. 

Students may present themselves for Examination in any of 
these groups (a), (h) or (c), separately or together, at any of 
the Examinations during their Fifth Year ; but they must leave 
at least one of these groups until the end of their Fifth Year. 
Before presenting themselves for any of these groups, Students 
must have attended all the prescribed Courses of Instruction in 
the subject in which they present themselves for Examination, 
and paid the Liceal Fee (£5). Candidates in any group who fail 
to satisfy the Clinical Examiners are not permitted to proceed 
with the other parts of the Examination in which they have failed. 

Total Expenses of the required Courses. 

I. Lectures .. .. £67 4 

IT. Hospitals . . . . 55 13 

ITI. Degrees (M.B., B.CL, B.A.O.) . . 27 



Total .. £U9 17 

UNIVERSITY DIPLOMAS. 

Candidates for the Diplomas in Medicine, Surgery, and Obste- 
tric Science must be matriculated in Medicine, and must have com- 
pleted two years in Arts, and five years in Medical Studies. 

The dates, regulations, and subjects of Examination are the 
same as for tlie Degrees. 

Diplomates on completing the Course in Arts, and proceeding 
to the Degree of B.A., may be admitted to the Degree of Bachelor 
on paying the Degree Fees. 

Tlie Liceat fees are the some as for the Finals. 

Candidates who have completed the prescribed Courses of 
study and passed all the Examinations will be entitled, if Grad- 
uates in Arts, to have conferred on them the Degrees of M.B., 
B.Ch., B.A.O. . on payment to the Senior Proctor of the Degree 
Fees amounting to £17. A corresponding reprulation applies to 
the Diplomas, the Fees for which are £11. They will also obtain 
from the Senior Proctor a Diploma entitling them to be entered 
on the Register of Medical Practitioners under the Medical Act, 
1886. 



Medical Kducatioii and Exarninations in Ireland. 299 

DIPLOMA IN PUBLIC HEALTH OR STATE MEDICINE. 
The Diploma in Public Health is conferred, after examination, 
by the University of Dublin, upon Candidates fulfilling the 
conditions required by the General Medical Council. 



II. 
The National University of Ireland. 

THE MATRICULATION EXAmNATION. 
This Examination will be held in Dublin, and at certain local 
Centres selected by the Senate. 



DEGREES OF M.B., B.Ch., AND B.A.O. 

Printed Forms of application for admission to any Medical 
Examination may be had from " The Registrar, The National 
University of Ireland, Dublin/' 

Each Candidate must send to the Registrar a printed Form of 
Application for admission, accurately filed wp and signed by the 
Candidate, together with the prescribed fee. 

THE M.D. DEGREE. 

Candidates may present themselves for the Examination for 
this Degree after an interval of three academical years from the 
time of obtaining the M.B., B.Ch., B.A.O. Degrees ; but in the 
case of Candidates who shall have obtained a degree of the 
University in the Faculty of Arts, an interval of two academical 
years shall be sufficient. 

Printed Forms of application for admission to this Examination 
may be had from " The Registrar, The National University of 
Ireland, Dublin." 

Candidates at this Examination must answer in the following 
subjects : — 

I. Medicine. 
II. Pathology. 

The Examination in each subject consists of : — 

(a) A Written Examination. 

(b) An Oral Examination. 

In addition every Candidate must diagnosticate at the bedside 
at least three Medical cases, and prescribe treatment. He must 
also write detailed reports on at least two cases to be selected by 
the Examiners, and discuss the questions arising thereon. 



300 Medical /Education and Exai)iinatio)is in Ireland. 

THE M.Ch. degree. 
Candidates may present themselves for the Examination for 
this Degree after an interval of three academical years from the 
time of obtaining the M.B., B.Ch., B.A.O. Degrees ; but in the 
case of Candidates who shall have obtained a degree of the 
University in the Faculty of Arts, an interval of two academical 
years shall be sufficient. 

Printed Forms of application for admission to this Examination 
may be had from " The Kegistrar, The National University of 
Ireland, Dublin." 

Candidates at this Examination must answer in the following 
subjects : — 

I. Surgery, Theoretical and Practical, including Ophthal- 
mology and Otology. 
II. Surgical Pathology. 
III. Surgical Anatomy and Operative Surgery, with the use 
of Surgical Instruments and Appliances. 
As far as practicable, there will be a Written and an Oral 
Exajuination in these branches, and in addition every Candidate 
will be required to diagnosticate at the bedside at least three 
Surgical cases, and prescribe treatment. He must also write 
detailed reports on at least two cases, to be selected by the 
Examiners, and discuss the questions arising thereon. 



THE M.A.O. DEGREE. 
Candidates may present themselves for the Examination for 
this Degree after an interval of three academical years from the 
time of obtaining the M.B., B.Ch., B.A.O. Degrees ; but in the 
case of Candidates who shall have obtained a degree of the 
University in the Faculty of Arts, an interval of two academical 
years shall be sufficient. 

Printed forms of application for admission to this Examination 
may be had from " The Kegistrar, The National University of 
Ireland, Dublin." 

Candidates at this Examination must answer in the following 
subjects : — 

I. Midwifery. 
II. Diseases of Women and Children. 

III. Pathology. 

IV. The use of Instruments and Appliances. 



Medical Education and Eccaminations in Ireland. 301 

The Examination in each subject consists of — 

(a) An Oral Examination, with practical illustrations, in- 
cluding use of instruments and appliances. 
(h) A Written Examination, 
(c) A Clinical Examination, as far as practicable. 

The Medical Regulations set out above refer only to those 
Students of the late Royal University of Ireland wlio, after the 
dissolution of that University, registered as Students of the 
National University of Ireland ; they form only a portion of the 
Medical Regulations of the National University ot Ireland. All 
Medical Students of the latter University, except those of the late 
Royal University of Ireland aforesaid, must enter one of the Con- 
stituent Colleges and go tlirough their courses under the College 
Regulations, Each College holds its own Examinations, but an 
Extern Examiner, appointed by the Senate of the University, is 
associated with the College Professor in the conduct of the 
Examination in each subject. All particulars about the Examina- 
tions will be found in the calendars of the Constituent Colleges. 



QUALIFICATIONS IN STATE MEDICINE. 

This University grants a Diploma in Public Health and a 
B.Sc. in Public Health. The Diploma may be granted to 
matriculated students of the University who shall have completed 
approved courses of study, and shall have passed the prescribed 
Examination, provided that it shall not be granted except to a 
Registered Medical Practitioner. 



III. 
TnK Queen's University of Belfast. 
DEGREES IN THE FACULTY OF MEDICINE. 

Statutes. 
1. There shall be six degrees of the University in the Faculty 
of Medicine, viz. : — 

Bachelor of Medicine (M.B.), 
Bachelor of Surgery (B.Ch.), 
Bachelor of Obstetrics (B.A.O.;, 
Doctor of Medicine (M.D.), 
Master of Surgery (M.Ch.), and 
Master of Obstetrics (M.A.O.). 



302 Medical Education and Examinations in Ireland. 

2. The degrees of M.B., B.Ch., and B.A.O. shall be the primary 
degrees in the Faculty of Medicine, and shall be conferred at the 
same time and after the same course of study. No student shall 
be admitted to the final Examination for these degrees until he 
has shown (1) that he is a Matriculated Student of the University, 
(2) that he has completed the prescribed course of study in the 
Faculty of Medicine extending over a period of not less than five 
academic years from the date of his registration as a Student of 
Medicine by the General Council of Medical Education and 
Registration of the United Kingdom, and (3) that he has passed 
the several examinations prescribed. 

3. The Senate shall not confer the primary degrees in the 
Faculty of Medicine upon any person who has not attended in the 
University during three academic years at least the courses of 
study prescribed for such degrees. The Senate may accept, for 
not more than two academic years of the required five, courses of 
study pursued in any other University or School of Medicine 
approved by the Senate. 

4. Every candidate for the primary degrees in Medicine shall 
be required to show that he has attained the age of twenty-one 
years on or before the day of graduation. 

5. The degrees of M.D., M.Ch., M.A.O. shall not be conferred, 
nor shall any of them, until the expiration of at least three 
academic years, or in the case of graduates of the University in 
Arts or Science, of at least two academic years after admission to 
the primary degrees in the Faculty of Medicine. Every candidate 
must show that in the interval he has pursued such courses of 
study or been engaged in such practical work as may be prescribed. 
Any of these degrees may be conferred by the Senate either (a) 
after an examination or [b) on the submission of a thesis or other 
evidence of original study or rcseiirch to be approved by the 
Faculty of Medicine after an oral or other examination of the 
candidate on the subject thereof. 



THE DEGREE OP DOCTOR OF INrEDICINE. 

Regulations. 

1. The Degree of Doctor of Medicine shall not be conferred until 

the ex})irati()n of at least three academic years, or in the case of 

graduates of the University in Arts or Science, of at least two 

academic years after admission to the primary degrees in the 



Medical Education and Examinations in Ireland. 303 

Faculty of Medicine. Every candidate must show that in the 
interval he has pursued such courses of study, or been engaged in 
such practical work as may be prescribed. This Degree may be 
conferred by the Senate either (a) after an examination, or (b) on 
the submission of a thesis or other evidence of original study or 
research, to be approved by the Faculty of Medicine after an oral 
or other examination of the candidate on the subject thereof. 
2. The subjects of the examination under (a) shall be : — 
The Principles and Practice of Medicine, and one other 
special subject to be selected by the candidate. 

The special subjects shall be as follows : — 
i. Human Anatomy, including Embryology. 
ii. Physiology, 
iii. Pathology 

iv. Pharmacology and Therapeutics. 
V. Sanitary Science and Public Health, 
vi. Forensic Medicine and Toxicology. 
vii. Mental Diseases. 

The examination in Medicine shall include : — 

(a) A written paper. 

(h) A commentary upon a selected clinical case or cases. 

(c) A clinical and vivd voce examination. 
The examination in the Special Subjects shall include : — 

(a) A written paper. 

(6) A clinical or practical and vivd voce examination. 



THE DEGREE OF MASTER OF SURGERY. 

Kegulations. 
1. The Degree of Master of Surgery shall not be conferred until 
the expiration of at least three academic years, or in the case of 
graduates of the University in Arts or Science, of at least two 
academic years after admission to the primary degrees in the 
Faculty of Medicine. Every candidate must show that in the 
interval he has pursued such courses of study or been engaged 
in such practical work as may be prescribed. This Degree may 
be conferred by the Senate either {a) after an examination, or (b) 
on the submission of a thesis or other evidence of original study 
or research, to be approved by the Faculty of Medicine after an 
oral or other examination of the candidate on the subject thereof. 



304 Medical Education and Examinations in Ireland. 

2. The subjects of the examination under (a) shall be : — 

(1) Surgery, Theoretical and Practical, including Ophthal- 

mology and Otology. 

(2) Surgical Pathology. 

(3) Surgical Anatomy and Operative Surgery, with the use 

of Surgical Instruments and Appliances. 
There shall be both written and oral examinations in these 
branches, and a clinical examination upon selected surgical cases. 



THE DEGREE OF MASTER OF OBSTETRICS. 
Regulations. 

1. The Degree of Master of Obstetrics shall not be conferred 
until the expiration of at least tliree academic years, or in the case 
of graduates of the University in Arts or Science, of at least two 
academic years after admission to the primary degrees in the 
Faculty of Medicine. Every candidate must show that in the 
interval he has pursued such courses of study or been engaged 
in such practical work as may be prescribed. This Degree miay 
be conferred by the Senate either (a) after an examination, or 
(6) on the submission of a thesis or other evidence of original study 
or research, to be approved by the Faculty of Medicine after an 
oral or other examination of the candidate on the subject thereof. 

2. The subjects of the examination under (a) shall be: — 

(1) Midwifery. 

(2) Diseases of Women and Children. 

(3) Pathology in its special bearing on Midwifery and Diseases 

of Women and Children. 
The examination shall consist of : — 

(1) A written examination. 

(2) A clinical examination. 

(3) An oral examination with practical illustrations, including 

those of instruments and appliances. 



THE DIPLOMA IN PUP.LIC HEALTH. 

Statute. 

Tjic Senate may confer Diplomas in Public Health upon legally 

quahlicd UK.'dical practitioners who have ])ursued such courses of 

study and passed such examinations :is may be prescribed: 

Provided always that the Regulations for such study and examina- 



Medical Education and Examinations in I Iceland. 305 

tions are in accordance with the rules made from time to time by 
the General Council of Medical Education and Registration of the 
United Kingdom. 

Examinations. 

One examination will be held yearly, and will consist of two 
parts. Candidates may present themselves for either part 
separately, or for both parts together at their option. 

A pamphlet giving all necessary information regarding entrance, 
examinations, lectures, fees, scholarships, prizes, &c., may be 
obtained on application to the Secretary of the University. 



IV. 

Royal Colleges of Physicians and Surgeons, 

Ireland. 

regulations for the examinations in medicine, 
surgery, and midwifery required for regis- 
tration under the medical act, 1886. 

These liegulations aj^e obligator// on all Candidates commencing their 
Studies on or after October \st^ 1902. 



Preliminary Examination. 



REGULATIONS. 

The following arc the subjects ol Examination : — 
I. Latin. 

II. Any one of the following languages : — Greek; French, 
German, Itahan, Lish, Dutch, Spanish, or any other 
modern language approved by the Board ol 
Examiners. 
lil. Enghsh. 
IV. Elementary Mathematics. 

The Candidate, when entering his name, is rcquiicd to state in 
what Language selected from II., and in what Authois he desires 
to be examined. 

If he desires to be examined in Dutch, he must send, at least a 
month before the Examination, notice of the pojtions of the Dutch 
Authors he has selected. 

U 



306 Medical Education and Exa)ninations in Ireland. 

1. The folio vviug works are prescribed in English till December 
31st, 1914 :— 

{a) Macaulay - Biography of Goldsmith. 

(h) Tennyson - Ulysses ; Tithonus ; Dream of Fail- 

Women, 
(c) Lowell - From my Study A\'indows — A Good 

Word for Winter. 

2. Grammar. 

3. Paraphrase. 

4. History and Geography. 

5. Essay. 

The Examination in Mathematics embraces Arithmetic. 
Algebra — Definitions and Explanations of Algebiaical Signs and 
Terms. Addition, Subtraction, Multiplication, and Division. 
Simple Equations in one unknown quantity. Easy Problems. 
(knmetry — The subjects covered by Euclid, Books 1, 2, 3 ; and 
Book 4, Pjopositions 1, 2, 3, 4 and 5. with some adelitionai Elemen- 
tary Practical Constructions, and some Elementary loci. 
Geometrical methods other than those followed by Euclid will 
be accepted, such as regarding tangents as limiting positions 
of chords, &c. Candidates are reqiiiied to provide tln^mselves 
with a rule]', set squire, protractor, and pencil compasses. 

S\B. — Candidates are reminded that yreat importance is attached 
to unprescribed translation, and to composition, at idl Examinations 
of which these subjects form a part. Preparation of the prescribed 
authors (done will not secure Pass marks. 

The Examination shall be conducted entb'cly by \mttcn papers. 

'' Typical Exjniiiuatioii Papers." price (id., post fiee Gjd.. may 
be obtained on application to the Secretary. 

Marks 
Marks shall be alh'tted us under : — 

Latin . . . . . . . . . . . . 120 marks. 

English 180 

Greek, or alternative language . . . . 120 

Mathematics 12(» 

1. Candidates who pass in all 8ul)jects, and are awarded seventy 
])er (-(jnt. of the total marks ()btaiiiabh\ are ])laced m a separate 
list, and are (considered to have passed with '' Uonoms." 

2. A Candidate may get credit for every subject in which he 



Medical Education and Examinations in Ireland, 307 

obtains pass marks, provided ho passes in all four subjects at 
not more than two Examinations. He can offer himself for re- 
examination as often as may be necessary to satisfy this condition. 

3. Candidates who hold the complete Pass Certificate of the 
Middle or Senior Grade of the Intermediate Education Board of 
Ireland may complete the Preliminary Examination under the 
Conjoint Board by passing in any subject or subjects required 
by ■ the General Medical Council which are not passed at the 
Intermediate Examination. 

4. The fee for the first admission of a Candidate to the 
Examination shall be Two Guineas. Fee for each subsequent 
admission One Guinea. 

Proof of Age. 
No Candidate shall be admissible to the Preliminary Examina- 
tion who does not produce evidence of having attained the age 
of sixteen years on or before the first day of the Examination. 

Date of Preliminary Examinations for 1914. 
Wednesdays— March 18th, June 17th, October 7th. 
The Examinations are held at the Royal College of Physicians, 
Kildare Street, Dublin, commencing each day at 10 a.m. 

Preliminary Examinations accepted by the Colleges. 
All Examinations in General Education recognised by the 
General Medical Council (a list of which will be found in the 
Register of Medical Students) are accepted by the Colleges in Ueu 
of the Preliminary Examination held by them. Information as 
to such Examinations may be obtained at the Branch Medical 
Council Office, 35 Dawson Street, Dublin. 



professional examinations. 
Every Candidate is required to pass four Professional Examina- 
tions. 

Candidates will be admissible to the various Examinations 
as under : — 

First Professional Examination, not earher than the end of the 

first winter session. (Fee is £15 15s.) 
Second Professional Examination, not earlier than the end of 

the second winter session. (Fee is £10 10s.) 
Third Professional Examination, not earlier than the end of the 
third year of medical study. (Fee is £9 9s.) 



308 Medical Education and Examinations in Ireland. 

Final Professional Examination, not earlier than the end of the 

fourth year of medical stud}^ ; but it cannot be completed 

till the end of the fifth year of medical study. 

No Candidate shall be admitted to any Examination within 

three months of his rejection in the subjects of that Examination 

by this or any other Licensing Body. 



Final Professional Examination. 
The Fee for this Examination is £6 6s. 

The subjects of the Final Professional Examination are : — 
Division A. — Medicine, including Fevers, Mental Diseases, 

and Diseases of Children. 
Division B. — Surgery, including Operative Surgery and 

Ophthalmic Surgery. 
Division C. — Midwifery and Gynaecology, Vaccination, and 
Diseases of New-born Children. 
Before admission to the Final Professional Examination, 
every Candidatt^ must have passed in the subjects of the Third 
Professional Examination. 

Candidates are recommended to present themselves in all the 
subjects of the Final Examination at one time ; but a Candidate 
at or after the end of the fourth year may present himself in 
any one of the Divisions A, B, or C, provided he has completed 
his Curriculum as far as concerns the Division in which he presents 
himself. The Examination in at least one of the Divisions must 
be deferred till the end of the fifth year. 

Before completing the Final Examination a Candidate must 
have passed four years in Medical Studies other than those for the 
First Professional Examination. 

Candidates must have passed in all the subjects of the Final 
Examination before any Diploma can be granted. 

Each Candidate before receiving his Diplomas must produce 
a Registrar's Certificate, or other satisfactory evidence, that he 
has attained the ape of twenty-one years. 

EXEMPTIONS. 

Candidates who have passed in any of the required subjects at 
Examinations conducted by any Licensing Body recognised by 
the lloyal College of Physicians and the Royal College of Surgeons 
may, at the discretion of the Committee of Management, be 



Medical Education and E.xaminations in Ireland, 309 

exempted from further examination in such subjects under these 
regulations. 

REGULATIONS FOR CANDIDATES FOR THE DIPLOMA 
IN PUBLIC HEALTH, 

Stated Examinations for the Diploma in Public Health com- 
mence on the first Monday of the months of February, May, July, 
and November. 

A special Examination for the Diploma may, at the discretion 
of the Committee of Management, be obtained — except during 
the months of August and September — on application at least 
one fortnight before the date of the proposed Examination, and 
payment of £15 15s. in addition to the ordinary Fees mentioned 
below. 

Every Candidate for the Diploma in Pubhc Health must be a 
Registered Medical Practitioner. He must return his name to 
the Secretary of the Committee of Management under the Con- 
joint Scheme, Royal College of Physicians, Dublin, one fortnight 
before the Examination, and lodge with him a Testimonial of 
Character from a Fellow of either of the Colleges, or of the Royal 
Colleges of Physicians or Surgeons of London or Edinburgh, 
together with certificates of the prescribed course of study. 

Candidates registered as Medical Practitioners or entitled to be 
so registered after January 1st, 1890, must comply with certain 
Resolutions and Rules, adopted by the General Medical Council. 

The Fee for the Examination is Ten Guineas, which must be 
lodged in the Ulster Bank, Dubhn, to the credit of the Committee 
of Management. Fees are not returned to any Candidate who 
withdraws from, or is rejected at, any Examination. The Fee 
for re -examination is Five Guineas. 

The Examination for the Diploma in Pubhc Health comprises 
the following subjects : — Chemistry and Physics, Engineering 
and Architecture, Meteorology, Sanitary Law, Vital Statistics, 
Hygiene, Bacteriology. 



V. 

Apothecaries' Hall tn Ireland. 

The Primary, Intermediate and Final Examinations are held 
fom- times a year — viz., commencing the first Monday in January^ 
April, July, and October. 

The Final Examinations are held quarterly. 



310 Medical Edncation and Exauiinatioii'( in Ireland. 

The Fees payable for each Examination me as follow : — 
J*riniary Professional . . . . ..£550 

Intermediate ,. 10 10 

Final Examination . . . . . . if) 15 

A Candidate is allowed for each Professional Examination which 
he has completed at any other Licensinij: Body, except the Final. 

Ladies who comply with the reojulations will be admitted to 
these examinations. 

Candidates may be admitted to a Special Examination, nnder 
special circumstances, which must be laid before the Examination 
Committee. If tiie Candidate's application be granted, an extra 
fee of Ten Guineas over and above the full fee is required. 

Candidates already on the Register will receive the Diploma 
of the Hall on passing an Examination in Medicine. Materia Medica 
and Pharmacy, 

Each Candidate, before receiving his Diploma, must produce 
evidence that he has attained the age of twenty-one years. 

Licentiates of this Hall are entitled to enter as Candidates for 
the Fellowship of the Edinburgh Royal Colle^ie of Surgeons. 

All infoninition relative to the Examinations may be obtained 
from the Registrar of the Apothecaries' Hall, 40 Mary Street, 
Dublin. 



VI. 
Dkntal Education and Examinations in Ireland. 



UNIVERSITY OF DUBLIN. 
DEGREES IN DENTAL SCIENCE. 

Combined Arts and Dental Curriculum. 

The University of Dublin grants the degrees of Bachelor aiK 
Master in Dental Science. 

Either of these quahfications entitles the holder to be registered 
as a licensed Dental Practitioner. 

In order to obtain the Degree of Bachelor (B. Dent. Sc), 
Candidates must have completed the course for the Arts Degree 
(B.A.) of the University and have spent at least four years in the 
School of Dentistry. The Degree of Master in Dental Science 
(M. Dent. Sc.) is awarded after a further examination, and cannot 
be taken until the end of a fifth year of study. 



Medical Education and Examinations in Ireland. 311 

The Dental and Arts Courses may be taken separately or 
concurrently. 

The Degree of Bachelor in Dental Science is conferred on 
Students who have completed the above Courses and Examina- 
tions, and passed the B.A. Degree Examination in Ethics and 
English Composition. 

The total fees in order to obtain the degree of Bachelor in 
Dental Science are : — 

Entrance fee, Arts fees (4 years), and fee 

for B.A. Degree £83 4 

Lectures, Laboratory, and Hospital fees 186 18 
Examination fee . . . . . . . . 5 

Fee for Degree 10 



£285 2 



IVIASTER IN DENTAL SCIENCE. 
Candidates for the Degree of Master in Dental Science must be 
Bachelors in Dental Science of at least one year's standing. 
They will be required to pass an examination in Pathology and 
Bacteriology, and either to cari^y out Dental work of an advanced 
character to the satisfaction of the Examiners, or to present a 
thesis to be approved of by them, giving evidence of original 
research on some subject connected with Dentistry. 



ROYAL COLLEGE OF SURGEONS IN IRELAND. 

DIPLOMA IN DENTAL SURGEKY. 

The Royal College of Surgeons in Ireland grants Diplomas in 
Dental Surgery under revised conditions adopted by the Council 
on November 25, 1909, of which the following is a synopsis: — 

The Candidate must be twenty-one years of age before being 
granted the Diploma. 

The Cajididate must have passed three Examinations. 

1. Preliniinaiy (identical with the Medical Preliminary). 

2. First Dental. (This Examination is much the same as 
the Second Conjoint Professional.) 

3. Final Dental Examination. Candidates are examined in 

General Pathology, Medicine and Sur«;ery ; Dental 
Surgery, and Dental Pathology, with the Materia 
Medica and Therapeutics applicable to Dental Surgery ; 
Dental Mechanics and Metallurgy ; Orthodontia, 



312 Medical Education and Examinations in Ireland. 

l^rge reductions in the Special Certificates required are made 
in the cases of qiialilied Medical Practitioners."^ 

As regards Dental Hospital practice, full information is con- 
tained in the Calendar for 1910-14 of the School of Dentistry in 
connection with the Incorporated Dental Hospital of Ireland, 
Lincoln Place, Dubhu. The Calendar may be obtained on appU- 
cation to the Dean. 

* Fuller particulars cau be obtaiued by applicatiou to the Kegistrar, 
Royal College of Surgeous, .St. Stephen's Green, Dublin, 



CANCER RESEARCH IN DENMARK. 

What may turn out to be a research of tremendous import- 
ance has been published lately by Professor Fibiger, of 
Copenhagen, in the BerUn€<r klini^cke Wochcnschrift. This 
observer a long time ago discovered in some rats certain 
papillomatous-l<x)king timiours of the stomach which proved, 
ou microscopical examination, to be cancerous, and also to 
contain in their interior parasitic worms of the nematode 
genus. For some time he was unsuccessful in the search for 
further material of the same sort to work on, but at last he 
came across the same condition in rats from a sugar refinery. 
Two- thirds of these animals harboured the nematode worms, 
and nine out of forty had also the peculiar stomach growth 
in association therewith. Fibiger tried by artificially infect- 
ing rats with the worms to reproduce the stomach cancer, 
but failed. Thinking that this might indicate an interme- 
diate host, he hit uikdii the cockroacli, which insect existed 
in large numbers at the sugar works. By feeding rats on 
these cockroaches lie produced thirty-six cases of this par- 
ticular stomach-tumour out of fifty-seven rats. In a few of 
the cases secondary growths also appeared, and these did 
not contain nematodes. The hy|X)thesis of an intennediate 
host was further proved by feeding cockroaches on the 
faeces of the rats wherein the ova of tlie woiTns are con- 
tained. It is still matter for speculation whether these 
observations prove that any irritant may set up cancerous 
tissue changes ; or whetlier they point to a specific cancer 
parasite. If the latter, further research with this clue to 
help should result in it*« discovery. — The Hospital, June 21, 
1013. 



THE DUBLIN JOURNAL 

OF 

MEDICAL SCIENCE. 



NOVEMBEE 1, 1913. 

PART I. 
ORIGINAL COMMUNICATIONS, 



Art. XIV. — Examinations, Examiners , and Examinees.^ 
By Sir William Osler, Bart., M.D., F.K.S. ; Regius 
Professor of Medicine in the University of Oxford. 

In every department of human knowledge men are asking 
guidance in the solution of a world-old problem — how to 
train the mind and heart and hands of the young. The 
past and the present are in the melting pot — the moulds 
are ready, and all await with eagerness the result of the 
casting, and none with greater eagerness than our own 
profession. For we are in a quandary. Naturally con- 
servative, we are bewildered by the rapidity of a forced 
progress and change. There is a new outlook in every 
department — not alone in the fundamentals of Science and 
in methods of practice, but in the relations of the pro- 
fession to the [)ublic j^d to the State. The actual care 
of the sick, once our sole duty, is now supplemented by 
such a host of other activities, social, scientific, and 
administrative, that an ever-increasing number of our 
members have nothing to do w^th patients as such. But 

' a An Introductory Address delivered at the opening of the Winter 
Session at St. George's Hospital Medical School on October 1st, 1913. 

VOL. CXXXVI. — NO. 503, THIRD SEIZES. X 



314 Examinations, Examiners^ and Examinees. 

the chief diRiculty is the extraordinary development in 
every subject of the curriculum — a new anatomy, a new 
physiology, a new pathology, new methods of practice, 
to say nothing of the phenomenal changes in physics, 
chemistry, and biology. Everywhere increased com- 
plexity and mind-burdening terminology. What is the 
teacher to do? And more important, What can the poor 
student do, confronted with so much new knowledge and 
a Rabelaisian onomatomania? How sim[)le was a cell 
in the days of Schwann and of Schultze — nucleus, 
nucleolus, protoplasm, and cell membrane; to-day in one 
of the very briefest of recent descriptions I counted 40 
new names, not one apparently superfluous. Turn to the 
index of a new treatise in embryology, to a work on 
immunity, or to a text-book on neurology, and you will 
appieciate the extraordinary complexity of the diet of the 
modern student. Even the titles of the journals startle, 
and to read intelligently an article in the Zcitschrift fiir 
Chemothcrapic or in Ihe new archives dealing with im- 
niunily and metabolism recpiires a special education. 

The truth is, we have outrun an educational system 
framed in simpler days and for simpler conditions. The 
[)rcssure comes hard enough upon the teacher, but far 
harder upon the taught, who sutler in a hundred diflerent 
ways. To help you to realise this pressure and to suggest 
measures of relief are the objects of this address. 

Examinations and riii;!!; Ixi.i.midns to EnrcATioN. 

What a student knows and what he can do — these are 
judged by exanunations, oral, written, and practical. 
Tests of progress, tests on behalf of the public of fitness 
to follow certain callings, they have always loomed large 
in educational systems. At the best, nutans to an end — at 
the worst, the end itself -they may l)e llie best part of an 
education or the worst — they may be its very essence or 
its ruin. Helpful if an integral part of the training, they 
niay, and do, prove the intellectual ruin of many good 



By Sir William Osler, Bart. 315 

men. Long practice as an examiner — year by year since 
1875 — in many subjects, in many methods, and in many 
places, an intimate relation with a large body of students, 
and a keen interest in medical education give me the 
assurance, if not of wisdom, at least of experience. More- 
over, at the old universities survives a media} val tradition 
of the omniscience of the professor, and with my brother 
Begins of Cambridge I enjoy the rare privilege of examin- 
ing in every subject in the curriculum, from organic 
chemistry to obstetrics, a privilege with this advantage — 
it enables me to see the work of many examiners. 

Kegarding examinations, I have one question to ask — 
Are they in touch with our system of education? and one 
suggestion to make — That from the day he enters the 
school, in laboratory, class-room, and wards, the w^ork of 
the student should count, and count largely, in the final 
estimate of his fitness. 

The Influence of Examinations on Medical Ediica- 
tion. — Apart from a general feeling of dissatisfaction with 
the present system, two things strongly suggest a nega- 
tive answer to the first question. As a discipline of mind 
and memory examinations play a leading part in all edu- 
cational schemes. How they may finally control and 
sterilise the mind of a nation may be read in the story of 
China. For this has come about, not from lack of brains, 
not from any failure to appreciate the value of learning, 
not from any defect in the system itself, which is more 
rigid and exacting than anything in Western life, but 
from the blighting influence of an education directed to a 
single end, the passing of examinations. To test an 
education by its practical results at the table is to sin 
against the spirit of the Greeks, who first taught the 
fundamental lesson that the pursuit of knowledge to be 
productive must be disinterested. Nothing is more fatal 
to a true intellectual training than a constant preoccupa- 
tion with its practical results. To be of any value an 
education should prepare for life's work. To train the 
senses for observation and the mind for reasoning, and to 



316 Examinations, Examiners, and Examinees. 

acquire a knowledge of the human machine and its dis- 
orders, a man spends five or more years at a medical 
school. Given a knowledge of the sciences on which it 
is based there is no more fascinating study, since Medicine 
is the only one of the great professions engaging equally 
head and heart and hand. ]n its subject matter there is 
everything in its favour, and it is the easiest possible 
thing to carry out John Locke's primary canon in educa- 
tion — arouse an interest. With our present methods 
there is scarcely a subject which cannot be taught easily, 
and so many of them are practical, manijnilative, and not 
at all dilliciih to acquire. To an iiupiisitive mind the 
study of medicine may become an absorbing passion full 
of fascinating problems, so many of which present a deep 
human interest. In the long category of man's conquests 
none are more brilliant than those with which a teacher 
of Medicine can inspire his class, it is hard indeed to 
name a dry subject in the curriculum. And yet in an 
audience of medical students such a statement nowadays 
raises a smile. Why? Because we make the examina- 
tion the end of education, not an accessory in its acqui- 
sition. The student is given early the impression tlial 
he is in the school to pass certain examinations, and 1 
am afraid the society in which he moves grinds this im- 
pression into his soul. Ask at what he is working, and 
the student will answer for his first ]\[.B. or his final. 
The atmosphere is Chinese, not (Ireck, and too often th(' 
one aim is to get through. We liav(> become quite shame- 
less about it, and piactically admit a failure in nur 
teaching when we advertise special tutorial classes for the 
different examinations, and consign a large proportion of 
our pupils to the tender care of " grinders " — and to no 
purpose! The spirit is taken t)ut of instruction, and 
teacher and taught alike go down into the valley of 
Ezekiel — where they stay among the dry bones. 

The Nuvibcr of Rejections. — And a second circum- 
stance jiroclaims loudly how out of touch are our tests 
willi our teaching. The (pialifying examinations of this 



By Sir William Osler, Bart. 317 

country are well organised and admirably conducted, and, 
speaking by the book, I may say that nowhere is the 
knowledge that a man can use so freely tested in the 
laboratory and at the bedside. And it has been so for 
several generations, yet year by year the General Medical 
Council issues a report that gives any teacher food for 
serious thought, as it demonstrates, beyond peradventure, 
how completely out of touch he or the student, or both, 
has got with the examiner. A medical school is a human 
factory, turning out doctors as the finished product at the 
end of five years of careful preparation and fitting of the 
mental machinery. Failure is incidental to every human 
effort, and even the Rolls-Koyce Company turns out 
cars from their shops that fail in the tests, but not many. 
But from our shops, after five long years or even more, 
we send our medical motors to be tested for the road by 
the official experts, and nearly one-half are declared to 
be defective and sent back to the shops. Use and Wont, 
those " grey sisters," have so dulled the edge of this 
bitter experience that we have become accustomed to con- 
ditions nearly insupportable. Year by year for a genera- 
tion the returns in the two great final subjects, the most 
attractive and the easiest to teach, show from 35 to 45 
per cent, of rejections. 

To the question much thoughtful attention has been 
given, and in the General Medical Council so far back as 
1896 Mr. Pridgin Teale introduced a motion with the 
following preamble : " That the present system of accu- 
mulated examinations and the enormous increase in the 
number of rejections resulting from it are not only un- 
just to the student but damaging to medical education." 
Mr. Teale pleaded wisely and forcibly for a reduction of 
the examinations and for the substitution in certain 
subjects of certificates from the teachers and class 
examinations. 

The Council reports show that the percentage of re- 
jections at the final examinations has progressively risen 
from 1-2.4 in 1861 to 2-2. -2 in 1876, to 34.8 in 1886, and to 



3 IS Examinations, Examiners, and Examinees. 

41.9 in 1895. Mr. Teale, whu (juotes these figures, re- 
marked that with the niultiphcation of examinations the 
more fatal do they become. The figures for the five years 
1908 to 1912 show a continuation of the upward move- 
ment. Take the great final subjects, medicine and sur- 
gery, at the three Boards before which we may say 
the average student presents himself. T will put the 
collected figures as concisely as [)ossible. ^Phe JOnglish 
Board : medicine — passed 1,812, rejected 1,135, per- 
centage 38.12; surgery — passed 1,821, rejected 1,50G, 
percentage 45.23. Scotland : medicine — passed 489, re- 
jected G53, percentage 57.18; surgery — passed 492, re- 
jected 731, percentage 59.77. Ireland : medicine — passed 
322, rejected 231, percentage 41.77; surgery — jiassed 326, 
rejected 239, percentage 42.30. In the five years a total 
of 4,572 students were examined at the Conjoint Boards 
of the three kingdoms in medicine, of whom 2,019 were 
rejected, a percentage of 44.10. Of 5,105 examined in 
surgery 2,475 were rejected, a percentage of 48.48. Take 
for comparison the three universities — Edinburgh, Oxford, 
and Cand)ridge — for the five years ending 1912. At the 
Scotch capital there were 985 examined in medicine, of 
whom 207 were rejected, 27.10 per cent. ; in surgery 974, 
of whom 317 were rejected, 31.52 per cent. In Oxford, 
where lh(> three final subjects aic l;iken togt^thtir, it is 
impossible to say upon wbicli subject a man came down, 
but in lli(> final examination of 135 candidates 47 were 
rejected, a percentage of 34.81. At rand)ridge during 
the five years, in medicine of a total number of 519, 3()5 
|)assed and 151 wcic rejected, a percentage of 29.()7 : and 
in surgery of a total of 003, 233 were rejected, a per- 
centage of 38.04. 

l^hei'e is not so inncli (lilTcicnce, you notic(\ between 
what may be calh^l the piiss men of the Conjoint Boards 
and the men entering the universities, and 1 do not 
believe there is any special difference in stringency 
between the Oxford and Cand)ridge examinations and 
those of the London Conjoint lH)ard. There aie two other 



By Sir William Osler, Bart. 319 

examinations which the elite of the student body affect. 
How do they stand? All regret that in London only the 
select and the elect attempt to get the degree of their own 
University. And it is difficult ! Twice in the past five 
years more students have failed than have passed the final 
subjects for the M.B. The total figures for the period 
are : of 1,001 candidates examined 481 were rejected, a 
percentage of 41.01. And, lastly, to one other qualifica- 
tion, greatly prized, sought only by the very best men, 
the Olympic athletes of their classes, I will refer — the 
F.R.C.S. Eng. Consider, please, how^ carefully this 
group is trained — only the very best venture to compete, 
and they have a diet of which the intellectual calories are 
gauged with surjiassing accuracy. There is no doubt they 
are our very best, the picked steeplechasers of our stables. 
How do they fare? I am almost ashamed to read the 
figures. Your ears have tingled already, but only those 
hardened by familiarity will not be shocked at the demon- 
stration of such a chasm between education and examina- 
tion. Of 1,186 men who have tried for the primary 
Fellow^ship examination of the Royal College of Surgeons 
during the past five years 821 were rejected, 69.45 per 
cent. Of 680 men at the final Fellowship examination 
294 were rejected, 43.23 per cent. The high-water mark 
of examination futility was reached in May, 1912, when 
of 118 candidates for the primary Fellowship only 31 were 
approved. These are picked men, our very best students, 
the most carefully prepared, who rarely attempt the trial 
w^ithout months of extra study and attendance upon 
grinding classes. Of the ploughed I have known person- 
ally, many seem to have been over-trained, others had 
spent their time in unprofitable original research ; but all, 
passed and ]^lucked alike, I maintain, are of the highest 
type of our students, wiiose calamities proclaim to the 
world the breakdown of our present educational system. 

The failure is general all along the line and in all 
grades — at the licensing bodies, at the older TTniversities 
of Oxford and Cambridge, at Dublin and Edinburgh, at 



320 Examinations, Examiners, and Examinees. 

South Kensington, and at Lincoln's Inn-fields with 
singular uniformity all tell the same tale. There have 
been uneasiness and talk, but too much self-satisfied in- 
difference, and even after the famous rout for the primary 
Fellowshi]) in May last year I am told that satisfaction 
was expressed with the scope and method of the exami- 
nation ! Satisfactory to the examiners, jierhaps, though 
1 doubt it ; but most unsatisfactory to the teachers, most 
|)ainful to the students, and by no means a pleasure to the 
iniblic as represented by the parents. 

How May Relief re Obtained? 

I venture to offer a few suggestions. First, by simplify- 
ing the curriculum to give the students more time. Allow 
the teachers a free hand in the matter of systematic 
lectures. Let them be reduced to a minimum or abolished 
altogether. One advantage they have — subjects may be 
dealt with which cannot ])ossibly be illustrated in the 
wards. But such may hv better presented in the 
" Seminar " Conn, the senior students arranging the sub- 
jects among themselves under a skilled assistant. London 
students still have too many lectures in medicine and 
surgery to attend; Scotch students many more. 1 do not 
speak without ex^HMiencc^ wlicn T say that the subject of 
medicine, for example, may be taught without the set 
lecture. The lecture has its value, a precious one from 
some lips — a Watson's or a Trousseau's; but its cLiy has 
gone to give place to other nicthods better adai)ted to 
modern conditions. Tliink of the saving of time if the 
lecture list was snipped in half, or if the lecture was 
limited to a few subjects, such as ])hysiology and patho- 
logy, and if it were an offence for a senior student to be 
seen in a lecture-room ! 

Then let us boldly acknowledge the futility of attempt- 
ing to teach all to ;ill students. Burn the anatomical 
fetish to which w(> have sacrific(>(l long enough, and to 
our great detriment. Just glance at ** Cunningham's 
Anatomy " — 1,465 pages, many in small type, not one of 



By Sir William Osler, Bart. 321 

which is without a w^ater-jiimp for the first Grand 
National of the medical student. It is barbaric cruelty 
with so much ahead to burden the mind with minutiie 
which have only a Chinese value — a titanic test of 
memory. To schedule a minimum of the essentials 
should not be difficult, once the ^reat principle is 
acknowledged that in all departments of the curriculum 
only a few subjects can be mastered thoroughly. I am 
afraid the secret of the tragic tale I have related lies in 
a quotation which Socrates made to Alcibiades : — 

Full man}- a thing he knew, 
But knew them all badly. 

I acknowledge the difficulty of defining in different sub- 
jects a minimum of the essential, but it is not insuperable, 
and such schedules are issued in some universities. 

Secondly, relief may be obtained by giving credit for 
work done throughout the course, changing the present 
system of " signing up " for one of reports by demon- 
strators and assistants on the character of the work done 
by each student. Let all who teach examine. Let edu- 
cation and examination go hand in hand. Let the day's 
work tell from the moment a student enters the school. 
Everyone from the junior demonstrator who supervises 
the students' first dissection to the professor — all should 
weigh while teaching. Day by day as I see John Smith 
in the wards, and read his notes, and watch his clinical 
work and discuss the features of the patients, or as he 
narrates his case to the class about the bed and he and I 
have a Socratic dialogue, instruction and examination go 
hand in hand, and in such a way that at the end the 
formal tests should be but an amplification, an extension, 
and an inclusion of the scores of examinations which have 
been part of the routine of his life. Perhaps at present 
Utopian, this plan will be feasible in a new and reorgan- 
ised generation ; indeed, it is feasible now in self-contained 
universities. Once accept the principle that instruction 
and examination should go hand in hand and the difficulty 
is solved. The returns are automatically passed on to the 



322 Examinations, Examiners, and Examinees. 

head of the flepartnicnt. Yes, but someone will say, 
" Take the judouient of a ^ronp of young teachers? It is 
absurd! " Not a bit. They see more of the students, 
come into closer contact, and are better able to judge of 
the quality of their work than llic j)rofessor, and much 
more than any outside examiner. According to the char- 
acter of his work a student should acquire much or little 
merit, and should be able to take to the examination table 
enough to pass, or at any rate to make the final test in any 
subject pro forma. Where the classes are small, as in 
many of the provincial universities, this plan could be 
easily worked. 1 have had practical experience of it and 
came to the conchisiOn early that the judgment of the 
man who wns fit to teach could be taken in estimating the 
progress of the student's education. And the system is 
being adopted. A few months ago T went into the beauti- 
ful chnical and pathological laboratory of the new Toronto 
General Hospital, and in one room T found an examina- 
tion in pathology going on. The candidate had a set of 
cards in his hands, on each of which were written the 
details of the post-mortem, examination lie had made with 
a careful discussion of the eas(>. Pass or pluck really de- 
pended on the cards a man held. Tie brought his marks 
with him— instruction and examination had gone hand in 
hand. 1 was delighted to he;ir fiom Trofc^ssor MacKen/.it* 
that the system, introducf^d at McClill by my pupil and 
successor, the lat(> much lamented Wyatt -loimston, had 
proved very successful in both Canadian schools. 

Thirdly, simj)lify the examinations. Cut olT some of 
the written papers. In the final subjects the long rejiort 
on cases, th(» bedside virCi, suppltMnented if need be by a 
special "oral," will give examiners the necessary know- 
ledge of a candidate's mental outlook. If th(>y will con- 
sider, not how much h<' knows, but how he knows wiiat 
he knows, the long " wiitte?i " is superfluous. As one 
watches a man liandh^ a ]iatient it is easy to tell whether 
or not h(> has had a pioper training, and Im this pur|X)se 
fifteen minutes at the bedside are worth three hours at 



By Sir William Osler, Bart. 323 

the desk. We must substitute for the quantitative esti- 
mate the qualitative, and jnd^e the student as much by 
manner as by matter. 

Fourthly, when 2:)ossible, evidence of original work 
should be substituted for examination. Think of the 
stimulus to British surgery if, in place of the Egyptian 
tyranny to which our best students now slavishly bow, the 
President and Council of the Koyal College of Surgeons 
selected for the Fellowship each year the 15 or 20 
of the men under thirty w^ho had distinguished them- 
selves most highly in surgical research. It would change 
the mental attitude of the younger generation, instil the 
spirit of Hunter into its members, and prevent the paralys- 
ing mental sterility that overtakes many good men who 
now spend precious plastic years in the dry drudgery of 
examination details. 

Fifthly, compel no student to pass an examination twice 
in the same subject. At present brain and pocket alike 
suffer, and the burden could be lightened by a free reci- 
procity betw^een the examining boards. 

Examiners and their Duties. 

Men are usually very superior to the system in which 
they work, and so it is with examiners. After what has 
been said you may be disa]^pointed not to hear a tirade 
against them ; but I have had a singularly happy experi- 
ence with my fellow inquisitors, whom I have found, as 
a rule, among " the mildest-mannered men that ever 
scuttled ships or cut throats." The two extreme types, 
the metallic and the molluscoid, illustrate inborn defects 
of character. The aggressive, harsh nature comes out 
strongly at the table, and the hard face, with its " what- 
the-devil-do-you-know " expression, sends a chill to the 
heart of the candidate, and it reaches his bone marrow 
when the first question relates, perhaps, to a serious mis- 
take in his paper. Imagine the mental state of a poor 
chap greeted with " What did you mean by saying that 
the ciliary muscle is supplied by the pneumogastric 



324 Examinations, Examiners, and Examinees. 

nerve?" And the worst of it is that the metallic ex- 
aminer may have no sense whatever of his failin^^s, hut is 
rather apt to pride himself on a keen aj^preciation of his 
duties. I rememher a hard-faced inquisitor who took, so 
it seemed, the greatest pleasure in torturintr his victims — 
dwellin^^ with fiendish ^^^lee on all the small mistakes he 
could find, criticising^ the spelling, mid ending on one 
occasion with the cheerful remark : " Mr. Jones, who 
taught you to write? " That evening, talking ahout ex- 
aminations, T said in a joking way : " Judge Jeffreys, you 
are a heartless hrute ; I wonder some student has not 
assaulted you." He took it very much to heart, and T 
had a long letter ahout the great responsibility of the 
position and the rigid sense of duty he felt towards the 
university and the public. ;\nd the facial expression of 
the fellow examiner is not without im]K)rtance, whether 
sympathetic, neutral, or antagonistic. One co-examiner 
always had a sardonic (^xj)ressi()n, a sort of Arian grin, 
))lainly saying : " Well, you are a ho])eless idiot ! " The 
examination room may have the atmosjihere of a cold 
storage chamber, and a student knows at once the tyju' of 
man with whom he has to deal. 

At the other extremity is the invertebrate examiner, so 
soft and slushy that he has not the heart to reject a man. 
It is a variety not often met with in this country, i)ut it 
exists. Sympathy with tlu* student and a strong feeling 
for his ])osition may conipletely overniastei- tin* sense of 
duty to the university and to llie public. A former 
colleague was made unhappy b)r days if be had to reject 
a candidat(\ I'or some years I sat on an (examination 
board with an eldcM'ly professor, a man of great force of 
character and ability, who never gavt^ a candidate less 
than 80 \)vv cent, of the possible marks. In the case of 
the most hoj^eless duffers with 20, 30, or 40 per cent, in 
other subjects he would call out " pass." ITe was a great 
grief to me, as well as a mystery. At the last meeting 
which he attended as an examiner be tossed his book to 
me with a malicious smile. There were IIG candidates. 



By Sir William Osler, Bart. 325 

not one of whom he had rejected, and not one of whom 
had less than 80 per cent. ! 

Between the metaUic and the moUascoid is the large 
group of sensible examiners who try to put the candidate 
at his ease and to find out what he knows in a simple, 
sympathetic manner. But in any case the examiner is 
apt to take an unfair advantage of his position, and quite 
unconsciously. A specialist to whom the facts of his sub- 
ject have become familiar and ingrained is apt to forget 
the years that have given the facility and the knowledge ; 
and he may wonder when a man hesitates over an Argyll- 
Robertson pupil or mistakes a pericardial rub for an aortic 
insufficiency murmur. The most grievous mistake of the 
examiner is to regard the candidate as his mental equal 
and to expect from him knowledge of the same quality as 
that which he possesses, ignoring his long years of study 
and the short years into which the student has had to 
cram the knowledge of a dozen subjects. 

Examining is often a heart-breaking task, with little 
to relieve the monotony of the long-drawn papers. It is 
distressing to meet with abysmal ignorance of elementary 
facts, and to realise with sorrow how many more minds 
are constructed as sieves than as sponges. But there are 
compensations, and who is there among us who does not 
appreciate Comte's statement that there were few more 
delightful experiences than the sweet and softened feeling 
when a young man's examination was thoroughly satis- 
factory ? But it is much nicer to watch the gradual growth 
of a student's knowledge and to get it out retail day by 
day than to drag it out wholesale at set times. One thing 
is certain — the best we have should be devoted to our 
duties as examiners. Men should give their whole time 
to the business when at it. Much-engaged men should 
not be chosen, and to examine in the evening, after a hard 
day's work, is to handicap the candidates. We shall no 
doubt come to a time when professional examiners will 
be appointed by the General Medical Council to act as 
associates and assessors to the professors. That it is not 



326 Examinations, Examiners^ and Examinees. 

a task lightly or inadvisedly undertaken the returns I have 
{?iven indicate only too clearly. Not that we can lay at 
the doors of the examiners the responsibility for the 
lamentable state of affairs to which I have referred. No 
doubt there are unduly severe examinations, and there 
are examiners wilh hearts as hard as pieces of the nether 
millstone, but these are exceptions. 



The Examinee and his Position. 

When (juolin^ li^ures I |)urposely dcah chiefly with the 
results of the final examinations, and \ am sure the feel- 
ing upj)ermost in your minds was one of sympathy with 
the hundreds of young men who, after five years of hard 
work, fail in ordinary tests, and this brings us to a brief 
consideration of the examinee and his position. In two 
respects he is an unfortunate victim. Of one T have 
already spoken — the enormous development in the sub- 
jects of the curriculum; and here, T am sure, lies his 
serious dilliculty. It is the case of a (juart measure and a 
pint pot. Intellectual dyspepsia from cranuiiing is at the 
bottom of his trouble. It is like a diet of hot bread, which 
a man can stand at lirsl, but, as Lowell says in the 
"Fable for Critics"— 

By gradual steps lio 
Is brought to death's door by a niontal dyspeptiy. 

Another cause of Ihe widespread rejeclions is defective 
preliminary education ; hut Kl nic emphasise the fact (hat 
the percentages of rejections are nowhere higher than 
among the very best students — e.g., Cand)ridge men, 
among whom in some subjects more than 50 [)er cent, are 
rejected. 1 do not deny that much could be done to re- 
lieve the present stasis if all medical students began 
thoroughly trained in physics, chemistry, and biology. In 
this respect matters are iinpioving year by year. And we 
should be more honest with the feeble ones, not fitted 
either by breeding or by pasture to pursue their studies, 



Tests for Liver Function. 327 

who should be asked early to withdraw. It is infinitely 
kinder to stop a man in his career than to allow him to 
struggle on painfully and submit to the humiliation of 
half a dozen or more rejections. 

The conclusion of the matter is, the student needs more 
time' for quiet study, fewer classes, few^er lectures, and, 
above all, the incubus of examinations should be lifted 
from his soul. To replace the Chinese by the Greek spirit 
would enable him to seek knowledge for itself, without a 
thought of the end, tested and taught day by day, the 
pupil and teacher working together on the same lines, 
only one a little ahead of the other. This is the ideal 
towards which w^e should move. The pity of it all is that 
we should have made an intolerable burden of the study 
of one of the most attractive of the professions, but the 
reform is in our own hands and should not be far off. A 
paragraph in an address of the late Dr. Stokes contains 
the pith of my remarks : " Let us emancipate the student, 
and give him time and opportunity for the cultivation of 
his mind, so that in his pupilage he shall not be a puppet 
in the hands of others, but rather a self -relying and reflect- 
ing being." 



Art. XV. — Ted^ for Liver Function." By G. E. Nesbitt, 
M.D., F.K.C.P.I., Assistant Physician to the Rich- 
mond, Whitworth and Hardwicke Hospitals, Dublin. 

In bringing forward this subject I wish to ask for such 
indulgence as may be granted to a " preliminary commu- 
nication ' ' for the reason that the material and opportu- 
nities at my command have not yet been sufficient to 
enable me to form a final judgment as to the value of 
these tests. 

Amongst similar investigations of the functions of 
various organs they occupy a prominent place in routine 
clinical examination at the Continental schools. But, 

*R.en.rl before the Section of Medicine in the Royal Academy of 
Medicine in Ireland on Friday, May 16, 1913. 



328 Tests for Liver Function. 

with the exception of an occasional case of special in- 
terest, I believe that no such systematic methods have 
been adopted here. 

Considering the number and complexity of its various 
functions, the liver works in a curiously silent and un- 
obtrusive fashion. Beyond a few conditions where very 
gross evidence of disease is apparent , we have little infor- 
mation at hand as to how this organ is conducting any, or 
all, of its vital duties. This difficulty is quite obvious in 
text-book as well as at the bedside, where we find full de- 
scriptions of organic diseases of diverse types, but little or 
nothing as to the disturbance of function arising there- 
from, and often nothing at all concerning " functional 
as opposed to " organic " affections. It is a firmly-rooted 
idea with, at any rate, the valetudinarian layman that 
many and varied sym[)toms are due to " the liver being 
out of order," and though we are apt to discredit the idea 
in the majority of cases, it is not difficult to imagine, on 
brief reflection, that the view is not entirely without 
foundation. 

Murchison's classical work on this subject is probably 
still unsurpassed, i)ut i( may be questioned whether he has 
not gone too far, and attributed to derangement of liver 
function symptoms which should be ascribed to interfer- 
ence with other organs. 

The four tests which I have emi)loyed, and wliich T 
shall now describe, will \)v seen to depend n|H)U three 
important functions of the liver — i.e., metabolism of 
sugars, the assimilation of protein-substances such as 
arnino-acids, and the excretion of waste bile pigments. In 
some cases these tests have been founded on recent de- 
velopments of physiology, and, it may be, will prove at 
variance with some hitherto established views. In the 
first three, at any rate, the principle is simple. Certain 
substances are administered to the patient, and the sub- 
sequent effect on the urine is noted. 

Lrrvulose and Cnlactosc Tests. — These sugars have 
been adopted instead of glucose in examining for liver 



By Dr. G. E. Nesbitt. 329 

function, in consequence of the fact noted by Bauer, of 
Vienna (to whom I am indebted for my first acquaintance 
with these and numerous other suggestive methods), that 
considerable tolerance for glucose can exist with marked 
organic liver disease. When we remember, on the one 
hand, that the tissues may be capable of destroying even 
an unusually large amount, while, on the other hand, 
disease of the pancreas will cause its too ready appear- 
ance, the uselessness of glucose as a pure liver test is 
apparent. Bauer further noticed that in a case of cir- 
rhosis with glycosuria the sugar was not glucose but 
galactose, and in this case, on stopping milk in the diet, 
the sugar disappeared from the urine. The reason may 
be that both galactose and Icevulose are normally altered in 
the liver to glucose before conversion into glycogen, and 
if the liver is not healthy this conversion cannot occur. 
Whether this be true, clinical evidence shows that these 
sugars will pass through where glucose is retained. 

Lcevulose Test. — 100 grm. of la^vulose is given on an 
empty stomach in the morning in tea, and the urine for 
some hours examined by Fehling or other sugar tests. 
Any trace of sugar indicates liver disturbance of some 
kind, though the test is useless for the purpose of differen- 
tiating the disease. It is an extremely delicate test, but 
has two objections — the amount of sugar given is exces- 
sive, and in quite a number of cases results in vomiting or 
diarrhoea. This may be got over to some extent by wash- 
ing out the bowel the previous night and giving a dose of 
opium ; but this objection seems too great for its use as a 
routine test. Secondly, it is positive in about 10 per cent, 
of normal cases, and alone has not a great clinical value. 

Galactose Test. — 40 grm. of galactose are given in the 
same w^ay as before. The dose is smaller, not very sweet, 
and, as I have ascertained by personal experiment, quite 
easily taken. The urine is collected hourly, and in 
normal cases will show the presence of sugar for at most 
one or two hours. Total output under 1 grm. In certain 
cases of liver disease — i.e., cases where general cell as 

Y 



330 Tests for Liver Function. 

apart from local lesions are present — galactose is elimi- 
nated for six or more hours, the total quantity reaching 
in some cases as much as 20 grms. 

For example, the test will be found positive in such 
cases as cirrhosis of all varieties, toxic forms of icterus 
(including catarrhal jaundice, now regarded as a toxic 
affection of the liver), degenerative conditions, such as 
phosphorus and chloroform i)oisoning and acute yellow 
atrophy, general syphilitic disease of liver, and fatty de- 
generation. Further, and an im|)ortant point in differen- 
tial diagnosis, a positive result may be frequently obtained 
before physical signs of any kind develop. On the other 
hand, local lesions in the liver give a negative result — 
e.g., obstructive icterus, tumours of all kinds, and two 
conditions where one perhaps might have expected other- 
wise, chronic passive congestion and amyloid disease. The 
only objection that I have met with in using the test is 
that pure galactose is somewhat expensive. One might, 
however, substitute lactose in a larger dose, owing to the 
splitting in the intestine of this sugar into glucose and 
galactose. 

Aniino-acid Test. — This test, though somewhat more 
troublesome to carry out, has been of most interest to me, 
and has indeed, I believe, given the most satisfactory re- 
sults. To give an adequate description of its rationale 
involves an excursion into the current theories and de- 
velopments of the physiology of protein metabolism, 
which extremely interesting though it may be, 1 trust I 
may be pardoned for omitting on this occasion. In brief, 
it depends on I he fact that after a dose of amino-acids 
they appear in but small traces in the urine in normal 
cases, whereas a substantial quantity can be recovered 
from cases with liver disturbance. The experiment con- 
sists in giving 10 grm. of glycocoll or amino-acetic acid 
(CH2NPI2COOH), one of the simplest of the amino- 
acids or end-products of protein digestion. Normally this 
causes no increase in the urinary output of amino-acid (as 
I have had the satisfaction of demonstrating in my own 



By Dr. G. E. Nesbitt. 331 

person), but in disturbed conditions of liver function a 
substantial increase (even up to 5 grm.) may be found. 
The method of estimating is slightly tedious, and is a 
modification of Henrique's. As regards its accuracy I 
was extremely gratified to find, on checking it with a 
known quantity of aniino-acid, that it left nothing to be 
desired, the very small discrepancy being quite explicable 
by my own want of skill in technique. 

50 c.c. of urine are taken from a twenty-four hours 
specimen, 20 c.c. of 95 per cent, alcohol added to prevent 
undue frothing, and 30 c.c. S.S. Ba(0H)2 solution. By 
the pump NH3 is drawn over and caught in 25 c.c. deci- 
normal H2SO4. By subsequent titration with deci-normal 
NaOH the total N in the form of NH3 may be easily 
ascertained, as in the Kjeldahl estimation, and this is an 
important side issue. At the end of about half-an-hour 
what remains in the flask is made up to 250 c.c. with dis- 
tilled water. 50 c.c. of this are taken, neutralised w^ith one- 
fifth normal HCl, and 10 c.c. strong formalin added. The 
amino-acid combines with formalin, forming a body w^ith 
acid reaction, and subsequent titration with deci-normal 
NaOH will give the amount. Each c.c. of alkali = .0014 
grm. of N as amino-acid. Multiply by 5 (for orig. 250), 
which gives amount in original 50 c.c. of urine used. 
Hence calculate the excretion per day. The total amino- 
acid can then be found by simple comparison of atomic 
weights. 

The process sounds difficult, but with a little practice is 
perfectly simple — not at all beyond the resources of a 
Vir^ry moderate laboratory. 

My results in a few cases may be of interest : — 

I. Normal case — after 10 gims. glycocoU. 

N as ammonia .48 grm. .36 

N as amino-acid .H grm. ..'i 

II. Suspected amyloid liver — 

N as ammonia .308 grm. .49) , . ,. 

. , „ , . - negative result. 

N as ammo-acid .24o grm. .25 > 

III. Suspected cirrhosis of liver — 

N as ammonia .21 grm. .29) i i -r i li. 

^^ . . ^ ,„ ° '^ doubtful result, 

N as amino-acid .204 grm. ,56) 



332 Tests for Liver Function. 

The Aldehyde Reaction. — ^The foregoing tests are, hovs- 
ever, after all but adaptations to clinical work of experi- 
ments that have been performed for years in physiological 
investigations bearing ii2:)on metabolism — the last of my 
series has the merits of novelty, simplicity, and, I believe, 
reliability. If the results obtained by those who have 
worked much with this test can be established and con- 
firmed we have in the aldehyde reaction a diagnostic 
method unsurpassed by any procedure in clinical labora- 
tory work. Before entering upon the technique and re- 
sults it is necessary to state ])lainly that the test depends 
upon what is now becoming an established fact in physio- 
logy — namely, that urobilin, which most of us have 
hitherto believed to be one of the important constituents 
and colouring matters of the urine, really exists in normal 
urines in very small quantities indeed. Further, any 
urobilin which is 2)resent is derived by oxidation on stand- 
ing from a precursor called urobilinogen. Whence does 
the urine get this urobilinogen? The modern view is 
that bile pigment (bilirubin) is acted upon in the intes- 
tine (mainly in the ca-K'um) by organisms chiefly of the 
colon group, and reduced to urobilinogen. Most of this 
is excreted in the faeces (when reoxidation will often cause 
a bright stool to become brown on exposure), but some is 
reabsorbed and carried in the portal system to the liver, 
where the normal liver cells reconvert it to bile ])igment. 
Hence little or none is allowed to pass through healthy 
livers into the general cinuilatiou. But should the liver 
cells be defective, or should a collateral portal circulation be 
developed, it will be obvious that considerable quantities of 
urobilinogen may |>ass, aiul lience appear in the urine. 
Now, in 1001 Khrlich discovered that one of his syn- 
thetic preparations — viz. , dimethyl-jiara-amino-benzalde- 
hyde — gave a red colour with certain urines. He did not 
appreciate the reason, but Neubauer, in 1903, showed 
that the reaction was due to the presence of urobilinogen. 
This is the " aldehyde reaction." 

The test solution is a J per cent, solution of this 



By Dr. G. E. Nesbitt. 333 

aldehyde powder in 50 per cent. HCL, and can be made 
in a moment. The addition of a couple of drops of this 
solution to about 5 c.c. of urine produces in cases when 
urobilinogen is present almost immediately a rose-red 
colour. In a few cases the colour takes some minutes to 
appear. The test is not affected by any other substances 
that may be present, though, naturally, the result is 
prettier in a clear urine. Spectroscopic examination 
shows the presence of two absorption bands — an aldehyde 
band in the yellow, and a urobilin band between green 
and blue. It is important that the urine be examined 
fresh owing to the alteration of urobilinogen to urobilin 
on standing in the air, but a specimen may be kept some 
time if well corked. 

I do not propose here to discuss the chemical reaction 
of the test. The most accessible information on this point 
will be found in a paper by Chase in the Journal of the 
American Medical Association, 1912, Vol. IT., where an 
excellent account of the test is given in full. I will just 
note two curious facts : — (1) That normal urine gives the 
test on boiling, and (2) that antipyrin (phenazone) is the 
only drug which has been found to produce a positive result. 

Now, with regard to the clinical results : Many urines 
give a very faint pink colour, due, no doubt, to small 
amounts of urobilinogen, and in these cases it is generally 
easy to find a satisfactory reason — e.g., constipation, liver 
congestion, &c. This does not constitute a positive re- 
action (the difference is very obvious), but may, I think, 
be very useful in indicating a suitable line of treatment. 
I have never obtained more than this slight pink in really 
healthy people ; frequently not a trace of colour is present. 

There is also a slight possibility that, in cases of marked 
liver disease — e.g., cirrhosis — if much diarrhoea were 
present bile pigment might be hurried out of the intestine 
before reduction or reabsorplion could occur, thus produc- 
ing a negative result, but the possibility is not very 
probable. 

With these unimportant exceptions, the aldehyde re- 



334 Tests jw Liver Function. 

action is found to an extraordinary degree with all kinds 
of liver disturbance — bein*^^ best marked in chronic passive 
conf^estion, cirrhosis, amyloid disease, fatty defeneration, 
syphilis, and tumours. 

The test will not, of course, differentiate the type of 
disease, but in doubtful or suspected liver cases will prove 
iiu])ortant evidence — as in many othiT instances, a negative 
result bein«i[ quite as important as a jiositive ; indeed, some 
of my best results have been negative. Instances of this 
will readily suggest themselves — (-'.(j., early cirrhosis, 
ascites, liver metastases in malignant cases before or after 
operation, and the onset of parenchymatous degeneration 
in fevers. The result is well marked in most fevers, 
where a good reaction is a bad sign, but often negative in 
typhoid — here the a|i]^earance of a positive result may 
indicate gall-bladder trouble. 

Owing to its sim])licity my experience with this test 
has been considerably larger than with the others; 
indeed, 1 eni|)l()y it in any case where the liver is at all 
open to suspicion. T do not remember any case, except 
one, where the result tuiiud out to be fallacious, and in 
a few it was decidedly interesting. Let me give an in- 
stance : — Dr. Coleman kindly permitted me to examine a 
case with very marked ascites; the result was negative, 
and on confirming by the galactose test a negative result 
was also obtained. When T reported my belief that the 
liver was not affected, he informed me that he had just 
come to the same coiichisioii after tapping and obtain- 
ing a chylous-looking tliiid. which, however, contained 
neither cells nor fat. Subsequent autopsy showed cancer 
of the head of the pancreas and peritoneum, but in the 
liver no trace of disease. One hesitates to dogmatise in 
th(^se days when the tlieory and practice of to-day are 
wiped out to-morrow, but I believe this test to hav(^ a 
very real value. I strongly recommend its trial — indeed, 
I will go fuither and say tbat 1 thiidv it should have a 
place in all routine urine-testing, as it already has in many 
of the foreign clinics. 



Cancer of the Rectum. 335 

I regret that my experience with the other tests is not 
yet sufficiently large to warrant the expression of an 
opinion. I have, at any rate, satisfied myself as to their 
accuracy with regard to normal individuals. 

It is not easy to obtain a supply of suitable cases just 
when one requires them, but the results obtained hitherto 
lead me to hope that, with extended opportunities, my 
experience will coincide with that of other observers, who 
find these tests of assistance in trying to illuminate a very 
dark corner of our complex organism. 



Art. XVI. — A Short Communication on Cancer of the 
Rectum.^ By William Taylor, M.B., F.K.C.S.I., 
Surgeon to the Meath Hospital and County Dublin 
Infirmary. 

During the past eighteen months out of a number of cases 
of rectal cancer that came under my care in four only was 
it possible to perform a complete radical operation. These 
cases, I thought, might serve as a suitable text for some 
remarks which I hope may excite discussion and elicit from 
the surgeons present any views they may now hold as to 
what the radical operation for cancer of the rectum should 
be. 

The first case was that of a gentleman, aged about 70 
years, who had been com]')laining for some months of the 
passage of blood, mucus and muco-pus. Nothing could be 
detected by digital examination, but by the sigmoidoscope 
a small cancerous growth was seen high up. 

The abdomen was opened in due course and a small, 
freely movable growth was found in the pelvic colon. A 
few enlarged glands werei present in the mesentery, but 
there were no evidences of secondary deposits elsewhere. 

It was obvious that free removal of the visibly affected 
gut would render it impossible to re-establish the contin- 
uity of the bowel by end to end anastomosis. It was there- 
fore decided to remove the entire pelvic colon and rectum. 

" Read before the Biological Club on Tuesday, October 21st, 1913. 



336 Cancer of the Rectum. 

This was accordinoly clone — the cut end of the sigmoid 
flexure bein^ brought out through the split muscles in the 
inguinal region to form a jx^rmanent anus. 

The abdominal part of the operation completed, the 
bowel was removed from below by the parasacral route. 

The entire operation took almost two hours to finish, 
but, I regret to say, the result was unsatisfactory, as the 
patient (lied four days subsequently. 

On thinking over this case since, I feel sure I should have 
done much better for the man had I contented myself with 
the free excision of the visible exj^ressitm of the disease, 
closed the divided end of the rectal segment and infolded 
it by a purse-string suture instead of removing the entire 
lower segment. The ])elvic jieritoneum then could have 
been sewn across so as to shut olT tlu^ abdominal cavity and 
the liliiid it'clal segment could have been syringed gently 
at intervals. The time rerpiired would have been reduced 
to at least one half, possibly one third, and the lisks of 
shock and sepsis correspondingly diminished. 

The second case was that of a lady, aged 50 years, upon 
whom Dr. 1 fastings Tweedy very kindly asked me to assist 
him to o]x^ial(\ The condition for which Or. Tweedy was 
opeialing was a u1eiin(» fibromyoma, l)ut the |)atient had 
been com|)laining for som(^ months of rat hei; indefinite in- 
testiuiil trouble — increasing constipation with colicy pain 
and occasional mucous discharge. The hysterectomy com- 
pleted, a small carcinomatous growth was found occupying 
the lower portion of the |)elvic colon, so that a clam)) could 
not be placed below \hc growth for the purpose of resection 
and anastomosis. 1 th(M(^fore decided to divide the sigmoid 
flexure and remove the entire pelvic colon and rectum. 
The sigmoid divided, the ])elvic colon and rectum were 
separated to within about three inchc^s of th(^ anal margin, 
at which point the bowel was cut across and removed, the 
remaining lower segment was dcmuded of its mucous nuMii- 
brane, after which the sigmoid flexure was mobilised and 
prolapsed through the lower segnuMit and sutured to the 
skin at the anal margin, A few points of suture were also 



By Mr. William Taylor. 337 

passed through the upper end of the lower segment and the 
prolapsed sigmoid. An opening was then made through 
the posterior vaginal fornix , and a gauze drain passed into 
the operation region. The peritoneum was brought across 
from each side of the pelvis and sutured carefully round the 
sigmoid flexure above the gauze drain, thus closing off 
the peritoneal cavity com^>letely. Another gauze drain 
was brought from the operation area out through the lower 
angle of the abdominal wound which was closed in layers. 
The subsequent course of the case was uneventful. The 
lady was able to leave hospital in four weeks, has since 
gained over a stone in weight, and is at present in perfect 
health. It is now one year and six months since the 
operation was performed. 

The third case w^as that of a woman, aged about 52 
years, who was sent to me to the Meath Hospital by Dr. 
Winder, of Glasnevin, suffering from symptoms of rectal 
cancer. A growth was detected as high u]^ as the finger 
could reach. After the usual preliminary operation, the 
abdomen was opened, when it was determined that it was 
possible to remove the trouble completely. Bearing in mind 
the facility with which 1 was enabled to extirpate the rec- 
tum and pelvic colon in the former case after hysterectomy 
had been performed, I at once removed the uterus. The 
diseased area of bowel was then removed just as in the 
former case, and the sigmoid brought out through the anal 
canal, which had been denuded of its mucous membrane. 
•About one and a half inches of the lower end of the sigmoid 
sloughed off, but otherwise recovery was uneventful, and 
the patient has perfect control over the bow^el and is in 
perfect health. 

The last case was that of a man, aged about 60 years, 
who was sent to me by Dr. Jacob, of Maryborough, with 
the diagnosis of rectal carcinoma. The growth was 
situated about five or six inches above the anal margin. 
After the usual preparation, the abdomen was opened and 
carefully exj^lored. There were no evidences of secondary 
deposit. Having regard to the situation of the growth, 



338 Cancer of the Bectiim. 

which was just at the junction of the pelvic colon and 
rectum, it seemed to me that the safest procedure, so far 
as the patient was concerned, was to divide the sigmoid and 
extirpate the entire bowel below. The sigmoid divided, the 
bowel was separated as low down as possible after which the 
peritoneum from the pelvic sides was sutured over a gauze 
sponge which was j)acked over the separated bowel. The 
abdominal wound was closed after the permanent anus had 
been established, by bringing the lower end of the upper 
sigmoid segment through the split abdominal muscles. 

The patient was then ]ilaced in an exaggerated lithotomy 
position, and the entire bowc^l and anal canal were com- 
pletely excised. Free drainage was employed. 

The subsequent course of the case was satisfactory, the 
patient being able to id inn home in less than four weeks 
after the operation. 

Two im])ortant principles i\rr to ])o borne in mind, viz. : 
the complete removal of the local disease with as nmch 
adjacent tissue as may possibly seem to be affected, and the 
removal, as far as jiossible, of \hc associated lymphatics. 
Mr. Fagge has recently demonstrated an extension down- 
wards of the cancerous infection into the lymphatics of 
the anal canal without visible involvement of the canal 
itself. M'his would indicate that the anal canal should 
always be removed in any operation undcMtaken for the 
complete extir|)ation of rectal carcinoma. Mr. TTandley 
has shown thai cancerous pei'meation may be found in the 
bowel wall as high as six indues above* the obviouslv visible 
limit of the disease. 

This observation would indicate that a considerable area 
of bowel jibove i]\v \ isil)le site of (hseas(* should be re- 
moved. If these (l(Mnonst rations of h'agge and llandley 
are accepted as corn»ct it means that i*\vvy radical opera- 
tion for rfH'tal carcinoma should consist in th(^ removal of 
the entire l)ow(>l from the sigmoid to the anal margin 
together with the associated lymph nodes. Whether such 
an extensive opeiation is absolutely necessary ia still a 
disputed point, but. it may be said that the majority of 



By Mr. William Taylor. 339 

the younger generation of surgeons are of the opinion that 
it is so. 

Granted that such an extensive operation is necessary 
it can only be satisfactorily carried out by means of a com- 
bined abdominal and perineal or sacral operation performed 
in one or two stages. 

By such a procedure the operative treatment of rectal 
carcinoma is brought more into line with the modern 
operation for cancer in other situations — notably the 
breast. By such a method of operating, cancers which, by 
the perineal or sacral routes, would be considered inoper- 
able, can be readily removed. 

It may be said that it is seldom one finds that a growth 
which w^ould be considered readily removable is associated 
with any extensive glandular involvement. 

On the other hand it must not be forgotten that one 
frequently finds that a secondary deposit has already 
occurred in the liver in a case in which there is practi- 
cally no glandular enlargement and in which the primary 
growth is still very freely movable. Such a condition 
can be discovered only by palpation of the liver through 
the opened abdomen. No good result could be expected 
to follow rectal excision in such a case, and yet, if surgeons 
religiously followed the perineal or sacral methods of 
operating, many such cases would be, and I believe, are, 
operated upon. 

I have o]:)ened the abdomen in four cases with the object 
of performing a complete combined abdomino-]ierineal 
or sacral operation, but, unfortunately, secondary de])osits 
were discovered in the liver. The local conditions were 
eminently suited for complete removal. In one of these 
cases the growth was situated in the pelvic colon, so that 
I was able to excise it and do an end to end anastomosis 
so as to prevent the inevitable obstruction. It seems 
strange that in each of these four cases the secondary de- 
posits in the liver were only detected upon the diaphrag- 
matic surface. 

The mortality of the combined abdominal and perineal 



340 Cancer of the Recfvm. 

or sacral operation seems to be the chief stumbling-block 
to its general adoption. Tt is put down by different opera- 
tors as varying from fifteen per eent. to forty per cent., a 
somewhat wide variation. 

I think it cannot be doubted that this high mortality is 
attributable in some measure to the fact that many cases 
are operated upon by this method which would otherwise 
have been deemed ino])erable, and condemned to much 
misery and certain death. The combined oj)eration per- 
formed in two stages should give a much reduced mortality 
as com] )a red with the complete operation performed at one 
sitting. 

W. J. Mayo states in a recent paper that the combined 
operation performed in two stages is attended by a 
mortality of less than one half that of the combined 
ojieration completed in one stage. For cancer situated 
in the lower ])art of the pelvic colon in patients not suited 
for prolonged operative ]^rocedures the best method of 
treatment, it seems to me, is to sim])ly excise the growth 
with as much bowel above and l)elow as may ap)>ear 
advisable, and where it seems impossible to perform an 
anastomosis let the cut end of the lower rectal segment be 
closed and the closed end inveited by a ]»nrse-string 
suture. Close tlu^ pelvic peritoneinn over this and bring 
the lowTr end of the sigmoid segment through the left 
rectus muscle to form a permanent anus. The blind rectal 
end thus left might be removed at a later date if Fagge's 
demonstration is accepted, or it may be left and syringed at 
intervals to wash out the mucous secretion. By such a pro- 
cedure the time necessary for the comj)letion of the 
operation coidd Ix' reduced by at least one half, with a 
corresponding reduction in the shock and risk of sepsis. 

Tt can easily be seen from what I have stated above that 
T am convinced that an abdominal section shoidd always 
be performed as a ]ireliminary to rectal excision, no matter 
what the subsequ(Mit stcjis may be, and 1 also feel con- 
vinced that n combined abdomino-perineal or sacral 
operation is that which in the majority of cases will 



By Mr. William Taylor. 341 

give the best results. In stout or enfeebled patients, 
I believe that cancerous growths situated about the 
junction of the pelvic colon and rectum can be most 
satisfactorily treated by dividing the sigmoid flexure and 
establishing a permanent anus through the left rectus 
muscle, after which the pelvic colon with the growth can 
be separated and the bowel divided well below the disease. 
The lower cut end should then be closed and infolded by 
a purse string suture and the peritoneum drawn over it. 

In men, I think, it is much safer to complete the com- 
bined operation by the establishment of a permanent anus 
rather than make any attempt to bring the sigmoid down 
to the normal anal region. 



THE TYPE OF BACILLUS IN TUBERCULOSIS OF THE BONES AND 

JOINTS. 

The view that tuberculosis of the bones and joints is almost 
exclusively due to the human type of tubercle bacillus is 
emphasised in the Deutsche medizinische WochenscJirift for 
September 18th by Dr. B. Mollers, Koch's late assistant. 
His investigations in 12 cases of tuberculosis involving the 
bones and joints failed to demonstrate any but the human 
type of tubercle bacillus. Of the patients examined, three 
were between the ages of five and sixteen, the rest being 
older. Pure cultures of the bacilli were obtained in every 
case ; in one case three cultures were obtained at different 
periods, and in another case two cultures. From the 15 cul- 
tures thus obtained 49 rabbits were inoculated with a dose 
of 10 mgm. each. These subcutaneous inoculations, which 
were to a certain extent supervised by Koch, conclusively 
proved, accordiug to Dr. Mollers, that only the human type 
of tubercle bacillus was present. He has also collected the 
observations on this subject made by 15 workers in 163 cases 
(including the 12 cases already referred to) of tuberculosis 
of the bones and joints. Of these, only four were associated 
with the bovine type of bacillus. The remainder were un- 
doubtedly due to the human type. In other words, only 
2.45 per cent, of these cases showed the bovine type of 
bacillus. — The Lancet, October 11, 1913. 



PART II. 
RKVIKWS AND lUBLIOGRAPHICAL iNOTICES. 



Contribution's to Practical Medicine. IJy Sir James 
Sawyer. Fifth Edition. Biniiiugliaiii : Cornish 
Brothers. 1912. Cr. 8vo. Pp. 410. 

When an author starts with Pythagoras's injunction 
(quoted in French), " taisez-vous, ou dites (juelque chose 
de meilleur que le silence," we are at any rate prejudiced 
in his favour. The a])])earance of a fifth edition of this 
work — the first liaving appeared as long ago as 1SS(5 — 
gives the impression that this laudable ambition has 
succeeded in the previous ones. 

The book is made up of a collection of essays and pa])ers 
which have previously appeared in various medical 
journals, annotated and ke])t u}) to date as far as the 
nature of tlie su))jects \\\\\ allow, \\\\\\v to this edition are 
ad<led the Luiuleian Le('tures for 11)08 on '* Points of 
Practice in Maladies of tlie Heart." 

The scope of the work is accordiiigly wide, though the 
book is small, and ranges through many topics of interest 
to the physician — from insomnia, const i])ation and heart 
diseases to the use of " medicated cliocolate creams." 
Everywhere we can see that a teacher is s])eaking from 
his own large clini('al experience, while the elegance of 
style makes the ])erusal of the book a continual pleasure. 

Its atmosphere, indeed, transports us from tlie cut and 
dry, strictly scientific treatise of the present day back to 
the time of the famous older teachers and writers like 
Graves and Addison, who gav(* us those classics which laid 
th(^ foundations of our knowledge. Herein, in fact, is the 
only fault we (;an find — tliat of the reproduction of views 
wliich liave now beconu' " out of date " or ])ass(Hl into the 
stage of medical axioms. For exaniple, speaking ot 



HiNDHEDE — Protein and Nutrition. 343 

intestinal obstruction, the author says : " Surgical art 
. . . has rescued not a few whom the skill of the physi- 
cian has proved powerless to save, and this great art 
promises . . . a material reduction in the present high 
mortality of intestinal closure." The surgeon will doubt- 
less agree, but will he be satisfied with this ? 



Protein and Nutrition. By Dr. M. Hindhede, Director 
of the Hindhede Laboratory for Nutrition Research, 
Established by the Danish Government. London : 
Ewart Seymour & Co. 1913. Pp. x+ 20 L 

Those who have hitherto thought that the value of 
protein in nutrition had been finally settled ought to lose 
no time in reading the above book. They will find — 
probably to their surprise — something new and refreshing. 
The book distinctly conveys the impression that its 
author is trustworthy — an enthusiast it is true, but an 
honest one, and well informed. 

Dr. Hindhede had had a remarkable career. The son 
of a Danish farmer of well-to-do circumstances, he was 
nevertheless brought up in a frugal way, and after 
graduating in medicine in the University of Copenhagen, 
settled down in practice in his native district of West 
Jutland. Becoming interested in questions of nutrition, 
he was soon driven to the conclusion, from his obseravtions 
on the dietary and industrial efficiency of the West 
Jutland farmers around him, that there was something 
erroneous in the Voit's dietary standard of 118 grms. of 
protein and 3,000 large calories of energy per diem for a 
man doing moderate work. This he had implicitly 
accepted as a medical student. But the agricultural 
labourers of his district, doing strenuous work for 14 to 16 
hours per day, obtained in their food only a fraction of the 
" standard " amount of protein. He was consequently 
forced to conclude that the value of this constituent of the 
dietary is much overrated. In this belief he was confirmed 
by a preliminary experiment upon himself, in which he 
kept for a month in excellent health on a low protein 



344 Reviews and Bihliographical Notices. 

dietary of bread, butter, potatoes, sugar and truit, taking 
vigorous physical exercise all the time. 

Dr. Hindhede also extended his ideas to the feeding of 
cattle, and induced several farmers to adopt them with 
very satisfactory results both economically and otherwise. 
These investigations attracted con8idera])le attention, 
and ultimately led the Committee of Agriculture to 
petition the ])anish Government to secure Dr. Hnidhede's 
services for scientific research exclusively. The ])etition 
was granted, and in January, 1911, at the age of forty-nine. 
Dr. Hindhede was installed in a laboratoiy of his own in 
Copenhagen. Prior to this, in 1905, the first edition of 
the work now under review a])])eai*ed in Dajiish. To the 
second edition, and to its translation into English, are added 
the results of experinifpnts carried out in the new laboratory. 
The book contains eighteen chapters. Eleven of these — 
nearly half the whole work — are devoted to a critical 
survey of pre^'ious investigations on the subject of 
nutrition. The errors of Liebig and \'oit are convincingly 
shown. Then the experiments of HirscJifield, Klemi)erer, 
Rubner, Landergren, Chittenden, Irving Fisher, Siven 
and others ; also the investigations of Kuniagawa, Baeltz 
and Oshima on the dietary of the Japanese, of Atwater 
and A\^oods on that of twenty negro families in Alabama ; 
of ,JalTa on l^^ruitarians in California ; and even the later 
observations of \'oit liimself are all tellingly recounted, to 
show that the optimum of protehi intake lies far below, 
probably at less than one luilf of the Voit standard. 
A special chapter is given to Professor M'Kay's ex])eri- 
ments in Ijulia, and a strong case, ])ased on M'Kay's own 
data, is made out against his conclusions, ^\Jlicll, as is 
known, are in favour of a liigli ])rotein dietary. 

Jii chapter Xli. the (piestioii is raised : " Are vegetable 
foods difficult to digest." The answer is in the negative, 
the experimental basis for the old belief to the contrary 
being shown to be erroneous. Next comes an account of 
the special investigations of tlie autlior. The outstanding 
feature of these is the value proved to belong to the 
potato as a staple article of diet. 



HiNDHEDE — Protein and Nutrition. 345 

Experiments with various human subjects — in two 
cases extending to 300 hundred days each — showed 
that excellent health and unimpaired capacity for work 
could be maintained on a diet consisting solely of potatoes 
and margarine. But the reservations are made that : 
" one must know how to buy potatoes " ; " one must 
know how to boil potatoes " ; " one must know how to eat 
potatoes " ; and conditio sine qua 7ion, one must never eat 
a bad potato : it kills the appetite. 

The experiments so far made were of two classes — 
(a) those on cheap nutrition ; (b) those to decide the 
nitrogen minimum. Dr. Hindhede found that with a 
liberal supply of cereals, potatoes and vegetables, and a 
reduced supply of meat, an average man could be fed on 
5d. per day, giving him 75 grms. of protein and 3,000 
calories of energy. He had lived himself for eight weeks 
on such a diet, and never felt better. During its con- 
tinuance he made a bicycle tour of 155 miles through 
hilly country to test his condition. Starting at 6 45 a.m. 
a,nd ending at 8 30 p.m. on the same day he rode 108 
niles. Next morning he rode the remainder of the 
listance, 47 miles, in a little over four hours, arriving at 
10 45 a.m., and this without undue fatigue and without 
having been previously in training. 

To determine the nitrogen minimum, experiments were 
carried out with a subject for over five months. This was 
divided into several periods during which the protein of 
the diet was steadily reduced. The following are samples 
of the results. In period 2 (11 days) the diet contained 
43 grms. protein with 3,000 calories. In period 15 (19 days), 
using potatoes with a lower content of protein, the amount 
in the dietary was reduced to 30 grms. with 3,900 calories. 
This was further lowered in subsequent periods, the figures 
for period 19 (8 days) being 21 grms. protein and 4,054 
ja^ories. In all cases the above figures represent gross 
quantities, no allowance being made for unabsorbed nitro- 
gen, and in all the equilibrium showed a slight -f balance. 

Needless to say these are remarkable results. In no pre- 
vious investigations extended over any lengthened period 

z 



346 Reviews and Bibliographical Notices. 

was so low a protein level maintained. Chittenden's 
results come nearest, and in these the lowest for himself 
was 35 J grms. of gross protein with a yield of only 1,549 
calories, which represents, for a yield of 3,000 calories, 
a protein level of 70 grms. 

In the remaining chapters of the book Dr. Hindhede 
discusses such questions as " Over-feeding," " Meat and 
Energy," " Low Protein Diet and Children," finishmg up 
with a chapter entitled " Enjoyment of Life," in which 
he gives a balance of the advantages and disadvantages 
(the latter being negligible) of his system of dietary. 

The book is attractively written and, on the whole, well 
translated. There are a few slips, mostly ])rinter's errors. 
One of these, on p. 74, is a little embarrassing till the error 
is detected. The statement reads " 28 gnus, of protem," 
when it should be 98 grms. There are eight full-page 
illustrations, mostly reproductions of photographs. 



The Dublin University Calendar jar the Year 1913-1914, 
to which are added the Ordinary Papers set in the Year 
1912-13. Vol. I. Du]>lin : Hodges, Figgis & Co. 
1913. 8vo. Pp. viii + (34* + 488. 

The Calendar contains the usual information, so indis- 
pensable to all students in Ai-ts and in the various pro- 
fessional Schools. The last 143 ])ages contain the •i)a])ers 
set at the ordinary examinations in ^Vrts during the 
Academic year, 1912-13. 

A commonly believed legend is that the organ in the 
gallery of the Public Theatre, usually called the Examina- 
tion Hall, of Trinity College, was taken frojn the Spanish 
Arjnada. But the con p-de-grdce is given to tliis legend in 
the following paragraph at ])agc 328 : — " In the galleiy 
is the case belonging to the oigan of the old chapel. Tliis 
organ was built in Holland for a church in Spain, but was 
taken from the S])aniards in Vigo Bay, 1 702, and repaired 
and enlarged in 1705. It was presented to the College 
by the second Duke of Ormonde." 

The present volume contains 20 pages fewer than the 



Drew — Manual of Invertebrate Zoology. 347 

Calendar for the previous year. But this is accounted for 
by the omission of the Letters Patent, A.D. 1911, which 
occupied 30 pages of the volume for 1912-1913. It is a 
pity that no reference is given to this fact. 

The Calendar is very well brought out, and reflects 
credit on the Editor, Mr. M. W. J. Fry, M.A., F.T.C.D., 
the University Press, and the Publishers. 



E. Merck's Annual Report of Recent Advances in Pharma- 
ceutical Chemistry and Therapeutics, 1912. Vol. XXVI. 
Darmstadt : E. Merck. 1913. 8vo. Pp. 524 + xix. 
This unpretending, paper-bound volume of over 500 
octavo pages is really a valuable work of reference. On 
this occasion, as often in past years, we would emphasise 
the fact that Mr. Merck's Annual Report embodies an 
impartial review of the literature published during the 
past year on chemicals, drugs and new remedies of medical 
and pharmaceutical interest, and no commercial con- 
siderations influence the contents of this valuable work. 
The work is compiled from the publications of the authors 
referred to — full particulars of the publication quoted 
being given in each case — and the author purposely 
refrains from any comments, except where a somewhat 
unusual statement compels him, in the interest of the 
reader, to draw attention to the views contained in other 
publications or text-books on the point in question. 

A limited number of copies of the present volume will 
be sent to members of the medical profession on application 
to Mr. E. Merck, the Chemical Works, Darmstadt, or to 
his London Oflice, G6 Crutched Friars, E.C. The book will 
also be obtainable through the bookseller at Is. 6d. per copy. 



A Laboratory Manual of Invertebrate Zoology. By Oilman 
A. Drew, Ph.D. Second Edition, Revised. Phila- 
delphia and London : W. B. Saunders Company. 1913. 
Pp. 213. 
This carefully thought-out manual contains sets of labora- 
tory directions dealing with nearly a hundred species, as 



348 Reviews and Bihliogr(iphical Notices. 

well as connecting paragraphs designed to keep the 
essentials of classification before the student. The 
directions are clear and concise, and direct attention to 
individual peculiarities rather than to repetitions of 
structure. This keeps students from trying to make 
everything conform to type, and leads them to look out 
for the adaptations that fit the different animals for their 
particular lives. 

In the present edition short but helpful references to 
literature are added ; these will enable students to become 
acc^uainted with methods of work, and perhaps imbue 
them with the spirit of research. 



Our Outsides : and what they Betoken. A Summary by 
W. T. Fernie, M.D. Bristol : John Wright & Sons. 
1913. Cr. 8vo. Pp. xv + 413. 

This final contribution from the fertile pen of a veteran 
])hysician is built on the plan of the old-fashioned 
"Commonplace Book." "The Hands," "The Eyes," 
" The Nose," and similar lieaduigs seem to have been 
set down, and then whatever turned u]) relating, even 
reniotely, to the subject-matter of the title was entered 
under it. 

Thus under "The Ears" a parody entitled "The 
Village Choir " is given ; the first of the seven verses 
runs : — 

"" Half a bar, half a l)ar, 

Half a ])ar onward ; 
Into an awlul diU-li, 
Choir and IVcMjontor sw iU^h ; 
Into a moss of ' piU'h ' 

Lead the Old Hundredth : " 

The whole of the " Battle of Blenlieim " is quoted under 
" The Head," because the grandchild describes a skull as 
" so large, and smooth, and round." 

Tjideed, under tlie heading " The Mouth," Eliza Cook's, 
"The Old Armcliair ■ is given first in English, and then 



NoRRis — Gonorrhoea in Women. 349 

in Latin, simply that the reader may the better appreciate 
a somewhat halting parody entitled " The Dentist's 
Chair ! " 

This method of setting down what comes to hand leads 
to many omissions ; thus in treating ol the markings of 
the nails the author fails to note the transverse ridges 
left by illness, an omission that shows a strange lack of 
observation . 

Once, however, " Our Outsides " is recognised as " a 
book that is not a book," it can be read with pleasure and 
profit. 

As the mention of a feature of the face is considered 
sufficient justification for dealing discursively with anyone 
in whom that particular feature was peculiar, the reader 
of Dr. Fernie's book will renew acquaintance with many 
old friends in popular history and other fiction. 

The following verse, which occurs in the section devoted 
to " The Ears," may be useful as a memory test : — 

" Conclusive tenderness ; fraternal grog ; 
Tidy conjunction ; Adamantine bog ; 
Impetuous, arrant toadstool ; thundering quince ; 
Repentant dog-star ; inessential prince ; 
Expound, pre- Ada mite, eventful gun, 
Crush retribution, carranb jelly, pun, 
Oh ! eligible darkness, fender, sting, 
Heav'n-born insanit}', courageous thing, 
Intending, bending, scourging, piercing all. 
Death-like pomatum, tea, and crabs must fc.ll."' 



Gonorrhoea in Women. By Charles C. Norris, M.D. 
Philadelphia and London : W. B. Saunders Company. 
1913. 8vo. Pp. 521. Forty Illustrations and Coloured 
Plates. 

This large work on the subject of gonorrhoea may be 
divided into three parts — the bacteriology, diagnosis, 
symptoms, and complication of gonorrhoea in the female ; 
secondly, the remote effects of gonorrhocal infection, in 
tubes, ovaries, uterus, &c., with a clear and full account 



350 Revietcs and Bihliocjraphical Notices. 

of the operative treatment necessai^ in such cases ; almost 
all of this section is dealt with fully in the ordinary works 
on gynie(K)logy. The third portion of the book deals with 
the sociology of gonorrhoea. In dealing with this subject 
the author refers to and gives statistics of gonorrhoea m 
the male. The disease and its prevention in women is 

hardly dealt with at all. 

A veiy large number of references— some 2,300— are 
given, but the book is too diffuse. An unnecessary 
amount of space is devoted to unimportant matters, while 
im])ortant sul)jects are barely dealt with at all. The 
history of gonorrhoea and prostitution fills some fifty to 
sixty pages. The whole question of gonorrhoea serums 
and vaccines, their mode of preparation and administra- 
tion, are dismissed in three pages. The space devoted to 
these subjects might with advantage have been reversed. 



A Text-hook on Oonorrhcra and Us Cojuplications. By 

Dr. Georoes Luys. Translated by Arthur Foerster, 

M.R.O.S., L.R.C.P. (Lond.). London : Bailliere, 

Tindall & Cox. Royal Svo. Pp. xx + 384 . 200 

Illustrations. 

Dr. Foerster has succeeded in producing an excellent 

translation of Dr. Luys's admirable work on gonorrluya. 

Dr. Luys's name is so well kno^\^l in connection with 

recent bladd(T and urethial worlv, and is so intimately 

associated with his urethrosc^ope, that this volume is 

certain to meet with a warm reception from l^>ritish 

medical men. 

The history, patliologA% and retiology of gononh(ra are 
all fully gone into ; the very iuiportant subject of non- 
gonorrho\al inflammations of the urethra, is well dealt 
^^'itll ; the dia.mic^sis and treatment of gonorrhoea and 
its many cojnplications are discussed in the most interest- 
ing way. Tlie author wisely refrains froni giving a numlier 
of treatments, l)ut describes fully the details of the line 
of treatment lie has found to be most useful in such cases. 

Dr. (Jeorges Luys is frankly an instrumentalist : he 



Leftwick — Tabular Diagnosis. 351 

does not believe it is at all possible to treat a chronic 
gonorrhoea and its complications without the use of 
the urethroscope. The use of the urethroscope has been 
in some countries much overdone, and for this cause 
possibly has fallen into a considerable degree of disuse 
in Great Britain. Dr. Luys makes out a strong case for 
its more frequent use in chronic cases. 

The illustrations are numerous, most of them are 
original, and add clearness to a text that is throughout 
concise and pleasant reading. 



Synopsis of Midwifery. By Aleck W. Bourne, B.A., 
M.B., B.C. (Camb.), F.R.C.S. (Eng.) ; Obstetric 
Registrar and Tutor, St. Mary's Hospital, London, &c. 
Bristol : John Wright & Sons, Ltd. 1913. Cr. 8vo. 
Pp. viii + 212. 

This hand-book is an attempt to set the principal points 
of obstetrics before students preparing for qualifying 
midwifery examinations in a simple and concise manner. 
We consider that this attempt is abortive without the 
assistance of an efficient teacher, and we are strongly 
against the use of this book and of other such books, 
which are only of value to those with prodigious memories. 
Practical obstetrics has taken such a prominent place 
in the medical curriculum that, although it is stated that 
this synopsis is only intended as a supplement to the 
ordinary text books, these bald statements of facts without 
illustrations or explanatory text are of little worth to 
the practitioner or to the student. 

Tabular Diagnosis : an Aid to the Bapid Differential 
Diagnosis of Diseases. By Ralph Winnington 
Leftwick, M.D. ; Late Assistant Physician to the 
East London Children's Hospital. London : Edward 
Arnold. 1913. 8vo. Pp. vi + 359. 

It is difficult to form a clear estimate of the value of such 
a book as this. It consists of a collection of 350 tables 



352 Reviews and Bibliographical Notices. 

of diagnosis. The preface claims that " this mode of 
exhibiting at a glance the divergencies of two otherwise 
similar diseases offers great and obvious advantages to a 
busy practitioner." The author further states that he 
has been " at some pains to make it unavailable as a 
cram book," but considers that it may be legitimately 
used })y students who have read their text-books as a 
means of testing their knowledge. 

IMany of these tables are familiar to us in text-books 
of medicine or on the blackboards used at hospital 
cliniques — tables such as those differentiating alcoholic 
from apoplectic coma, ascites from ovarian cyst, scrotal 
hernia from hydrocele, chancre from soft sore, &c. On 
the other hand, the author's contention that a collection 
of 350 such tables is quite unprecedented is undou])tedly, 
we believe, true. These tables have evidently been 
prepared with considerable care and accuracy, and many 
of them would undoubtedly prove useful for the ])uipose 
for which they are intended. 

We take exception to the folloAving instances, more to 
show the impossibility of meeting all cases in differentiat- 
ing ta])les such as these than to niark actual error. Thus 
in Table 25 .r-rays are said to " show a tumour * in 
aneurysm of th(^ a])dominal aorta and to be " negative " 
in })ulsating aorta. The value of the rays can, we think, 
seldojn l)e relied upon in these cases. In Table 51 Argyll- 
Ro])ei*tson ])U])ils arc said to be a sym])tom common to 
ataxic paraplegia and hereditary cerebellar ataxia, while 
in Table 105 the fonner disease is distinguished from 
locomotor ataxy by the pupil l^eing normal. In Table 02 
x-rays are not mentioned for differentiating calculous 
from sijnple cystitis, although the cystoscope is sometimes 
contraindicated. In Table OS the temperature in diph- 
theria is said to be " high." Table 113 does not mention 
the scalp, an examination of which we have known to be 
useful in diagnosticating hqnis erythematosus from other 
skin affections. In Ta))l(^ 41, on ascites and greatly dis- 
tended bladder, the s(\\ in ihv ]att(M' rase is given as 
" female." 



Barbour — Watson — Gyncecological Diagnosis. 353 

Many other similar instances might be mentioned, but 
this does not alter the fact that the book is full of a great 
deal of carefully compiled and compact information. 
The tables should prove useful for the purpose for which 
they are intended, but they must be used with intelligence, 
and only by those who have studied their text books. A 
good index is to be found at the end. 



Gynmcological Diagnosis and Pathology. By A. H. F. 
Barbour, M.D., LL.D., F.R.C.P. Ed., and B. P. 
Watson, M.D., F.R.C.S. Ed. Illustrated. London : 
Wm.. Green & Sons. 1913. Pp. xvi + 220, with Index. 

This short work on gynaecological pathology is intended 
mainly for students. It consists first of some 30 pages 
devoted to a description of methods of diagnosis, and then 
the remainder of the book deals with pathological condi- 
tions. We are glad to see that the importance of the 
bi-manual method of examination is laid down, but we 
would rather see more insistance on asepsis than on the 
use of carbolised vaseline and the warming of the speculum. 
Marion Sims posture is described, and Sims' speculum is 
said to be the only one with which the sound or the curette 
can be used ! 

The pathological part of the book is on the whole very 
sound. We notice a few omissions, notably all reference 
to hydro-salpinx, and tubo-ovarian cysts. The description 
of tubal tuberculosis is rather confusing. The authors 
begin by stating that it may take two forms, and then 
illustrate (Fig. 138) a third. Our own experience leads 
us to say that neither of the two forms first mentioned 
is the more common, and indeed in most cases miliary 
tuberculosis of the peritoneum covering the tube can 
hardly be correctly termed tubal tuberculosis at all. 

The book might, with advantage, be carefully revised 
and a number of small discrepancies corrected. Omitting 
these fpoults, however, it is a safe guide to gynaecological 
pathology . 



PART III. 
SPECIAL REPO RTS, 



REPORT ON MEDICINE. 

By T. GiLLMAN MooRHEAD, M.D., F.R.C.P.I. ; Physician 
to the Royal City of Dublin Hospital. 

I. USE OF SALICYLATES IN ACUTE RHEUMATISM. 

Miller has studied the effects of salicylates on a series 
of cases of acute rheumatism treated at St. Mary's 
Hos})ital, more especially with a view to answering or 
admitting the truth of certain objections levelled against 
the salicylate method of treatment. He formulates the 
following conclusions : — (I) The objection that the larger 
doses of sali(^ylates do not imply increased al)sor|)tion is 
without foundation, as the amount of salicylate excreted 
in the urine varies directly with the ajnount ingested. 
(2) The objection that large doses are prone to produce 
vomiting is only partially true. Salicylates are gastric 
irritants, and will tluM'efore produce voniiting in a certain 
percentage of cases, but this may occur quite inde])endently 
of the dose given. Vomiting is more a niatter of the type 
of case under treat jnent than anything else, and is 
specially seen in cases with sev^ere cardiac lesions. In 
such cases it niay be necessary in consequence to limit the 
use of the drug. (.*}) The objection that large doses are too 
])rone to produce acid intoxication is only partially true. 
Provided consti])at ion is avoided, and that alkalies are 
given with the salicylate acid, intoxication can usually 
be avoided. (4) The objection that large doses are in 
theniselves dangerous is not su])ported ])y an analysis of 
cases, no fatality in his series being attributable in any 
way to the drugs em])loycd. ('>) The objection that 
salicylates do not prevent relapses is unsound, as most 



Report on Medicine. 355 

relapses occurred after small doses or a short period of 
administration ; cases taking large doses showed some im- 
munity to relapse. — Quarterly Journal of Med., July, 1913. 

II. THE SIGNIFICANCE OF THE PRESENCE OF ALBUMEN IN 

SPUTUM. 

Kauffmann (Beiirage zur Klinik d. TuherJml, Bd. 26, H. 3) 
points out that the recognition of albumen in sputum is 
very easily carried out by a simple test available at the 
bedside. Albumen is found in the sputum in pulmonary 
tuberculosis, in pneumonia, in congestive catarrh and in 
foetid bronchitis ; it is absent in chronic bronchitis. 
When a positive albumen reaction is in accord with other 
physical signs it is confirmatory of a diagnosis of active 
tuberculosis. In healed tuberculosis the albumen dis- 
appears, and in croupous pneumonia it disappears soon 
after the crisis. If it should later return it points to a 
fresh pneumonic invasion, or to empyema, or to the 
formation of a pulmonary abscess. 

III. SYPHILIS OF THE HEART. 

Orkin {Berlin klin. Woch, 1912, No. 25) points out that 
syphilis plays an important part in the aetiology of myo- 
carditis. Often one finds no cause for the sickness, and a 
history of syphilis is not obtained, but the Wassermann 
reaction may prove positive, and ;r-rays will show a heart 
enlarged in every direction, and with a dilated aorta. In 
young individuals in whom cardiac symptoms suddenly 
appear without apparent cause, one should especially 
think of syphilis. In almost ail young patients relief ot 
symptoms rapidly follows on appropriate treatment either 
by mercurial inunction or by potassium iodide. In older 
patients cure is much more difficult of attainment. It 
has not yet been determined whether salvarsan can safely 
be used. 

IV. VALUE OF luminal AND OF CROTALIN IN EPILEPSY. 

Hauttmann {Milnch med. Woch, 1912, No. 35) states that 
the number and the severity of epileptic fits can be 



356 Report on Medicine. 

diminished by the tadministmtion of kiininal. This is 
specially noticeable in certain severe cases of epilepsy 
which can no longer be influenced by even the highest 
doses of bromides. In cases of moderate severity doses 
of from .15 to .2 gramme may be given doily, and in 
severer cases .3 gramme. Even after the daily use of 
luminal for a month no cumulative effects are ])roduced. 
Spangler writes on the use of crotalin for the sanie 
disease. He has now tried it in thirteen cases (Neiv York 
Med. Journal, 1012, Sept. 14) of idiopathic epilepsy, and 
is of opinion that it diminishes the frequency and the 
severity of the fits. It also calms the excita})ility of the 
nervous system, and in general exercises a favourable 
influence on jnetabolism and on the mental state. Pro- 
vided aseptic precautions are taken and the patients are 
carefully observed no ill results follow the use of the drug. 
It is su])])lied in sterilised ampulla? containing 1 cubic 
centimetre. 

V. ANTE-MORTEM THROMBOSIS IN PNEUMONIA. 

Fleming (Edinburgh Med. Journah Sept., 1013) discusses 
the nature of the clots so often found in the right heart 
in death from lo})ar pneunionia, and ex])resses the o])inion 
that such clots are frequently forjned hours, or even days, 
before death. Excess of COo in the blood, and the forjna- 
tion of abundant thrombokinase owing to disintegration 
of large nujubers of leucocytes are probably imiiortant 
factors in bringing about this ante-mortein thrombosis, 
(clinically he believes that thrombosis may be feared in 
any case in which engorgenient of the jugular veins is 
present along with diminution in loudness of the pulmonary 
second sound. In order to conibat the tendency to 
thronibosis in pneumonia he advocates the er,rlv adnunis- 
tration of cardiac tonics, with the addition of diffusible 
stimulants if the heart shows any signs of difficult action. 
He thinks that the administration of oxygen jnay be 
useful also by counteracting the excess of carbon dioxide 
in the blood, and also sugg(^sts the use of dra.rhm doses 
of citric acid everj' four hours, l^lerding he thinks should 



Report on Medicine. 357 

never be performed unless in robust patients, as it may 
only aid a thrombosis which has already begun. 

VI. ehrlich's aldehyde reaction in hepatic con- 
gestion. 

JoNASS (Wiener klin. Woch, 1912, No. 10) has made 
investigations on the amount of urobilin found in the 
urine in cardiac and pulmonary diseases. In each case 
he has tested fresh urine by means of Ehrlich's aldehyde 
solution, a pink colour indicating the presence of urobihn. 
He finds that the reaction is positive in all cases in which 
the right heart is congested, and that the amount increases 
if extra work is thrown on the heart in such cases. In 
nervous asthma the reaction is positive during the par- 
oxysm, and subsides as the sj^mptoms pass off. In 
valvular disease of the heart a positive reaction is obtained 
while failure of compensation exists, and a negative one 
when compensation is normal. In each case presumably 
the appearance of the urobilin is due to the hepatic 
insufficiency caused by congestion secondary to pulmonary 
or cardiac disease. As a measure of the amount of venous 
congestion present the test may be of some value. 

VII. tests for hepatic function. 

Whipple and others discuss the value of certain tests for 
hepatic function (Johns Hopkins' Bulletin, July, 1913). 
They point out that lipase exists in normal human and 
animal blood plasma in fairly constant proportions, and 
that experimentally injury of the hver by chemical means 
causes a rise in this plasma lipase. Clmically they have 
found a high lipase amount in several cases of eclampsia : 
in jaundice there may be a slight rise, but more often there 
is a fall. The amount of fibrinogen in blood is also fairly 
constant : it falls to a low level with injury to the liver 
and returns to normal as recovery takes place. Clinically 
a low index is found in hepatic cirrhosis, and in cases of 
delayed chloroform poisoning. The third test discussed 
is known as the phcnol-tetrachlorphthalein test, and is of 
special value, as this drug when injected intravenously or 



358 Report on Medidine. 

subcutaneously is excreted by the liver cells into the bile, 
and is excreted in the fa?ces. Under norjual circumstances 
from 40 to 50 per cent, of intravenous doses can be recovered 
from the faeces, but when the liver is injured the percentage 
may drop to 20 per cent, or even 10 per cent., and a certain 
amount of the drug begins to appear in the urine. The 
test is of course of no value in cases of obstructive jaundice, 
but clinical observation in other cases suggests that the 
test may prove of great ^ alue in the estimation of hepatic 
function. 

VIII. TUMOUR OF THE PINEAL BODY. 

BiULEY and Jeliffe (Archives of Internal Med., 1!)11, 

VIII. 6) report a case of tumour of the pineal body, and 
analyse the symptoms noted in it and in all other pre- 
viously pul)lished cases. An early symptom is great 
increase of intracranial pressure, caused by a rapid 
development of hydroce})halus, which leads to headache 
and attacks of vomiting. Cliddiness is an early s^-mptom, 
and is followed by optic neuritis. Lethargy, paralysis of 
ocular muscles, nystagmus, and inequality of the pupils 
are also met with, and sometimes dilatation of the puj)ils 
resulting from pressure on the coi7)ora (piadrigemina. 
Pressure on the cerebellum niay give rise to cerebellar 
sym])tonis. Among characteiistic symptoms is to bi- 
nientioned obesity, which probal)ly depends on the kind 
of tumour present, and on co-existing hy})opituitarisni 
produced by the tumour pressing on the ])ituitary body. 
In the same way probabl}^ arises the precocious develo])- 
ment of the genital organs that is met with, though Biach 
has shown that the ])incal gland and the sexual glam's are 
in some way related to one another, inasmuch as castration 
of young aninuils leads to atrophy of the ))ineal gland. 
Sometimes severe cachexia is encountered and is regarded 
as the direct result of changes in the pineal gland itself. 

IX. THE HISTOLOGY OF MYOCARDIAL DEGENERATIONS IN 

VARIOUS INTOXICATIONS. 

Anitschkow has investigated the changes produced in 
heart muscle by the toxin of diphtheria, and also those 
l)roduced by the combined action of adixnaHn and 



Report on Medicine. 359 

spartein. He found that the changes could be grouped 
under the three headings of degenerative changes in the 
muscle fibre, cedematous changes, and inflammatory 
changes. The degeneration consisted in practical destruc- 
tion of the nuclei of the muscle fibres, deposition of fat 
within the fibres, and a general loss of differentiation. 
The cedematous changes consisted of swelling of the 
interstitial substance accompanied by the appearance of 
new cells, and without any change of the fibres themselves, 
and were most noted in the hearts poisoned by adrenalin. 
Inflammatoiy changes presented the appearances common 
to inflammation elsewhere, and in later stages were 
represented by the development of granulation tissue. — 
Virchow's Archiv. Bd. 211, 2. 

X. RAIN-BEARING WINDS AND THE PREVALENCE OF TUBER- 
CULOSIS. 

W. Gordon discusses this subject, and, as a result of his 
investigations, concludes that populations exposed to 
strong, prevalent, rain-bearing winds tend to suffer 
considerably more from pulmonary/ tuberculosis than 
populations sheltered from them. He thinks it probable 
that similar exposure affects appreciably the course of 
existing cases of phthisis, and increases the prevalence of 
bovine tuberculosis. He urges the importance of taking 
into account the wind-exposure of any place recom- 
mended as a place of residence to a cured case of 
pulmonary tuberculosis, and points out the necessity in 
investigating any influence bearing on the prevalence of 
pulmonary tuberculosis of first recognising and eliminating 
the influence of strong, prevalent rain -bearing winds. — 
Practitio7ier , Jan., 1913. 



THE LISTON VICTORIA JUBILEE PRIZE. 

At the meeting of the Eoyal College of Surgeons of Edin- 
burgh, held on October 15th, the Liston Victoria Jubilee 
Prize of £100 was awarded to Mr. John David Malcolm, 
M.B., F.E.C.S.E., London, for his investigation of Surgical 
Shock. 



PART IV. 
MEDICAL MISCELLANY. 



Reports, Tratmcctions, ami Soientific InteUyjencc. 

♦ 

The ])iauy of an Irish Medical Student, 1831-1837. 
P^dited with Notes by T. Percy C. Kirkpatrick, M.D., 
M.K.I. A. ; Fellow and Kegistrar of the Royal College of 
Physicians of Ireland. 

The diary which is here printed was written by the late }lr. 
Robert Thompson, of Johnstown, Ck). Kilkenny, during the 
period that lie was a student of Medicine at Steevens' Hos- 
pital and the School of the Royal College of Surgeons in In- 
land. ^ Though the diary gives the merest outline of the 
writer's daily doings, yet it, has seemed worth while to pre- 
serve it as the record of a medical student of the time. 

Robert Thompson, in 1837, obtained the qualification of 
Licentiate of the Royal College of Surgeons, and the diary 
breaks off abruptly at that time. Subsecpiently he went tc:) 
Glasgow, where in the University of that town in 1838 he 
graduated M.D. Later on he started practice in Johnsk)wn, 
Co. Kilkenny, where he was appointed Dispensary Medical 
OHicer. His brother, Henry Thompson, so often referred to 
in the diary as " Harry " or " Henry," also a Licentiate of 
the College of Surgeons, and M.D. of Glasgow, after serving 
for two years as Medical Officer of the Dispensary of Richhill, 
was appointed to the Dispensary of Trillick, in Co. Tyrone. 
Seven years later he was ap})ointed Surgeon to the Co. 
Tyrone Infirmary at Omagh, where he worked with con- 
spicuous success till his death on April 8, 1875. Robert 
Thompson spent his long life in Johnstown, Co. Kilkennv. 
He lived at Mclross, in that niighbourhood, and retired from 
practice about 1004, and died a little later. The Rev. Mr. 
Thompson, father of Henry and Robert, was married first to 



The Diary of an Irish Medical Student. 361- 

a Miss Irwin, of Co. Tyrone, who was the mother of both 
these doctors, and secondly to Miss Neville, of Co. Tipperary. 
Selina, Eobert's sister, married a member of the Hely family. 



The Diary. 

I was bound to Colles (1) on the 27th of October, 1831, 
when just commencing my sixteenth year, the 12th of that 
month being my birth-day, and had left school only about a 
fortnight; I had received a pretty fair, though not a very 
well grounded, education, the method of teaching at my last 
school being very superficial; the rudiments of Latin I had 
been well taught at Portora (2), where I spent two years. I 
then remained at home for two and a half years, getting in- 
struction in Latin from my father and my brother, when he 
was at home from Dublin, where he was studying medicine. 
I went to Littleton School in January, 1829. At the latter 
part of this year my brother John returned from sea, where 
he had spent more than four years; he was very much dis- 
gusted with the service at that time, but I believe has 
been reconciled to it since. In the winter vacation of 1830 
we were all at home except Selina ; it is a curious fact that I 
never yet saw the whole number of us (eight) together at 
any one time, though I have seen seven frequently. 

At Littleton I read all the College entrance course ; the 
two first books of Euclid, Murray's Logic, and the classics 
for the two first examinations. 

The lectures I attended in Dublin were on Chemistry, 
Surgery, Anatomy and Physiology, lived in Steevens' Hos- 
pital, where a number of wild fellows messed in our room, 

(1) Abraham Colles, born July 23, 1773, studied medicine in 
Steevens' Hospital under Philip Woodroffe, and graduated B.A. 
in Trinity College in 1795. In 1799 he passed the College of 
Surgeons, and on July 26 of that year was appointed Resident 
Surgeon of Steevens' Hospital. In 1802 he was elected President 
of the College of Surgeons and two years later Professor of 
Anatomy. He continued in office as Resident Surgeon till 1813, 
when he was appointed Assistant Surgeon to the Hospital. In 
1836 he resigned his Professorship, and in 1841 his post as 
Assistant Surgeon. Ho died December 1, 1813. He was the 
first to describe the well-known fracture of the lower end of 
the radius, which still bears his name. 

(2) Portora. Boyal School, Enniskillen. 

2 A 



362 The Diary of an Irish Medical Student. 

generally spent our evenings sparring and drinking punch 
and going to the upper gallery at the theatre. 

In April, 1832, the cholera appeared in Dublin (1). 1 
left it immediately after, being afflicted with nostalgia and 
some other nervous symptoms, which disappeared imme- 
diately on my reaching home on Easter Sunday, 1832. This 
summer I spent idling and shooting snipe, reading a little of 
"Richerand's Phisiology " (2). 

Returned to Dublin, October, 1832, to Steevens' Hos- 
pital, where I found Harry and Graham working hard dis- 
secting, preparing to pass in May ; this was my first winter 
dissecting, which business I liked and worked very hard at, 
but at Christmas was laid up for eleven days with small-pox, 
caught, I suppose, from a subject in the dissecting-room; 
just after I came to Dublin this winter my father unexpect- 
edly followed (he having been presented to the parish of 
Templetuohy (3), near Templemore, the former occupant, 
Mr. Foster, dying of the cholera) to arrange about the 
change. 

My father proceeds by subpoena against the tithe de- 
faulters in Fennor parish (4), and I leave Dublin in March, 
'33, and served one fine morning 17 out of 20 that I received, 
drove in a hired car, which I brought from Thurlcs, on to 
Johnstown (5), where my father and our family were then 
residing. It was at this time the Johnstown Dispensary elec- 
tion took place, and Ryan was returned. I returned soon to 
Dublin to swear to the service of the subpoenas. In May, 
1833, our family came to Dublin to lodgings we had pro- 
vided in Camden Street, where they did not remain long, 

(1) In the years 1832 and 1833 a severe ei)ideniic of cholera 
visited Ireland. Though the returns are defective, 66,020 cases 
are recorded in these two years with 25,378 deaths, or a case 
mortality of 38.13 ])er cent. In the City of Dublin 5,798 deaths 
were recorded from the disease in the two years. 

(2) Nouveaux Elc^mens de Physiologic. Par A. Richorand. 
lOe Ed. revue, corrig<^, et augmentt^e par I'auteur et ])ar B(^rar<'l 
a!ne. Paris, 1830. Several English translations of this work 
were ])uhlishod both in Ijondon and Ainorica. 

(3) Tenipletouhy, a ])arish near Tenipleuiore, in County 
Tipperary. 

(•1) Fennor parish in Co\inty Ti|)porary. 

(5) Johnstown, a post-town in the Harony of Glamoy, County 
Kilkenny, fifty-eight miles from Dublin, on the road to Cork 
by Cashel. George Tfely owned considorahle ])roperty there. 
Urlingford is a parish about two miles from this town. 



The Diary of an Irish Medical Student. 363 

but soon removed to Steevens' Green (1). About July I left 
town with my father to arrest the tithe defaulters, passed 
through Carlow, and stopped one night at Mr. William 
Butler's, of Ashfield. During this journey I was laid up 
with the influenza, and was quite helpless for a week after- 
wards; however, I soon went about the business, and going 
to Urlingford arrested Dennis Cormack, and was going into 
Kilkenny gaol when he struck and paid. His example was 
followed by many others, and about £70 was raised by 
several giving their notes for the amount. During those 
doings my studies were very much interrupted from March 
until July. 

Eeturned to Dublin and found our family located at 
Merrion Avenue, the girls and Mun at school. About this 
time the boys at Steevens' got a boat in which we had 
several pleasant trips to Howth, Eyirlandseye (2), and 
Lambay, Kingstown. 

I had been very heavy and stupid one day, and on hearing 
that the boat was going to Kingstown I agreed to accompany 
them, which I did, and pulled all the way as hard as I could, 
but I did not get rid of the unpleasant sensation; took two 
glasses of brandy ; next day went out to Merrion, bathed in 
the sea, ill for two days more, and on the fifth day an erup- 
tion of papules appeared; decided measles; a few days after, 
when the eruption was not entirely gone away, I joined a 
party to see a launch, when I returned a pain commenced 
in my side, increased by inspiration and cough; decided 
pleuritis, was nauseated, bled and blistered. 

After the blisters a number of boils came on my side, 
and being very thin and having a cough, I was sent to the 
country, and arrived at Fallowbank the week of the races at 
Enniskillen, September 3, 1833; remained in the North at 
Bara until November, '33, when I returned to Dublin to 
Steevens' Hospital, where, since Henry passed in July, 
Colles (3) had been my chum; at this time my father and 

(1) St. Stephen's Green. 

(2) Ireland's Eye, off Howth. 

(3) William Colles, son of Abraham Colles, was born on July 2, 
1809. He studied medicine in Steevens' Hospital, where he was 
an apprentice to his father. On July 9, 1831, he passed the 
College of Surgeons, and ten years later graduated M.B. in the 
University of Dublin. On February 11, 1834, he was elected 
Resident Surgeon at Steevens' Hospital, and continued to hold 



364 The Diary of an Irish Medical Student. 

Henry had been at Templemore, arranging the schedules for 
application for a share of the million fund. A little after this 
Henry went to Glasgow ; worked away this winter very well ; 
passed the first examination the 15th of November, and was 
busy preparing for the second, which is to take place in 
May. Colics and I spent a jolly winter, drank a deal of 
punch, went to the theatre at least two a week, passed the 
second examination May, '34. 

In May, '34, Henry became Clinical Clerk to the Hospital, 
and the first grand turn out of old residents took place ; about 
ten left the hospital, and it is in prospective for each surgeon 
to have only two resident pupils, and to take charge of acci- 
dents month about (1). 

About this time I commenced writing a journal of all my 
transactions, which I have kept up ever since, but unfortu- 
nately the one I had of the first four months is lost, and the 
other so disconnected that I can scarcely form a continued 
narrative. However, I will at least transcribe the most 
material points and the dates of them. 

Left Steevens' for " Cranagh House," where our family 
are now staying, at the beginning of July, walked out from 

that ofiioo till 1841, when he succeeded his fatlior as Assistant. 
He continued connected with the Hospital till his death on 
June 18, 1892. 

(1) At the meeting of the Governors of Steevens' Hospital on 
February 11, 1834, several changes in the management of the 
hospital were introduced. James William Cusack, who had been 
Resident Surgeon for twenty-one years, resigned, and was 
a])|)ointed third Assistant Surgeon. Cusack's duties as Resident 
Surgeon had been very comprehensive. He had " to sui)crintend 
the whole establishment, the duties of the subordinate servants, 
the state of the wards and the ])remises generally, the registry 
and the attendance of the pupils, he has also to visit the wards 
twice a day to see that all directions have been carried into 
effect, and, moreover, he has special care of as many patients 
as either of the assistant surgeons, and is also required to deliver 
an equal number of clinical lectures." The Governors decided 
that for the future the Resident Surgeon " should be a young 
man who is not yet engaged in general ]>ractice in the city," 
and further, that the ai)pointment should be made annually, 
and though the same individual might be eligible for election 
for six successive years, yet " after the sixth year he can never 
more be elected to that olTlce." While Tusack was Resident 
Surgeon, like Abraham Colics, he had been President of the 
Royal College of Surgeons. 



The Diary of an Irish Medical Student. 365 

Templemore, and eat fniit in the garden. Next day could 
not come down to breakfast, with headache and feverish 
symptoms, quite floored, 12 leeches to my temples, James' 
powder, Henry came here from Dublin, and prescribed 
Dover's powder; recovered in about a fortnight, and was 
able to go about and eat quantities of fruit; amused myself 
shooting crows, woodquests, and had a few days' grouse 
shooting on Lord Carrick's bogs with the Helys, who were 
here frequently; killed a good number of plover. Mun and 
Henry left Cranagh together for Dublin about the beginning 
of August. 

Copy of some notes taken at this time — November 15, '33. 
On the 13th passed the 3rd class examination at the College, 
having put in the 1st this time last year, the 2nd in May, the 

3rd now, and with the help the 4th in May next. I am 

on duty to-day, and had a good deal to do in the way of 
dressing fractures, took in an old man with a broken humerus. 
At present there are only six resident pupils in the house 
besides Tuthill, who lives in his cousin's rooms, two Clinical 
Clerks, Harry and John Hill, and one resident surgeon, 
William Colles. Charles Hely went home to-day in his 
carriage. I promised to go and see him at Christmas. 

July, 1834. — This was the time I went to Cranagh, and 
had the fever, spent two months there in the way I have 
related above, read some Beclard's General Anatomy (1); 
returned to Dublin on the 8th of September of the year 1834 ; 
have paid nurse in advance until the 9th of December, 
1834 (2). Kead very hard for two months for the 3rd class 
examination, which I passed on the 15th of November, I 
believe the very day that my brother John returned the 
second time from sea; he had been in the ** Eover," 18-gun 
sloop, in the North Sea at the time of the siege of Antwerp, 
which was bravely defended by the Dutch General, Chape. 
After that he was at Alexandria and Tripoli, where the Arabs 
were besieging the town; he passed both of his examinations, 
seamanship abroad, and navigation a short time ago in 

(1) El^mens d'anatomie g^n^rale ou de tous les generes 
d'organs qui composent le corps humain. Par P. A. B^clard. 
Paris, 1823. Beclard's Elements of general Anatomy. Trans- 
lated by Robert Knox. Edinburgh. 1830. 

(2) The nurses in Steevens' Hospital at this time attended 
to the resident pupils' rooms and acted as their servants, for 
which service they were paid by the students. 



366 The Diary of an Irish Medical Student. 

Portsmouth, where my uncle Harry has a barrack at present. 
He spent about a week here with us; we were at Baldoyle, 
where my uncle Mark and his wife are now ; he came home 
to be present at Selina's wedding, which will take place in 
December, I believe. Henry went home for the same pur- 
pose. 

John Hely and I went out to Bray, where the Helys were 
staying after their marriage. I dined and slept there. 
They came into Gresham's Hotel. My Aunt Ann is stopping 
at Eccles Street; John Hely and I agreed to walk home to 
Johnstown for Christmas. We set out from Dublin at two 
in the morning, after a good row at the Exchange, in which 
John bore a part, and I assisted in expelling the arch- 
agitator from the theatre of his long uninterrupted seditious 
meetings. We walked to Monastereven the first day, to 
Johnstown the next, had some pleasant duck and snipe 
shooting, dined on Christmas Day at Cranagh. My brother 
John and I went for a week to Melross, where the Helys are 
now settled. Ketumed to Dublin. 

January 26, '35. — Walker called here to-day; paid him £1. 
This spring Henry and Westropp joined in a grinding specu- 
lation. I used to go into William Street with him every day 
at 11 ; continued for about six weeks, got a green frock coat 
from Walker, March 1st, 1835. 

March 29, '35. — McEvatt returned my boots, which he 
had since March 1. 

May 10, '35. — Henry went to the country to-day in a bad 
state of health after his year's clerkship. Paid washing 10s. 

May 22. — I have been examined to-day by Hart (1) on 
the phisiology of the nerves, next on the anatomy of the 
prostate and prostate glands, of which I missed not a word ; 
then on the bloody tumour of the scalp. Adams (2) on 
Medical Jurisprudence. 

May 16.— Sold a feather bed to Mrs. Morgel (3) for £1, 

(1) John ITart, M.R.C.S.I., was one of the Assistants on the 
Court of Examiners in the College of Surgeons. Tie lived at 
14 Stephen's Green, North, and was Professor of Anatomy in 
the College School from IH'M to 1853. 

(2) Robert Adams at this time a Censor, and aftorwards 
Presidont of the College of Surgeons, lie lived at 11 (Jreal 
Denmark Street. lie died .January 16, 1875. 

(li) Mrs. Cliarlotte Morgell, Matron at Steevens's TTo3i)ital 
from Ai>ril, 1817, till February, 1815. 



T/ie Diary of an Irish Medical Student. 367 

four stone ; dined at Eccles Street yesterday ; not gone to 
French Street (1). 

May 18. — Eemoved to French Street. Carriage cost os. 

May 21. — Have been boating all day at Kingstown; 2s.; 
have only 4s. 6d. ; received a letter with £5 ; will have to pay 
£3; dined at the Finish, 3s. 3d. 

May 23. — Have been at Kingstown all day with Boswell ; 
paid Is. to be let out of the Kijliney hill. 

May 24, '35. — Have been made an Orangeman to-day ; fee 
7s. 6d. ; paid Nurse Bryan Is. 6d. for washing; sundries, 
3s. 6d. 

May 25. — Paid Benson (2) for subjects dissected in '33, 
'34, 16s. 6Jd. Received my certificate. 

Monday — Went to the theatre with Boswell, Massancello, 
[?Masamello],3s. 

Wednesday. — Pulled a good deal about the bay, four oars ; 
spent Is. 6d. 

Thursday. — Went to the review with Osbury; dined at 
Foley's; 2s. 

Friday. — Bought letter paper, 5d. ; pens 5d. ; wrote home. 

May 26. — Saw Mun, have £1 ; going to boat to-morrow. 

Saturday, 27. — The two Richards, bow oars ; two Greys, 
John Dunne, and myself midship; Hely and John Grey 
stroke. O'Reilly, West, Wall, Grey, supemumeries ; pulled 
to Howth round by the Bailey light, remained some time 
there, pulled home again; my hands not much the worse; 
had coffee and eggs at the hospital ; spent 2s. 

May 28, Sunday. — Eat no breakfast; did not go out to 
dine as I had promised; no razor; bought tea, Is. 4d. ; have 
a bad cough, a bad cold. 

June 1st. — Dined at Killine's (3). 

35/2. Paid Benson £2 2s. for dissections; dined at 
Finish, 2s. 2d. 

June 3. — Hely, Richards, Bell, and I pulled to Merrion, 
where, the tide being almost out, we stranded; I jumped out 

(1) French Street, a small street off York Street, Dublin. 
Since 1860 it has been known as Upper Mercer Street. 

(2) Charles Benson, one of the Demonstrators of Anatomy in 
the College of Surgeons. In 1836 he was appointed Professor 
of Medicine in the College School, and in 1854 was elected 
President of the College. He died January 21, 1880. 

(3) Owen Killeen, proprietor of the Carlisle Tavern, 30 
Bachelor's Walk. 



S6S The Diary of an Irish Medical Student. 

and pushed her off three times; landed at the railway, took 
in John Grey, pulled home with four oars, unpleasant day; 
we were wet the greater part of it. 

June 4, '35. — Went to Seevens' Hospital; saw Wild (1) 
very ill in fever. 

June 5. — Had a letter from Harry, who is at Templemore. 

June 6. — Spent a day at the Zoological Gardens with 
Vesey's; dined at the Trafalgar Tavern (2) ; went to Vesey's 
lodgings on the quay, drank punch, played backgammon. 

Monday, June 7. — Very sick, headache ; went to the 
College of Surgeons; paid Kit for my ticket, Is. 6d., rowing 
about the river. 

June 8. — Chs. Hely is in town ; rowed to the lighthouse ; 
caught two gurnet, shot five brace of gulls. 

June 9. — At the Fellowship examination; dined at 
Macken's (3); went and bathed at Kingstown; came home 
on a car. 

June 10. — Wrote to Harry ; sent his book in a box. 

June 11, — To-day a full boat's crew pulled to Kingstown; 
dined there ; went on board the convict ship and also on 
board the " Shamrock " revenue cruizer. 

Monday. — I am completely stuck for money ; have not 
written home. 

June 14. — Borrowed £1 from John Hely ; John has come 
to town on his way to Portsmouth ; got from him £1 5s. 

June 16. — Walking about all day with John; went out to 
see Mun at school; dined at the Ropers, went to the gardens. 

June 17. — The captain started for England in the 
Shannon steamer; dined at the Finish; one of the crew over 
board as they started. 

June 18. — Went to the review very tiresome, to see Mr. 
Wood. 

June 20. — Boating to-day; crew, Hely, Brown, Grey, 
Richards, and I ; stiff north-west breeze, squally ; pulled to 
Kingstown and from that to Dublin in an hour. 

(1) Afterwards Sir William Wilde. Tlion an ai)prentice of 
Abraham Colles in Steevens' Hospital. Wilde qualified in the 
College of Surgeons in 1837, and in 1841 opened St. Mark's 
Ophthahnic Hospital in the ])reniises formerly occupied by the 
Park Street Medical School. Park Street was in 1802 renamed 
Lincoln Place. 

(2) The Trafalgar Hotel, 5 Burgh Quay, was owned by 
Horatio Ball. 

(li) Thomas Macken, hotelkeepcr, 12 Dawson Street. 



The Diary of an Irish Medical Student. 369 

June 22. — Paid £1 to Bowling's wife; owe her £3 lis. 6d. 
June 23. — Went out boating, six hands, hired a steers- 
man, wind N.W., squally; caught by a squall at the light- 
house, pulled up under its shelter; I leaped on shore with 
the painter, held her there till it blew over, pulled for an old 
wreck, made fast to it; went in to Kingstown. 

June 24. — Walking about Eingsend looking at ships. 
June 25. — Mun came here from school; we dined at the 
Northumberland (1). 

June 26. — Slept badly ; bought 5 lbs. of tea ; Mun and I 
dined at the Northern; borrowed £1 from John Hely. 

June 28. — Sent Mun home; found myself very ill; to 
bed; got up this evening; John Harbowin called here; paid 
2s, 6d. McEvatt called here; had no money for him; owe 
£1 lis. 6d. 

June 29. — Much better; wished I was assistant surgeon to 
any ship. 

June 30. — Spent to-day strolling about looking at ships. 

Tuesday, July 1. — Dined at Baggot Street Hospital; 
visited a yacht at Mr. Coppinger's, burthen 38 tons, lying in 
the basin. 

July 3. — Went with a crew of six to sea ; the swell was too 
heavy at the lighthouse, did not go past it; had a great lunch 
and heavy drink on the wall. 

July 5. — Wrote home for money; went to Baggot Street 
Hospital; walking about; dined and slept at Baggot Street. 

July 9. — Eeceived a letter with £5, which I must econo- 
mise; dined at the Northumberland; drank tea at Eccles 
Street. 

Tuesday. — Bought a rowing vest for the regatta. 

July 10. — Paid John's wife 10s., owe her 15s.; bread, 
butter, sugar, lid. 

July 11. — First day of the regatta; went there with Ned 
Koper; boat, dinner, travelling expenses, 4s. 

Thursday, 12. — Bought a cotton cheque shirt, 3s., rail- 
way, Is. ; the Kilrush boat and crew won to-day again. 

July 13. — From the far end of the east pier I saw all the 
boats start; the ** Fanny " won the time race; expenses 3s. 

July 14. — Paid J. Hely £1 I owed him; slept on board the 
yacht. 

July 16. — Paid Bowling £1 ; set sail for Kingstown in the 

(1) Northumberland Hotel, Eden Quay. Proprietor, John 
Charles Joseph. 



3*70 The Diary of an Irish Medical Student. 

boat with Connor; the wind fell, and the swell was very 
great ; nearly lost our spars ; got into Kingstown soon after ; 
slept on board in Hely's berth; Hely gone in to town. 

July 17. — Breakfast on bread and milk ; dined at Ten- 
niller's 

July 18. — Eemained at home reading. 

July 20. — Took a walk round by Rathgar and Donuy- 
brcJok. 

Monday, July 21, '35. — Reading Blackwood's magazine. 

July 22. — Walker (1), my tailor, called here to dunn; no 
cash. 

July 23. — In the evening I received letter from home. 

Thursday, 24. — Went to the Spanish Depot; saw the em- 
barkation ; when I came home had a letter from my father 
telling me to apply to Mr. Gallon for £31 10s., his dividend; 
showed the letter and got £33 9s. ; gave a receipt ; bought 
another cheque shirt and socks, 7s. 7d. paid; returned Geral 
Osbrey his book. 

Saturday, 26. — Lodged the £10 to my Uncle Harry's 
credit ; walked to McEwatt, paid him £1 ; went to the Zoo- 
logical Gardens. 

Monday, 29. — Paid Dowling 12s. 6d. ; Walker called here 
while I was out. 

Tuesday, 30. — John Hely called here to-day; dined with 
him at the hospital (2) ; saw a contused and lacerated wound 
of the ankle from the ball of the great toe to the inner side 
of the OS calcis, which was rough, and the tendon almost 
divided, the post, tibeal nerve quite bare, and the artery 
could be seen pulsating, the post tibeal tendon was bared. 
Mr. Harrison (3) put in three points of suture, one anterior, 
one under the malleolus, and another posterior to it; the 
wound dressed with lint dipped in blood ; there were 

(1) William Walker, tailor, 21 Crow Street. 

(2) Probably the Charitable Infirmary, Jervi."? Street, where 
llobcrt Harrison was one of the Surgeons. 

(3) Robert Harrison, one of the Surgeons of .Tervis Street 
irosi)ital, was oIocIcmI Professor of Anatomy and Physioloj^y in 
the Royal College of Surgeons in 1827, and ten years later, in 
1837, he became Professor of Anatomy in Trinity College. In 
1850 he was ai)pointed one of the Assistant Surpeons at Steevens' 
IIosi)ital. He died at his house, 1 Ilumc Street, on April 21?, 
1858. Harrison was the author of the well-known " Dublin 
Dissector," which was tho standard text-book in the Dublin 
Schools of Anatomy for over half a century. 



The Diary of an Irish Medical Student. 371 

globules of synovia in the blood. Went from that to 
Steevens' Hospital, packed up all the things, and sent them 
by a Thomas Street carman, 15s. ; paid my landlord, Ould 
Gallagher, 3 for three months. 

Thursday, July 31. — Took my seat in the Thurles coach, 
luggage 58. ; found Harry very ill with jaundice and saliva- 
tion; he is something better. 

Friday — Bobert and John Eupel came here to see him. 

Saturday, 2. — Went with Mun to Marradyke after plover. 

Monday, 4. — Beading the Lancet; Harry, the same way, 
went out to ride ; shot a crow. 

Friday, 8. — Harry's things come all right. 

Sunday, 10. — Walked to Templetuohy Church; beat the 
car there and back; while coming home fell into a ditch. 

August 11, '35, Templemore. — Walked to Clewn Castle 
and Marradyke, went round by the wash, fine house, getting 
up hay ; rain came on. 

Tuesday. — Bode the grey mare round by ** Loydsbor- 
rcugh " and Park, home by the Birr road. 

Wednesday, 13. — Beading the magazine on the subject of 
geology fossils ; commenced to write a translation of Lucian ; 
the Nevilles came here to-day; walking with them in the 
town; went to Ballyknockan in the evening; fell off the 
mare. 

Sunday, 16. — Went in the car to church; poulticed my 
leg; continued poultice; reading Lucian. 

23. — Went with Harry in the gig to Melross ; after had one 
day's walking on Lord Carrick's bog, only killed one bird; 
Harry is a great deal better. 

September 10. — Came home from Melross; pistol shoot- 
ing; Henry and Ed. Walsh at Mary Mount. 

16. — Old Porteus and I out by the way of shooting, 
spotting the houses of the tithe owners; killed a horn-shaw 
after a long hunt. 

October 1, '35. — Terrible wet weather this last fortnight, 
during which I have been reading the history of the war; 
Butlers gone away; since the first have been shooting about 
here. 

29. — Tom Neville is dead ; got a pair of Trews ; Henry is 
gone to Kilkenny; my hand very sore where the cow bit me 
in endeavouring to extract a potato from her throat. After 
this my father got assistance from the Lay Association to 



372 The Diary of an Irish Medical Student. 

proceed for his tithes in the Exchequer, and I was employed 
serving the lads with notice, after which I was always 
obliged to ride about with pistols, which I did until I left; 
Henry went to a place near this to try for a dispensary, 
which he did not get, Kinity (1); a comet appeared this 
winter for a good time visible; Henry went to Bally- 
brittas (2), where the dispensary was vacant; but Powell, of 
Eichhill, got it, and Henry got Powell's, where he went to 
take possession at the same <time that I went to Maun- 
sell's (3) to attend midwifery. 

Wednesday, December 3, 1835. — Left Templemore for 
Dublin by Koscrea in a caravan ! ! ! received from my father 
£21. 

5th. — Bought a hat, £1 3s.; paid Evans 2s., paid O'Keifo 
for putting down my name for lectures £4 4s. ; received from 
Henry to pay gun 15s. ; ordered a coat from Gately (4), 
£3 10s. ; paid Maunsell £5 ; boots vamped 12s. 6d. ; attended 
my first midwifery case. 

Monday, December 14, 1835. — Visited the Meath Hos 
pital; went round with Graves (5); will attend there; was 
called up four times last night. 

December 22. — The weather is very cold; thermometer in 
my room 8° below zero; had a case in Trinity Place; re- 
tained placenta ; got Maunsell to extract it. Went this even- 
ing to Steevens'; drank tea with Crampton (6); left with 
him Cheselden's Anatomy and Lloyd's book on Scrophula 
for library. 

December 25. — X Mass. The woman in Trinity Place is 
very well, but the pulse is 130; no pain in the hypogastrium, 
but a very slight tenderness ; no fever. Thomas dined at 
Eccles Street. 

(1) Kinnity, a parish in King's County, near Birr. 

(2) Ballybrittas, in Queen's County. 

(3) Henry Maunsell, Pi()f(«ssor of Midwifery in the CoUe^iro of 
Surgeons from 1835 to 1841. In 1800 he purchased the Dublin 
Evening Mail, and from that time to his death in 1879 he 
devoted himself to jnurnalism. 

(4) Thomas Gateley, tailoring establishment, 17 Corn Market. 

(5) Robert James Graves, M.D., the celebrated Physician of 
the Meath Hospital, who held olTice there from July, 1821, to 
October, 1842. 

(6) Cecil Crampton, M.IJ. In 1841, he succeeded William Colles 
as Resident SurK<'on at Stecvens' IIosi)ital. lie died in ofRco 
on April 22, 1811. 



The Diary of an Irish Medical Student. 373 

December 29. — My father came to town to-day; went ^o 
see my Uncle Harry. 

January 2, '36. — Eeceived a parcel from Bara; left the 
pistol to be mended, the letters to be engraved, and sent 
them off. 

January 4. — Left with Osbrey his botany and two French 
books. 

January 12. — We have established a mess; got a receipt 
from the butcher for £3 lis. 6d. 

February 10. — Eeceived a cheque for £>5 to pay for tea. 

February 15. — Had a breech presentation in Mary Street. 

February 18. — Found that the tea went to Templemore in 
mistake. 

February 26, '36. — Had a letter to-day from Henry, from 
which I learnt the death of my dearest sister, Letitia, sent 
by the mail his letters. 

27th. — Walking about the shipping, endeavouring to wipe 
away the rememberance of our great loss. 

March 2. — A letter from home with an order on Ball's 
Bank for £37 ; laid out £2 14s. in mourning. 

March 3. — Lent John Hely £3 10s., paid him 10s., paid 
McEvatt 14s., bought a hat for my father, £1 2s. 

March 4. — Bought cloth, £3 5s. l^d. ; wrote home; sent 
a bank post bill for £24 ; wTote to Mary ; for booking parcels 
3d., Calvert's theatre 6d., supper 3s. 6d. 

March 6. — Dined at Maunsell's; eyeglass 5s. 

March 10th. — Went to Steevens'; breakfast with Cramp- 
ton ; gave to one of my patients 6d. 

March 12. — Attended Medico-Chirurgy Society (1) ; Craw- 
ford read a very good paper on cancer. 

March 13. — Went with J. Hely to Kingstown, 2s. ; dined 
at O'Hara's (2), 2s. 8d. 

March 15. — Went to Steevens' ; a case of paral;>sis from 
tumour in neck ; letters from home ; sent a hat and letters by 
Bradly. 

March 19. — Went with Hely to bring home the gig from 

(1) The Dublin Medico- Chirurgical Society. Established 
November, 1835, by the Medical Students of Dublin for the 
advancement and improvement of students in every branch of 
medicine and surgery. Afterwards one of the constituent 
societies of the Academy of Medicine in Ireland. 

(2) Probably Daniel O'Hara, Shell-Fish Tavern, 1 French 
Street. 



374 The Diary of an Irish Medical Student. 

Merrion; had to nail canvas on the bow to keep her tight; 
f^ot on well as far as the lighthouse, but there was met the 
returning tide ; had to strain every nerve to pull her 
through ; at length moored her safe at Ringsend. 

March 22. — Saw Cusack (1) tie the carotid for aneurism. 

March 23. — Have £2; must do me for four weeks. 

March 31 — Good Friday; sent the rest of the circulars; 
was discovered by Walker, who asked me to pay him my 
bill ; got £2 from Hely. 

April 4. — At an Orange supper, at the circus; Richards 
failed at his wager. 

April 8. — The statue of King William blown up. 

April 9. — Henry informed me that he succeeded in 
Trillick (2). 

April 13. — Spent this day at a Grand Lodge meeting. 

April 15. — Had a letter from home with a cheque for 
£8 7s. ; ordered a pair of trews ; paid Hely £1 ; paid tailor 
£1 ; theatre Is. 

April 24. — Went to Kingstown; dined there; had a row 
with the carman. 

April 25. — Painting the boat. 

April 20. — Saw a flap operation of forearm. 

April 27. — Got my certificates, M. Medica, M. Jurispru- 
dence, Surgery. 

May 3. — A letter from Henry; bought a Mcintosh. 

May 8. — Moore and Hunter (who are both dead since, 
one in Limerick and the other at Madras) returned from 
Glasgow; we all, with Gelstone, supped at G'Hara's on 
leaving which place we got up a row with two watchmen, 
who were well beat; they got away, however, and brought 
back about twelve others, who soon turned the tables; 
Somerville was knocked down and eight of us arrested and 

(1) James William Cusack. ITe was born in 1788 and studied 
medicine in Steevens' Hospital. In 1812 he ]mssed the College 
of Surgeons, and on Fohruary 10, 1813, succeeded Abraham 
CoUes as Resident Surgeon at Steevens' Hospital. He remained 
in office for twenty-one years till ap[)ointed one of the Assistant 
Surgeons. In 1827, while still Resident Surgeon, he was elected 
President of the College of Surgeons. For many years, till his 
death on September 25, 1861, he occupied a leading position 
among the surgeons of Dublin. 

(2) Trillick, in County Tyrone, where Henry Thompson was 
appointed Dispensary Medical Oflicer. 



The Diary of an Irish Medical Student. 375 

fined 30s. each ; lent J. Hely £1 ; he and Chas. came here 
to-day. 

May 9. — William Colles called here from France ; bor- 
rowed 30s. ; C. Hely bought a hat, 9s. ; owe Motherwell 8s. 

May 13. — Paid Dillon 2s. 2d.; received £5 from home; 
had a letter, Henry, with £2 to buy tools. 

May 16. — Sent the instruments to Henry. 

May 21. — At the Medico-Chirurgy meeting. 

May 19. — Eeturned Gerald Osbrey's pistoll and thermo- 
meter. 

May 24. — Had a breech case to-day. 

May 25. — Dined with Osbrey. 

May 26. — At O'Hara's with Vesey, Banks, and Bigs. 

June 4. — Eeading Cooper on the testicle ; wrote home. 

June 9. — Letter from home. 

June 10. — Paid Courtney 2s., Hely 3s., a scarf, 9d. ; paid 
O'Hara 7s. 6d., washing 2s. 6d., Porter Is. 

June 11. — Dined at home and rede Porter on bone. 

June 13. — A case in which there was a great tumour of 
the scalp, in doubt what was the presentation. 

June 17. — Grind on exostoses, a desease of which I knew 
very little. 

June 22. — Letter from home; Somerville's trial came off; 
am accompanied by my father to buy a pistol. 

June 24. — Helping Hely to put in ballast. 

June 26, 1836. — Went with Hely, Courtney, and Hart to 
the Three Kock Mountain; dined in a cabin, consumed a deal 
of mountain dew; came home about three o'clock next 
morning. 

June 28. — Dissecting. 

June 29. — Dissecting. 

June 29. — Sailed out to Kingstown with Hely 

July 2. — Had a letter from home, lodged a bill for £140 to 
my father's credit; got £7, paid by Eyan £5, £2 Maunsell, 
owe him £5 more. 

July 17. — Have neglected grind this week past. 

July 16. — Paid to Parsons the amount of Henry's bill, 
£19 7s. 7^d. ; have been boating and idling most of this 
month. 

July 24. — Had a letter from home with £5, ordered a coat, 
£3 10s.; paid O'Hara 6s. 6d. 

July 26. — Dined at Steevens' with W. Colles, 



376 The Diary of an Irish Medical Student. 

August 8. — At a case of twins with Maunsell for nineteen 
hours. 

August 9. — Went to sail in the bay with the boat full of 
ladies; becalmed off Howth ; spent the night on board, 
where poor Green, who died since of fever, amused us with 
his stories; paid Parsons £3; had a letter from home. 

September 11. — Walked to Malahide, home by Baldoyle. 

September 16. — Paid McEvatt 10s., owe him £2 5s. 

October 12. — I am 20 to-day; dined at O'Hara's in the 
evening; at Bull's got into a fight; Brown and I well beat by 
six or seven fellows; J. Hely lodged a pound for him and 
me; in the morning went to College Street; no prosecution. 

October 14. — Wrote home by C. Hely. 

October 15. — Had a letter from Kilkee with £3; theatre 
Is. 6d. ; paid O'Hara 7s. 4d., Mrs. Hill 4s., wash 4s., 
Chamb. 4s. 

October 17. — Bought mutton 6s. 6d., vegetab. 10, 7s. 4d. 

October 19. — Paid McEvatt 15s., owe him 30s. yet. 

October 21. — Expense of mess for week 178. 8d., each 
4s. 5d. ; had a letter from home ; our poor Mary has died of 
typhus fever at Kilkea. 

October 25. — Left Dublin by the Cork Mail on this day ; 
went first to Melross, on to Templemore, where B. Nevile 
came soon after ; my father and the family came soon ; they 
left poor Mary at Kilrush; remained in the country three 
weeks. 

November 16, '36. — Arrived in Dublin from the country ; 
got from my father £30 Is. lOd. ; £7 for myself and £1 5s. 
to buy things for mother; bought the stuff at Tod and 
Burns, trews £1 7s. ; paid for Hely's ballast £1 Ss. 

November 26. — Lodged my money in bank ; gave bank 
receipt to O'Keefe. 

November 28. — Entered at Fannin's (1) reading rooms, 
14s. 

December 17. — Received £5, paid Urapiby 13s., Ryan 6s., 
Evening Mail £1 16s., O'Keefe £1 for stamp. Since I en- 
tered at Fannin's I have been reading and grinding at the 
rate of 11 hours a day; never was better or pleasanter. 
Maunsell had a letter from my father saying that I was ap- 

(1) Fannin & Co., Medical and Literary Institution, 41 
Grafton Street. 



The Diary of an Irish Medical Student. S77 

pointed to a ship ; he got Jacob (1) to apply for an extra day, 
and I got the first on the new court. 

January 17, '37. — Have put in my first day's examina- 
tion taken by Palmer (2) on the testicle hernia, by Hart on 
General anatomy of, by Harrison on fauces. Tongue. 

January 23. — Passed the College, examined by Eumly (3) 
on fever, by Mr. Colles on inflammation of bladder, naevi; 
answered well. 

January 24. — Hair cut; went to the Protestant meeting. 

January 27. — Beceived from my father £10. 

January 31. — Became very ill this morning with sore 
throat and fever. 

February 1. — Sent for Colles; confined to bed for a week 
with influenza. 

February 8. — Had a letter from John, who is at Malta; 
wrote to him; settled mess bill. 

February 11. — At an examination at the College. 

February 12. — Went to church. 

January 13. — Had my certificate of residence signed by 
Cusack, Wilmot (4). 

February 14, '37. — Left my gun at Calderwood's (5) to be 
repaired, charge 35s. 

February 16. — Arrived at Kilkenny this evening; came 
out (17th) next morning to Melross, heard that my people 
were gone to Clonmel to spend some time, and I remain here. 

March 20. — Have been here now one month doing little 
good but shooting, and a few days playing cricket, shot two 

(1) Arthur Jacob, one of the Professors of Anatomy in the 
College of Surgeons from 1827 to 1868, was in 1837 President 
of the College. He was the first to describe the " rodent nicer," 
which was often known as " Jacob's nicer." 

(2) Abraham Palmer, M.R.C.S.I., was a member of the Court 
of Examiners of the College of Surgeons. He lived at 38 York 
Street. 

(3) Thomas Rumley, M.R. C.S.I. He was a member of the 
Court of Examiners at the College of Surgeons, and in 1841 was 
elected President of the College. 

(4) Samuel Wilmot, M.D., was President of the College of 
Surgeons in 1815 and. in 1832. In 1826 he was appointed Pro- 
fessor of Anatomy and of Surgery in the College School. The 
former chair he resigned in 1827, but held the chair of Surgery 
till 1836. In 1814 he was appointed one of the Assistant Surgeons 
at Steevens' Hospital, and continued in office till his death on 
November 7, 1848. 

(5) Thomas Calderwood, gunsmith, 14 North Earl Street. 

2b 



S78 The Diary of an Irish Medical Student, 

hares, one in the evening before Patrick's Day. I intend to 
set out for the North some day next week; must get shirts, 
socks, and my gun before I go; have got eight shirts made. 

April 14, '37. — Father and mother at Clonmel; the grey 
horse laid up with a sore shoulder; punctured it and gave 
exit to some brownish serum; closed it again; in about a 
week it broke of itself and got well. 

May 8, '37. — My father and I started for Frankford to- 
day by Bourea, Roscrea ; slept at Birr. 

June 2. — Met at Frankford four L.R. C.S.I, whom I 
knew ; heard that Cook got the dispensary ; bought and had 
made two pairs of trews, two vests, price 22s. I must go to 
Dublin for my diploma. 

June 26, '37. — Cannot remember the day I left Temple- 
more ; it was the same that my father and Kate went to 
Edgeworthstown for Mun; came to Melross in the gig with 
James, spent about a week there; went to John Maguire at 
the Wood of Inch ; bought at Quinn's a scarf and stock lOs. 4d. 

Left Melross on the 3rd of July, 1837, for the ostensible 
purpose of procuring the midwifery diploma ; stopped three 
days at Hughes (1), Duke Street; bill 19s. 

July 4. — Bought 4 lb. of tea at 4s. 8d. ; sent this home. 

End of the Diary. 
(1) James Hughes, hotelkeeper, 16 Duke Street. 



NEW AMERICAN TARIFF. 

We have received from the Dorland Agency, litd., 3 Regent 
Street, London, American Merchandising and Advertising 
Specialists, a complete table of the new American Tariff 
Law published in book form. Scliodule A. includes 
" Chemicals," many of them included in the Materia 
Medica, and the " Free List " also contains many drugs, so 
that the new tariff is of direct interest to the Medical Pro- 
fession. The Table clearly shows the new tariff as compared 
with the old, and the entire schedule is enormously simpli- 
fied. Manufacturers and traders can obtain a copy post 
free for Is., and the rapidity with which it has been pre- 
pared and published within a few days of the passing of the 
Act is a striking tribute to the enterprise and foresight of 
the publishers. 



BOYAL COLLEGE OF PHYSICIANS OF lEELAND. 

At the Stated Annual Meeting of the President and Fellows 
of the Koyal College of Physicians of Ireland, held on St. 
Luke's Lay, October 18th, the following officers were elected 
for the ensuing year: — 

President — Dr. Charles E, Fitzgerald. 

Vice-President — Dr. James Craig. 

Censors — Dr. James Craig, Dr. T. G. Moorhead, Dr. A. 
Nixon Montgomery, and Dr. T. Henry Wilson. 

Examiners for the License to practise Midwifery — Dr. 
Hastings Tweedy and Dr. Gibbon FitzGibbon. 

Additional Examiners to take the place of an absent 
Censor or Examiner — Medicine : Dr. Alfred Parsons. Mid- 
wifery : Dr. Norman Holmes. Medical Jurisprudence and 
Hygiene : Dr. H. T. Bewley. 

Supplemental Examiners under the Conjoint Examination 
Scheme : — 

Biology — Dr. MacDowel Cosgrave. 

Chemistry — Dr. Edwin Lapper and Dr. Ninian Falkiner. 

Physics — Dr. W. G. Harvey and Dr. Eowlette. 

Pharmacy, Materia Medica, and Therapeutics — Dr. ' 
Travers Smith and Dr. D. J. O'Connor. 

Physiology— Dr. H. C. Earl. 

Pathology. — Dr. F. C. Purser. 

Medicine— Dr. J. F. 'Carroll and Dr. H. C. Drury. 

Hygiene and Forensic Medicine — Dr. W. A. Winter. 

Extern Examiners for the Conjoint Preliminary Examina- 
tion : — 

Languages— Mr. E. H. Alton, F.T.C.D. 

Mathematics— Mr. E. A. P. Eogers, F.T.C.D. 

Irish— Mr. Edward de Valera, B.A., E.U.I. 

Examiners for the Diploma in Public Health: — 

Chemistry — Professor E. Lapper. 

Hygiene— Dr. F. C. Martley. 

Bacteriology — Dr. H. C. Earl. 

Meteorology — Dr. Matson. 

Examiners for Membership: — Clinical Medicine: Dr. 
James Craig, V.-P. 

Practice of Medicine — Dr. T. G. Moorhead aiid Dr. 
Martin Dempsey. 



380 Royal College of Physicians of Ireland. 

Pathology and Bacteriology — Dr. H. C. Earl and Dr. A. C. 
O'Sullivan. 

Midwifery and Gynaecology — Sir William Smyly and Sir 
Andrew Home. 

Kepresentative on the General Medical Council — Sir John 
Moore. 

Kepresentatives on the Committee of Management — Dr. 
Walter Smith, Sir John Moore, and Dr. T. P. C. Kirkpatrick. 

Treasurer — Dr. H. T. Bewley. 

Kegistrar — Dr. T. Percy C. Kirkpatrick. 

Librarian — Mr. E. G. J. Phelps. 

Law Agent — Messrs. S. Gordon & Sons. 

Land Agent — Messrs. Townsend. 

Architect — Mr. Albert Edward Murray. 



ROYAL COLLEGE OF SURGEONS OF EDINBURGH. 

At a meeting of the College, held on October 15th, the 
following gentlemen, having passed the requisite examina- 
tions on the 12th of July, 1913, were admitted Fellows: — 
Henry Ernest Arbuckle, M.D. Univ. Edin., D.P.H. Camb., 
West African IMedical Service ; James Freeborn Bennett, 
M.B., Ch.B. Univ. Glasg., Marlborough, New Zealand; 
John Douglas Fiddes, M.B., Ch.B., Univ. Aberd., Aber- 
deen; Percy Leslie Foote, M.B., Ch.B. Univ. N. Zeal., 
M.K.C.S., L.K.C.P. Lond., New Zealand; McWilliams, 
Henry, L.E.C.S.E. (Triple Qual.), Halifax, Yorks ; Harry 
Foster Holmden, M.B., Ch.B. Univ. Edin., Edinburgh; 
Harris Cobum Mersereau, M.D., CM. Univ. McGill, Now 
Brunswick, Canada; John Joseph Harper Nelson, M.D. 
Univ. Edin., Captain, Indian Medical Service; Ardeshir 
Behramshah Pestonji, L.M. & S. Univ. Bombay, M.Ii.C.S. 
Eng., L.K.C.P. Lond., D.P.H. Camb., Ix^ndon, N.W. ; 
Kichard Francis Steele, M.B., Ch.B. Univ. Dubl., Captain, 
Indian Medical Service ; Howard Martin Blenheim Strat- 
ford, M.E.C.S. Eng., L.E.C.P. Lond., London, W. ; Artluir 
Eichard Thomas, M.E.C.S. Eng., L.E.C.P. Ix)nd., Staff 
Surgeon, Eoyal Navy; Stephen Harold Middleton-West, 
M.B., Ch.B. Vict. Univ., Mane, M.E.C.S. Eng., L.E.C.P. 
Lond., Captain, Indian Medical Service; and Hiram 
Bardsley Wyman, M.D., CM. Univ. McGill, L.E.C.S.E. 
(Triple Qual.) (Quebec, Canada. 



SANITARY AND METEOROLOGICAL NOTES. 

Vital Statistics. 
For jour iveeks ending Saturday, October 4, 1913. 

IRELAND. 

The average annual death-rate represented by the deaths — 
exclusive of deaths of persons admitted into public institutions 
from without the respective districts — registered in the week 
ended October 4, 1913, in the Dublin Registration Area and 
the twenty -six principal provincial Urban Districts of Ireland 
was 18.0 per 1,000 of their aggregate population, which for the 
purposes of these returns is estimated at 1,199,180. The 
deaths registered in each of the four weeks of the period 
ending on Saturday. October 4, and during the whole of that 
period in certain of the districts, alphabetically arranged, 
correspond to the following annual rates per 1,000 :— . • 



County Boroughs, &c. 


Week ending 


Average 
Kate 
for 4 
weeks 


Sept. 
13 


Sept. 
20 


Sept. 
27 


Oct. 
4 


27 Town Districts 


21.1 


19.8 


21.0 


18.0 


20.0 


Dublin Eeg. A.rea 


23.2 


18.1 


21.2 


20.1 


20.6 


Dublin City 


23.7 


18.1 


22.8 


20.8 


21.3 


Belfast 


20.4 


21.1 


19.5 


13.2 


18.1 


Cork 


26.5 


30.6 


24.5 


21.8 


25.8 


Londonderry 


19.1 


22.9 


22.9 


21.6 


21.6 


Limerick 


27.1 


10.8 


17.6 


23.0 


19.6 


Waterford 


5.7 


13.3 


26.6 


38.0 


20.9 



The deaths (excluding those of persons admitted into public 
institutions from without the respective districts) from certain 
epidemic diseases registered in the 27 districts during the week 
ended Saturday, October 4, 1913, were equal to an annual 
rate of 4.3 per 1,000. Among the 100 deaths from all causes in 
Belfast ^^'ere 3 from scarlet fever and 16 from diarrhoeal 
diseases. Included in the 32 deaths from all causes for Cork 



382 Sanitary and Meteorological Notes. 

Mere 5 from diarrhoea and enteritis of children under 2 years. 
Eight of the 17 deaths from all causes for Londonderry were 
from diarrhoea ^nd enteritis of children under 2 years. Among 
the 20 deaths from all causes for Waterford were 6 from 
diarrhoeal diseases. The 3 deaths recorded for Galway were 
from whooping-cough. Included in the 9 deaths from all 
causes for Lisburn were one from enteric fever and 2 from 
diarrhoea and enteritis of children under 2 years. Six of the 
7 deaths recorded for Portadown were from diarrhoea and 
enteritis of children under 2 years ; and 2 of the 4 deaths from 
all causes for Ballymena were from diarrhoea and enteritis 
of children under 2 years. Included in the 7 deaths from all 
causes for Tralee were 2 from diarrhoea and enteritis of children 
under 2 years. Three of the 8 deaths for Queenstown were 
from diarrhoea and enteritis of children under 2 years of age ; 
and one of the 5 deaths from all causes for Ne^vry was from 
measles. 

DUBLIN REGISTRATION AREA. 
The Dublin Registration Area consists of the City of Dublin, 
as extended by the Dublin Corporation Act, 1900, together 
with the Urban Districts of Rathmines, Pembroke, Blackrock, 
and Kingstown. The population of this area is 403,000 ; 
that oi the City being 308,187, Rathmines 38,769, Pembroke 
29,942, Blackrock 9,161, and Kingstown 16,941. 
' In the Dublin Registration Area the births registered 
during the week ended October 4 amounted to 225 — 132 boys 
and 93 girls, and the deaths to 163 — 83 males and 80 females. 

DEATHS. 

The deaths registered, omitting the deaths (numbering 8) 
of persons admitted into pu))lic institutions from localities 
outside the Area, represent an annual rate of mortaUty of 
2J).l per 1,000 of the population. During the forty weeks 
ending with Saturday, October 4, the death-rate averaged 
20.5, and was 1.4 below the mean rate for the corresponding 
portions of the ten j'ears, 191j3-1912. 

The total deaths registered, numbering 163, represent an 
annual rate of 21.1 per 1,000. The annual rate for the past 
forty weeks was 21.9 per 1,000, and the average annual rate 
for the corresponding period of the past ten years was 23.0 
per 1,000 of the moan ])opula.tion for all deaths registered. 



Sanitary and Meteorological Notes. 383 

The deaths included 1 from whooping-cough, 3 from 
diphtheria, 1 from influenza, 2 from enteric fever, 2 from 
scarlet fever, and 26 deaths from diarrhoea and enteritis of 
children under 2 years. In each of the 3 preceding weeks 
deaths from scarlet fever had been 0, 2, and ; deaths from 
enteric fever had been 6, 1, and 1 ; deaths from diphtheria 
had been 1, 0, arid ; deaths from whooping-cough had been 
2, 0, and ; deaths from influenza had been 0, 1, aud 1 ; 
and deaths from diarrhoea and enteritis of children under 2 
years had been 37, 25, and 33. 

Of 19 deaths from tuberculosis Call forms) 13 were attributed 
to pulmonary tuberculosis, 3 to tubercular meningitis, and 
3 to disseminated tuberculosis. In each of the 3 preceding 
weeks, deaths from all forms of tuberculosis had been 29, 16, 
and 22. 

There were 11 deaths from cancer, or malignant disease. 

The deaths of 4 children were caused by convulsions, 3 being 
infants under one year of age. There were 5 deaths of infants 
from congenital debility, and 5 deaths from premature birth. 

The deaths from pneumonia included 2 from broncho- 
pneumonia, and 2 from pneumonia {type not distinguished). 

Fifteen deaths were caused by organic diseases of the heart. 
There were 11 deaths from bronchitis. 

There were 4 accidental deaths, including 2 caused by 
drowning. 

In three instances the cause of death was " uncertified," 
there having been no medical attendant during the last illness. 
These cases were all infants under one year of age. 

Fifty-eight of the persons whose deaths were registered 
during the week were under 5 y^ears of age (43 being infants 
under one year, of whom 11 were under one month old), and 
37 were aged 65 years and upwards, including 30 persons aged 
70 and upwards ; among the latter were 14 aged 75 and 
upwards, of whom one (a female) was stated to have been 
aged 90 years. 

STATE OF INFECTIOUS DISEASE IN THE DUBLIN 
REGISTRATION AREA AND IN BELFAST. 

The usual returns of the number of cases of infectious 
diseases notified under the " Infectious Diseases (Notification) 
Act, 1889/' and the " Tuberculosis Prevention (Ireland) Act, 



384 



Sanitary and Meteorological Notes. 



1908," as set forth in the following table, have been furnished 
by Sir Charles A. Cameron, C.B., M.D., Medical Superintendent 
Officer of Health for the City of Dublin ; by ^Ii-. Fawcett, 
Executive Sanitary Officer for Rath mines and Rathgar Urban 
District ; by Mr. Manly, Executive Sanitary Officer for 
Pembroke Urban District ; by the Executive Sanitary 
Officer for Blackrock Urban District ; by. the Executive 
Sanitary Officer for Kingstown Urban District ; and b}'' 
Dr. Bailie, Medical Superintendent Officer of Health for the 
Cit}/ of Belfast. 

'I'able bhowinq the Ndmber of Cases op Infectious Diseasks notified iu the Dubli 
Registration Area (viz. — the City of Dublin and the Urban Districts of KathmitM 
and llathgar, Pembroke, Blackrock, and Kiugstown), and in the City of Belfaa 
during the week ended October 4, 1913, and during each of the preceding thn 
weeks. An asterisk (*) denotes that the disease in question is not notiBable in tl 
District. 



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Urban 
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Urban 
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Oily of UairiiNl 



Sept. 13 

Sept. 20 

Sept. 27 

Oct, 4 

Si-pt. 13 

8i-pt. 20 

Sept. 27 

Oct. 4 

Sept. 13 
Sept. 20 
Sept. 27 
Oet. 4 

Sept. 13 
Sept. 20 
Sept. 27 
Oct. 4 

Sept 18 

Sept. 20 

Sept. 27 

Oct. 4 

Sept. 13 
8<pt. 20 
Sept. 22 
Oct. 4 



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b Not including .1 cnROH of voricella. e Not including 3 cases of pollomj'olitl 
d Notifiable as from 17th September. 



Cases of Infectious Diseases under Treatment in Dublin 

Hospitals. 
During tho wook ended October 4, 1913, G cases of enteric 
fevor wero admitted to hosjutal, 13 were discharged, and 55 



Sanitary and Meteorological Notes. 385 

cases remained under treatment in hospital at the close of the 
week, the respective numbers in hospital at the close of the 
three preceding weeks having been 36, 49 and 62. 

One case of typhus v/as admitted to hospital during the 
week, 2 were discharged, and 2 cases remained under treatment 
in hosjiital at its close. At the close of the 3 previous weeks 
the cases in hospital had been 4, 3, and 3 respectively. 

Eighteen cases of measles were admitted to hospital and 
32 cases remained under treatment at the close of the week. 
At the end of the 3 preceding weeks such cases were one, 
6, and 14 respectively. 

Eighteen cases oi scarlet fever w-ere admitted to hospital, 
5 were discharged, there was one death, and 91 cases 
remained under treatment at the close of the week. This 
number is exclusive of 18 patients under treatment at 
Beneavin, Glasnevin, the Convalescent Home of Cork Street 
Fever Hospital. At the close of the 3 precedmg weeks the 
cases in hospital had been 65, 76 and 79. 

Thirteen cases of diphtheria were admitted to hospital, 
11 were discharged, and there were 3 deaths. The cases in 
hospital, w^hich at the close of the 3 preceding weeks had 
numbered 31, 30, and 37 respectively, were 36 at the close of 
the week under review. 

In addition to the above-named diseases, 10 cases of pneu- 
monia were admitted to hospital, 9 were discharged, there 
were 2 deaths, and 30 cases remained under treatment at the 
end of the week. 

ENGLAND AND SCOTLAND. 

The mortality in the w^eek ended Saturday, October 4, in 
96 large English towns (including London, in which the rate 
was 12.6) was equal to an average annual death-rate of 13.6 
per 1,000 persons living. The average rate for 16 principal 
towns of Scotland w^as 14.5 per 1,000, the rate for Glasgow 
being 14.8, and that for Edinburgh, 11.2. 

INFECTIOUS DISEASE IN EDINBURGH. 

The Registrar-General has been favoured by A. Maxwell 
Williamson, M.D., B.Sc, Medical Officer of Health for Edin- 
burgh, with a copy of his Return of Infectious Diseases notified 
during the week ended October 4. From this Report it 
appears that of a total of 78 cases notified, 36 were of scarlet 



29.952 inches. 


30.470 „ 


29.030 „ 


55.7°. 


53.7°. 


51.8°. 


, .390 inch. 



386 Sanitary and Meteorological Notes. 

fever, 24 of jihthLsis, 12 of diphtheria, 5 of erysii^elas, and 1 
of enteric fever. Among the 365 cases of infectious diseases 
in hospital at the close of the week were 171 cases of scarlet 
fever, 100 of phthisis, 51 of diphtheria, 16 of measles, 4 of 
whooping-cough, 8 of enteric fever, 6 of erysipelas, and 1 of 
chicken-pox. 

Meteorology 
Abstract oj Observations made in the City oj Dublin, Lat. 53° 20' 

N., Long. 6° 15' W., jor the Month oJ September, 1913. 
Mean Height of Barometer, - 
Maximal Height ot Barometer (7th, at 9 a.m.), 
Minimal Height of Barometer {14th, at 4 p.m.), 
Mean Dry bulb Temj^erature, - 
Mean Wet-bulb Temperature, 
Mean Dow -point Temperature, 
Mean Elastic Force (Tension) of Aqueous Vapour, 
Mean Humidity, - - - - 87.5 per cent. 

Highest Temperature in Shade (on 11th), - 70.0°. 
Lowest Temperature in Shade (on 18th), - 41.5°. 
Lowest Temperature on Grass (Radiation) (18th) 39.4°. 
Mean Amount of Cloud, - - - 66.4 per cent. 

Rainfall (on 13 days), - - - - 4.310 inches. 

Greatest Dail> Rainfall (on 19th), - 1.652 „ 

General Dii'ections of Wind, - - - Variable. 

ReTTiarks. 
The fine, dry weather of the summer of 1913 lasted till the 
8th of September, on tho attcrnoon of which day a shallow 
depression formed over Ireland within the limits of a largo 
anticyclone covering the Atlantic and stretching across Central 
Europe to Russia. This system caused a general though not 
heavy raintall. A rapid redu(^tion of atmospheric pressure 
took place on the 11th and 12th in coiiTiei^tion with tho advance 
south-eastward from Iceland of a depression in which tho 
barometer fell below 29 inches. On the 12th a secondary 
distur])anco formed over Ireland, Soutli Wales and the Cornish 
PeniiiHuIa. In connection with this system rain fell hoiivily, 
Dublin recci\ing 1.638 inches in the 48 hours ended 9 a.m. 
ot Sunday, the 14th. At that time tho centre of a well- 
marked cyclone la}^ over Wales. Thonco it travelled back- 



Sanitary and Meteorological Notes. 387 

wards to and across Ireland, finally again doubling on its 
course and filling up over the Bay oi Biscay. After a brief 
respite of fine but cold weather, a V-shaped depression arrived 
over Ireland from the Atlantic on the 19th. This system 
caused a downpour of rain on the east coast — 1.652 inches 
being recorded in. Dublin, 2.03 inches at Malahide, Co. Dublin, 
and 2.77 inches at Ardgillan, near Balbriggan, Co. Dublin. 
The precinitation was much less on the Wicklow roast. 
Another heavy rainfall occurred on the 22nd in connection 
with a large depression on the Atlantic off the west coast of 
Ireland. The changeable weather lasted to the 27th, but the 
closing days of the month were verj fine, and a heat-wave 
passed over the greater part of England; the thermometer 
rose to 78° in London, and at Manchester, Nottingham, Bath 
and Malvern on Saturday, the 27th. That day was very wee 
in the west of Ireland, Blacksod Point having 1.14 inches of 
rain and Valentia .72 inch. In a violent thimderstorm which 
passed over the south of France on the 29th, 4.53 inches of 
rain fell at Perpignan and as much as 6.54 inches at Cap Beam. 
At Cette the measurement was 1.85 inches. 

In DubUn the arithmetical mean temperature ^56.5°) was 
0.6° above the average (55.9°) ; the mean drj^-bulb readings 
at 9 a.m. and 9 p.m. were 55.7°. In the forty -nine years 
ending with 1913, September was coldest in 1886 and 1892 
(M. T. = 53.0°), and warmest in 1865 (M. T. = 61.4°) and 
1898 (M. T. = 60.2°). In 1912 the M. T. was 53.7°. 

The mean height of the barometer was 29.952 inches, or 
0.042 inch above the corrected average value for September — 
namely, 29.910 inches. The mercury rose to 30.470 inches at 
9 a.m. of the 7th, and fell to 29.030 inches at 4 p.m. of the 
14th. The observed range of atmospheric pressure was, 
therefore, 1.440 inches. 

The mean temperature deduced from daily readings of the 
dry-bulb thermometer at 9 a.m. and 9 p.m. was 55.7°, or 3.4° 
below the value for August, 1913. Using the formula. Mean 
Temp. = Min. + (Max. — Min.) x .476, the mean tempera- 
ture was 56.3°, or 0.6° above the average mean temperature 
for September, calculated in the same way, in the thirty-five 
years, 1871-1905, inclusive (55.7°). The arithmetical mean of 
the maximal and minimal readings was 56.5°, compared with a 
thirty-five years' average of 55.9°. The mean maximum was 



388 Sanitary and Meteorological Notes. 

61.6° ; the mean minimum was 51.4°. On the 11th the ther- 
mometer in the screen rose to 70.0° — wind, W. to S.W. ; on 
the 18th the temperature fell to 41.5°— ^nncl, W.N.W. The 
minimum on the grass was 39.4° on the 18th. 

The rainfall was 4.310 inches on 13 days. The average rain- 
fall for September in the thirt\'-five years, 1871-1905, inclusive, 
was 2.210 inches, and the average number of rainy days was 
15. In 1871 the rainfall was very large — 4.048 inches on, 
however, only 13 days ; in 1896 no less than 5.073 inches fell 
on 23 days, establishing a record rainfall for September. On 
the other hand, in 1865, only .056 inch was measured on but 
3 days. In 1912 only .570 inch fell on 8 days. 

High winds were noted on 8 days, but never attained the 
force of a gale. Fog occurred on the 23rd and 27th. A lunar 
halo was seen on the 20th. 

The rainfall in Dublin during the nine months ending 
September 30th amounted to 20.982 inches on 140 days, 
compared with 22.658 inches on 158 days in 1912, 12.599 
inches on 120 days in 1911, 25.108 inches on 159 days in 1910, 
18.493 inches on 134 days in 1909, 19.557 inches on 154 days 
in 1908, 17.140 inches on 153 days in 1907, 16.121 inches on 
146 days in 1906, only 10.968 inches on 112 days in 1887, 
and a thirty-five years' average of 20.160 inches on 146 
days. 



At the Normal Climatological Station in Trinity College, 
Dublin, the observer, Mr. C. D. Clark, reports that the me-an 
value of the readings of the dry l)ulb thermometer at 9 a.m. 
and 9 p.m. was 57.2°. The arithmetical mean of the daily 
maximal and minimal temperatures was 56.6°, the mean 
maximum being 62.7°, and the mean minimum 50.5°. The 
screened thermometers rose to 72° on the 11th, and fell to 41° 
on the 18th. On the 19th the grass minimum was 37°. Rain 
fell on 10 days to the amount of 4.26 inches, the greatest fall 
in 24 hours being 1.60 inches on the 19th. The duration of 
bright sunshine, according to the Campbell-Stokes recorder, 
was 84.6 hours, of which 9.3 hours occurred on the Uth. The 
mean daily duration was 2.8 hours. The me^n sub-soil tem- 
peratures at 9 a.m. were — at 1 ft., 58.1° ; at 4 ft., 57.5°. 



At Ardgillan Castle, Balbriggan, Co. Dublin, 210 feet above 



Sanitary and Meteorological Notes. '389 

sea-level, Captain Edward Taylor, D.L., measured 5.54 inches 
of rain on 12 days, the rainfall being 3.65 inches above the 
average and the rain -days being 1 in defect. The total rain- 
fall from January 1 amounts to 22.53 inches on 134 days. 
The rainfall is 1.74 inches above and the rain-days are 3 
below the average. The maximal temperature in the shade 
was 69.9° on the 11th, the minimum was 43.8° on the 17th. 
Within the past 20 years September was driest in 1894, with 
a rainfall of 0.110 inch on onty two days (the least in any 
month) ; wettest in 1896, the rainfall being 5.27 inches on 
24 days ; and in the present year (5.54 inches). The tem- 
perature of the sea, taken at high-water once daily, was 59.2°. 
The temperature of the air taken at sea level simultaneously 
was 58.1°. The maximal temperature of the sea was 65° on 
the 8th, the minimum was 54° on the 20th. 

Captain Taylor has kindly furnished the following additional 
details of the cyclonic rainfall of September 19th, in the neigh- 
bourhood of Dublin. At Milverton Hall, Skerries, Captain 
E. G. Woods measured 2.50 inches of rain on that day. The 
total for the month was 5.37 inches on 13 days, the rainfall 
being 4.03 inches in excess of the average and the rain-days 3 
in excess. At Milverton Hall, the rainfall from January 1st to 
September 30th amounted to 20.82 inches on 137 days, com- 
pared with averages of 18.74 inches and 133 days, respectively. 
At Stirling, Clonee, Co. Meath, about 8 miles N.W. of Dublin, 
Mr. J, Pilkington recorded 1.82 inches of rain on September 
19th. The total rainfall for the month was 4.09 inches on 
12 days ; and from January 1st to September 30th, 22.59 
inches fell on 140 days. 

Mr. T. Bateman reports that the rainfall at The Green, 
Malahide, Co. Dublin, was 4.91 inches on 13 days, the greatest 
fall in 24 hours being 2.03 inches on the 19th. The mean 
shade temperature was 54.8°, the extremes being — highest, 
70° on the 11th ; lowest, 38° on the 17th. 

The rainfall recorded at the Ordnance Survey Office, Phoenix 
Park, was 4.095 inches on 13 days, the greatest measurement 
in 24 hours being 1.340 inches on the 19th. The total amount 
of sunshine at this station was 88.3 hours, the most registered 
on any one day being 10.1 hours on the 11th. 

At Cheeverstown Convalescent Home, Clondalkin, Co. 
Dublin, Miss C. Violet Kirkj^atrick recorded a rainfall of 4.30 



390 Sanitary and Meteorological Notes. 

inches on 12 days, the maximal fall in 24 hours being 1.27 
inches on the 19th. 

At 21 Lceson Park, Dublin, Dr. Christopher Joj-nt, 
F.R.C.P.I., registered 4.270 inches of rain on 12 days, the 
greatest fall in 24 hours being LOGO inches on the 19th. Up 
to September 30, the rainfall at this station was 20.195 inches 
on 131 days. 

Dr. Arthur S. Goff reports that at Belfort House, Dundrum, 
Co. Dublin, the rainfall was 4.49 inches on 12 days. The 
greatest daily measurement was 1.60 inches on the 19th, but 
exactly an inch of rain fell also on the 13th. The tempera- 
ture in the shade ranged from 71° on the 11th and 27th to 
44° on the 18th. The mean shade temperature was 57.7°. 

At Manor Mill Lodge, Dundrum, Co. Dublin, Mr. George B. 
Edmondson recorded a rainfall of 4.55 inches on 15 daj^s, the 
greatest fall in 24 hours being 1.49 inches on the 19th. The 
shaded thermometer rose to 70° on the 11th and 12th, and 
fell to 43° on the 17th and 18th. The mean temperature in 
the shade was 56.9°. 

At Marino, Killiney, Co. Dublin, Mr. Wm. J. M'Cabe 
recorded a rainfall of 4.04 inches on 12 days, the largest 
measurements in 24 hours being 1.20 inches, on the 13th, and 
1.18 inches on the 19th. 

The average September rainfall at Cloneevin, Killiney, in 24 
years (1885-1908) was 1.961 inches on 12.9 days. 

At the Sanatorium of the Dublin Joint Hospital Board, 
Crooksling, Co. Dublin, Dr. A. J. Blake, Resident Medical 
Superintendent, recorded a rainfall of 4.08 inches on 17 days, 
the heaviest rainfall in 24 hours being 1.23 iiiches on the lf>th. 

Di. J. H. M. Armstrong, M.B., reports that at Coolagad, 
Greystones, Co. Wicklow, the rainfall was 4.71 inches on 18 
days. The heaviest fall in 24 hours was 1.15 inches on the 
13th. At Coolagad the rainfall since January Ist, 1913, has 
been 28.91 inches on 14() days. 

At ATiburn, Grej'stones, Mrs. Sydney O'SulIivan recorded 
a rainfall of 4.25 inches on 16 days. The greatest rainfall in 
24 hours was 1.07 inches on the 13th. 

Dr. Charles D. Hanan, M.D., Resident Medical Officer, 
reports that at the Royal National Hos^ntal for Consumption 
for Ireland, Newcastle, Co. Wicklow, rain fell to the anu)unt 
of 4.01 inches on 14 days, the heaviest rainfall in 24 hours 



Sanitary and Meteorological Notes. 391 

being .95 inch on the 12th. The screened thermometers rose 
to 72° on the 11th and fell to 42° on the 16th. The mean 
maximum temperature was 62.1°, the mean minipium 50.4°, 
and the arithmetical mean temperature 56.3°. 

The Rev. Arthur Wilson, M.A., returns the rainfall at the 
Rectory, Dunmanway, Co. Cork, at 6.97 inches on 18 days, 
the heaviest falls in 24 hours being 1.37 inches on the 22nd, 
1.28 inches on the 24th, 1.16 inches on the 15th, .64 inch on 
the 14th, and .57 inch on the 18th. During the first 11 days 
of the month only .05 inch of rain was measured. During 
the 81 days from June 23rd to September 11th, the rainfall 
was only 1.75 inches, whereas 6.92 inches fell in the interval 
from September 12th to September 28th. The total fall in 
the completed 9 months of 1913 has been 47.97 inches, or 
10.98 inches more than the average of the same period in 6 
years (36.99 inches). The weather was warm, and on the 
wet days close. A night frost occurred on the 12th. 



ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH, ROYAL COLLEGE 
OF SURGEONS OF EDINBURGH, AND ROYAL FACULTY OF 
PHYSICIANS AND SURGEONS OF GLASGOW. 

The following candidates, having passed the requisite examina- 
tions of the above Board in October, were admitted Diplo mates 
in Public Health : — Alexander David Campbell, M.B., Ch.B. 
Edin., Edinburgh ; Gurudas Ram Vohra, L.R.C.P. & S.E., &c., 
Punjab, India ; Charles Cameron, M.B., Ch.B. Edin., Bears- 
den ; William Aikman Muir, M.B., Ch.B. Glas., Glasgow ; 
Narain Rama Rao Ubhaya, L.R.C.P. & S.E., &c., Mangalore, 
India ; Andrew Campbell, M.B., Ch.B. Edin., Edinburgh ; 
Gordon Gray Jolly, M.B., Ch.B. Edin., Edinburgh ; William 
Smail M'Laren, M.B., Ch.B. Edin ; Edinburgh ; James 
Donaldson Saner, M.B., CM. Edin., Edinburgh ; Mangalore 
Laxumana Bangara, M.B., Ch.B. Edin., India ; George 
Richardson, M.D., &c., Edin., Leith; Alexander Gordon 
Ingram, M.B., CM. Aberd., Helensburgh; and John Andi-ew 
MacLeod, M.B., Ch.B. Edin., Edinburgh. 



PERISCOPE. 

THE HISTORICAL MEDICAL MUSEUM, LONDON. 

In response to numerous requests it was decided to defer the 
closing of the Historical Medical Museum, organised by Mr. 
Henry 8. Wellcome, until October 31st. During the month 
of October it remained open from 10 a.m. to 6 p.m. daily, and 
from 10 a.m. to I p.m. on Saturdays. After the i^res en t date 
it will be closed for a few months for re-arrangement as a 
Permanent Museum. It is proposed to re-open the Museum 
in its permanent form in the spring of next year. 



NEW PREPARATIONS AND SCIENTIFIC INVENTIONS. 

" Kepler " Malt Extract with Glycerophosphates. 

*' Kepler " Malt Extract with Glycerophosphates is now issued 
by Messrs. Burroughs Wellcome & Co. Each fluid oimce 
contains gr. 4 of calcium glycerophosphate, and of potassium, 
sodium and magnesium glycerophosphates, gr. 2 each. For 
these, " Kepler " Malt Extract forms an appropriate and 
palatable vehicle, ha\dng, as well, a definite food value of its 
own. While in no sense possessed of specific virtues, glycero- 
phosphates have been found distinctly beneficial in enfeebled 
conditions of the nervous system, resulting from worry, from 
overwork, and from exhaustion, as well as in such ajiparently 
diverse conditions as anaemia, urticaria, and incontinence of 
urine. In osteo-malacia and rickets the calcium salt is 
valua])le, and in the treatment of o])ilo2)8y by means of a salt- 
free diet, the administration of glycerophosphates in con- 
jimction with bromide is strongly recommended by authorities. 
" Kepler " Malt Extract with Glycerophosphates presents 
glycerophosphates in an agreeable medium, wliich is itself an 
easily assimilable nutrient, capable of aiding amylaceous 
digestion. To tliis extent the therapeutic value of the glycero- 
phosphates is considered to be enhanced. The preparation is 
issued in bottles of two sizes. 



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THE DUBLIN JOURNAL 

OP 

MEDICAL SCIENCm 



DECEMBEK 1, 1913. 

PAET I. 
ORIGINAL COMMUNICATIONS. 



Art. XVII. — Hour-glass Contraction of the Stomach, 
By Professor John S. McArdle, M.Ch. {Hon. Causa) 
K.U.I. (Illustrated.) 

The case I wish to bring under notice is one of surgical 
interest in many ways. The patient, Mrs. W., had 
already been operated for cystic ovaries, resection being 
carried out. Twelve months afterwards she gave birth to 
a healthy son. Then she got a severe attack of hcemor- 
rhoids, which were cured by excision. Some years later, 
developing signs of chronic intestinal obstruction, a kink 
of the ileum and extensive adhesions of the ascending and 
transverse colon were dealt with, and flie gall-bladder, to 
which the hepatic flexure of the colon adhered, was freed 
and fixed at the level of the ninth costal cartilage. Belief of 
the trouble was immediate and complete. Some years 
afterwards severe symptoms appeared, and Dr. Kice, of 
Portarlington, who was in attendance, diagnosticated 
gastric ulcer and treated her accordingly, but without much 
improvement. Sir C. Nixon then saw her, and agreed as 
to the diagnosis, but only slight progress was made under 
medicinal treatment. Soon after this I examined the 

VOL. CXXXVI. — NO. 504, THIRD SERIES. 2 C 



394 Hour-glass Coyitraction of the Stomach. 

patient with Sir C. Nixon and Dr. Rice, and, owing to her 
emaciation and general appearance, I feared carcinoma. 

Later, while in London, Mrs. W. got worse, and Dr. Rice 
consulted Dr. Herschell about her. The diagnosis of gastric 
trouble was agreed to, and Dr. Alfred Jordan was asked to 
ii'-ray the case. The photographs which are here appended 
confirmed the diagnosis, and proved that the scar tissue re- 
sulting from the ulcer of the stomach had so contracted 
that organ that it had become hour-glass in shape. 

Dr. Rice decided that nothing but operative measures 
could relieve this condition, and on September the 25th, 
1912, assisted by Drs. Rice and Reginald \Yhite, while Sir 
C. Nixon kindly took charge of the patient, I carried out a 
gastro-gastrostomy, aided very much by the information 
provided by Dr. Jordan's excellent a:-ray pictures. 

The patient made an uninterrupted recovery, and now, 
over twelve months after the operation, she can enjoy her 
food, take exercise freely, and join in her favourite sports 
as fit and well as ever she has been. 

The value of ic-ray photography as applied to gastro- 
intestinal work is well exemplified in this case, and to 
show the accuracy of Dr. Alfred Jordan's diagnosis I 
append his report : — 

"11 Bentinck Street, 

" Cavendish Square, W., 

" 2G//J August, 1012. 
" Nothing abnormal was shown in the chest. The posterior 
mediastinum contains no enlarged glands. Bismuth emul- 
sion passed through the oesophagus and entered the cardiac 
portion of the stomach, which portion forms an enlarged 
pouch ; the bisnuith then began to trickle down in a thin 
stream from a point well to the right of the lowest point of 
the cardiac pouch, and to enter the pyloric portion of the 
stomach, this portion being somewhat dilated and dropped, 
as is well shown in Fig. 1, taken in the vertical position." 

Examined on the couch the division of the stomach into 
two portions is clearly shown in the next plate (Fig. 2). 



The Pathology of CEdema and Dropsy. 395 

■ ** The pylorus, marked Py, appears normal in form. Bis- 
muth emulsion entered the duodenum fairly freely. The duo- 
denum showed active contractions, and the bismuth passed 
through it freely and entered the jejunum. Thus there is, as 
shown in Fig. 2, a well-marked hour-glass constriction of the 
stomach, due, no doubt, to a chronic ulcer of the lesser cur- 
vature. The pyloric portion of the stomach is somewhat 
dilated, but appears normal in other respects." 

The finding at the operation coincided exactly with this 
description, and 1 need hardly say how the plates here 
shown enabled me to carry out a rapid and successful pro- 
cedure. 



Art. XVIII. — The Pathology of CEdema and Dropsy, 
chiefly in relation to Colloids.^ By Walter G. Smith, 
M.D. ; President of the Koyal Academy of Medicine in 
Ireland. 

The pathological conditions termed oedema and dropsy are 
among the every-day phenomena which confront physi- 
cians and surgeons. It naturally happens that cases of 
general dropsy come more frequently under the care of the 
physician, and every thoughtful observer must, perforce, 
often feel puzzled by the clinical vagaries that fall under 
his notice. 

For example, in one case of heart disease he sees exten- 
sive dropsy supervene at the first breakdown. Another 
patient with advanced valvular disease, or even congenital 
heart disease, goes on for years with p)erhaps no more than 
slight oedema of the legs now and then. 

Again, in chronic renal disease, it is often difficult to 
correlate the occurrence of dropsy with recognised patho- 
logical conditions of the kidney, or with altered blood- 
pressure. Dropsy happens with and without polyuria, 
varies in localisation, and is even sometimes one-sided. 
The most acute nephritis may exist without anasarca 
(Osier). 

» Read before the Section of Medicine in the Royal Academy of 
Medicine in Ireland, on Friday, October 31, 1913. 



396 The Pathology of (Edema and Dropsy. 

Eenal dropsy may be highly developed in the subcuta- 
neous tissue without any large amount of fluid being 
poured out into the serous cavities. In some instances it 
is more marked in the face, in others in the legs or in the 
scrotum, and so on. 

Once more, acute general droj^sy is occasionally met with 
in the absence of any discoverable morbid state of the cir- 
culatory, respiratory, or renal systems. 

It, therefore, suggested itself to me that it would be in- 
structive, and might awaken a many-sided discussion, if I 
attempted, however inadequately, to sum up our present 
state of knowledge in regard to the causation and de- 
velopment of dropsy as compared with the teaching current 
when I received my first lessons in Clinical Medicine fifty 
years ago from the lips of William Stokes and Alfred 
Hudson. 

It may at once be premised that the conditions involved 
are highly complex, that the adaptive auto-regulating 
powers of the body are amazing, and that we are as yet far 
from being able to answer all the riddles concerning dropsy 
which the Sphinx of Medicine is ever ready to propound 
to us. 

Let us first take a brief retrospective historical glance. 
It is probable, for obvious reasons, that dropsy in connec- 
tion with cardiac trouble was the first form to be recog- 
nised, and dropsy, possibly renal, was described by 
Hi|)pocrates nearly two and a half millenniums ago. 

The explanations offered half a century ago were mainly 
based upon mechanical and hydrostatical considerations, 
and these still loom large in our t(*xt-books, and unqu(\s- 
tionably play a big ]mrt. 

Then the physical view, based upon filtration processes, 
was emi)hasised and developed by Ludwig (18G3) and his 
school, and held the groimd for many years. 

In icccnl limes this view has been ex|K)unded, in a 
modified form, by E. Starling, in his instructive lectures 
upon the Fluids of the Body (1900). But the more closely 
W(^ look into \hv matter \\\v less adequate apjiears th(* filtra- 



By Dr. Walter G. Smith. 397 

tion hypothesis, and it will probably soon be entirely 
abandoned. 

A stout opponent of the purely physical theories appeared 
in Heidenhain, who, more than twenty years ago, main- 
tained the essential importance of the secretory activity of 
the endothelium of the lymph and blood-vessels. Heiden- 
hain also laid stress, as did Wooldridge and Cohnheim pre- 
viously, on the significance of altered permeability of the 
capillary wall. This impairment of nutrition of the 
capillaries is undoubtedly an important factor. Other 
observers considered that w^eight should be attached to 
alterations in the quality and composition of the blood. 
But this is a vague and hazy conception, and the chief 
point to consider in relation to it is change in the viscosity 
of the blood. The viscosity of such colloidal solutions as 
the blood is enormously increased by slight traces of acid, 
and sundry observers have confirmed this observation ex- 
perimentally. 

Instigated by Graham's classical researches (1861) on 
colloids and crystalloids, physiologists were led to study the 
physico-chemical relations between the blood and tissues, 
and an extensive literature arose upon the applications of 
diffusion and osmosis to biological problems, which has 
been fruitful in results. 

Coming down to more recent times, oj)inions seem to be 
veering towards the consideration of another factor — viz., 
the state of nutrition of the tissues themselves — and here 
we meet with the observations and experiments of Lazarus- 
Barlow, Asher, Bechhold, Bainbridge, and others. 

The usual definition of oedematous and dropsical fluid is 
that it represents an excessive accumulation of lymph in 
the tissues and spaces of the body. This lymph may be 
normal or modified in composition. 

For the composition of lymph, or, better called, tissue 
fluid, is determined by — 

(a) The transudate from the capillaries. 

(5) The products of tissue metabolism. 

(c) The subtraction of materials utilised by the tissue cells. 



398 The Pathologij of O'jdenia (Did Dropsy. 

But the definition as thus formulated is inadequate to 
the pathogeny of dropsy. It is begging the question to 
assume that the origin of so-called lymph and of dropsical 
fluid is one and the same thing. Most of the physiological 
experiments bearing upon this topic have been executed 
solely from the point of view of the mode of lymph forma- 
tion. Yet it can, I think, be shown that the relations of 
the tissue cells to water and to saline solutions have, inde- 
pendently of osmosis or secretion, a significance in the 
causation of dropsy which has been frequently overlooked, 
or not taken sufficiently into account. 

It is held now that the lymph channels form a closed, 
freely-branching, series of ducts separated by an endo- 
thelial lining from the tissue spaces. 

It would be advisable if physiologists and patholo- 
gists would agree to restrict the term lymph to the 
contents of the lymphatic vessels, and not confuse the 
tissue fluids with it, even although we may not be able to 
separate them exf)erimentally. The tissues are the real 
parent of the lymph-stream ; the blood-vessels are the 
parent of a transudate. So lymph-formation and transu- 
date-production represent different processes, running in 
opposite directions. The puzzle is not so great in consider- 
ing the inflow from the blood as it is in speculating how, 
once in the tissue spaces, the fluid gets into the lymjih 
channels. 

The four areas of fluid accumulation in the body are the 
serous cavities, the lymph vessels, the interstices of the 
tissues, and the tissue cells. 

We may now briefly pass in review the |X)ssible factors 
in the causation of crdema, and, for convenience of refer- 
ence, I have arranged them in tabular form. 

I. Vascular — i.e., blood-vessels and lymph-vessels. 

(a) Increased supply or inflow of transudate. 
Haomorrhage. 
(b) Obstructed or diminished outflow through — 
(i.) Lymphatics, 
(ii.) Veins and capillaries. 



By Dr. Walter G. Smith. 399 

II. Osmotic pressure. 

III. Physico-chemical alterations in the blood. 

IV. Alterations in cell-nutrition. 

(a) Blood-vessels and lymph-vessels. 

(h) Tissue-cells. 

(c) Nervous influences. 

V. Turgescence of cells. 

I am quite conscious that it is easy to pick holes in this 
classification. 

I. Vascular. 

Under this term are included both the blood-vascular 
system and the lymphatic system. 

(1). Increased supply or inflow of transudate (transuda- 
tion) : (The so-called " active oedemas "). 

This is mainly due to increased pressure in the arterioles 
and capillaries. The driving force of the interchange of 
fluid between the blood and tissues is largely a hydrostatic 
difference of pressure. 

Hcemorrhage. — We all know that not only a colourless 
transudate but also red blood discs — e.g., in the kidney — 
sometimes make their way through the walls of the capil- 
laries and of the urinary structures, and so give rise to 
haematuria. This process of leakage of blood discs, apart 
from actual rupture of vessels, is usually termed diape- 
desis, and is a familiar clinical phenomenon. 

What is its mechanism? 

The existence of holes, so-called stomata, in the capillary 
walls, a fanciful hypothesis suggested by older patholo- 
gists — e.g., V. Kecklinghausen and Arnold — is now re- 
jected as a figment of imagination. 

The influence of blood-pressure must be discounted, 
because diapedesis occurs in various conditions associated 
with low blood-pressure. 

Cohnheim's view of altered permeability of the blood- 
vessel walls is vague until interpreted in modern language 
in terms of colloid chemistry. 

We can now say that a red disc may find its way through 
a tissue-colloid (the blood-vessel wall) whenever that 



400 The Pathology of G^jdcma and Dropsy. 

colloid is rendered abnormally soft and yielding by some 
pathological change — e.g., a slight increase of acidity. 

The problem, then, is reduced to that of one colloid 
wriggling its way through another colloid without losing 
its identity or leaving behind it any evidence of its passage. 

The physical forces involved are those of internal friction 
(viscosity) and surface tension. 

An ingenious experiment, due to Fischer, prettily illus- 
trates this matter, and we need not press the analogy too 
closely. (Experiment shown.) 

I drop some mercury on a 3 per cent. " gel " of gelatin. 
It remains on the surface, in sj^ite of its high specific 
gravity (13.5), and can be rolled about on the top of the 
gelatin without entering it. 

With a " gel " of lower concentration, say, 1.5 to 2 per 
cent., the drops of mercury " will move in all directions 
through the stiff gelatin, in which, of course, no holes exist 
and in which none remain after the mercury has passed " 
(Fischer). 

(2) Obstructed or diminished outflow — (the so-called 
" passive oedemas ") through : — 

(a) Lymphatics. 

On account of the free anastomoses of the lymphatics 
this factor is not of prime importance. Obstruction or 
even closure of the main lymph-duct does not necessarily 
lead to dropsy. 

Lymphatic obstruction is probably of considerable 
moment in the pathology of an acutely strangulated 
hernia. The fluid in the strangled gut is rich in albumen, 
although it is well known that the normal intestinal juices 
contain but a trace of albumen. In other words, we get in 
the injured gut a condition parallel to that of albuminuria 
in nephritis — i.e., damaged nutrition of tissue cells. 

Long-continued gradual lymph obstruction seems rather 
to conduce to altered nutrition and hardening of connective 
tissue, such as is seen in elephantiasis. 

(6) Veins and Capillaries. 

These are undoubtedly the chief return channel, and it 



By Dr. Walter G. Smith. 401 

is unnecessary to adduce evidence in favour of this proposi- 
tion. 

But even here other factors usually co-operate. Thus, it 
is a well-known fact that whjereas thrombosis of the 
femoral vein will give rise to pronounced oedema of the leg, 
yet ligature of the healthy femoral vein, or even of the in- 
ferior cava in dogs, produces no oedema of the legs. 

It is doubtful if oedema can ever be brought about in the 
limbs by a moderate rise of venous pressure alone, provided 
that the capillaries retain their normal impermeability 
(Starling). 

However produced, we may accept as a general state- 
ment that in all cases a primary cause of oedema is an in- 
creased transudation (Starling). 

II. Variations in osmotic pressure. 

Although the importance of this factor in determining 
alterations in form and contents of cells is over-estimated 
by some writers, it cannot be ignored, and must hold a 
place in all speculations upOn the movements of fluid in 
living tissues. It is, however, tied up with many limita- 
tions. For example, frog's muscle placed in isotonic 
solutions of various salts will take up very different quan- 
tities of w^ater.a 

Pfeffer and H. de Vries are the leading champions of 
the wide significance of osmosis in vegetable physiology, 
and it was their researches which instigated animal physio- 
logists to the study of osmotic processes. 

Osmosis is concerned chiefly with crystalloid solutions 
because the osmotic pressure of colloids is very small. On 
the whole, colloids, as compared with crystalloids, are the 
stable constituents of the organism, and it is important to 
remember that they constitute by far the greater part of 
the solids of the body. In the blood itself the water is 
really held in close association with the colloids of the 
blood, and cannot strictly be regarded as " free " water. 

•The words '• isosmotic." "isotonic," and •'physiological salt 
solution " are usually considered as synonymous terms. But this is not 
strictly correct, and the physiological coefficient is not identical with the 
physical. 



402 The Pathology of Oedema and Dropsy. 

For the blood, the ratio of colloids to crystalloids is about 
10 to 1, and the amounts of crystalloid substances in the 
blood and lymph are approximately the same. The 
chemical behaviour of colloids is largely determined by 
surface-phenomena (Starling). 

III. Physico-chemical alterations in the blood. 

Mere excess of water introduced into the blood-vessels 
of a healthy animal does not induce dropsy. The notion of 
increased filterability of the blood as involved by hydrtrmia 
or cachectic conditions is not well substantiated, and is 
now chiefly of historical interest, dating from the time of 
Richard Bright, who started the hydra^mic hypothesis. 

IV. Alterations in cell-nutrition. 

(a) Blood-vessels and lymph-vessels. 

This kind of change is, as Cohnheim and others showed, 
a factor of prime moment, and there is abundant experi- 
mental and clinical evidence of the import of variations of 
permeability of the endothelium and walls of the vascular 
channels. Moreover, the selective action of vascular endo- 
thelium, and the filtration-permeability of the capillary 
wall vary in different territories of the body, circumstances 
that determine certain clinical phenomena, and the distri- 
bution of dropsy. It is better to discard the term " semi- 
permeable " in dealing with colloidal animal structures. 
Permeability of the capillary wall is, in the main, quite in- 
dependent of hydrostatic pressure. 

In this context brief reference may be made to pul- 
monary oedema. The pulmonary capillaries are the widest 
in the body, and they possess a higher degree of vaso- 
motor autonomy than any other vascular area in the body. 
That is to say, they are little, if at all, regulated by vaso- 
motor impulses emanating from the central nervous 
system, either cranial or spinal. The lung capillaries are 
very sensitive to chemical alterations or abnormalities in 
Iho blood or interstitial fluids of the lungs. The tissues of 
the heart, are not so sensitive. 

(b) Tissue-cells. 

The changes that these undergo in connection with in- 



By Dr. Walter G. Smith. 403 

flammation have been exhaustively studied, although their 
relations to oedema have been neglected. Lazarus-Barlow 
aptly remarks that it is astonishing how in all discussions 
concerning lymph and oedema-formation the tissues have 
been left oul of consideration. 

(c) Nervous influences. 

This is obviously an obscure factor, although text-books 
speak so glibly of " angio-neurotic oedema." Still, we re- 
call such curious phenomena as sudden joint effusions in 
tabetic arthropathy, Kaynaud's disease, and soforth. 

The best marked experimental case of neurotic oedema 
is the unilateral oedema of the tongue which may be pro- 
duced by stimulating the peripheral end of one lingual 
nerve (Starling). Every one, of course, recognises the 
vasomotor influences of the nervous system. 

V. Turgescence of cells. — (Quellung , Quellharkeit, Ent- 
quellung). 

I have been somewhat puzzled about the best rendering 
for the German word Quellung. In German writings it is 
taken as synonymous with Inihibition, and in English 
text-books is always translated as Imbibition. 

Yet much confusion arises from the careless use of this 
word. 

For, on looking closely into the matter, it is easily seen 
that the word is really employed in three different senses : 

(a) Capillary imbibition (Fick) — i.e., penetration of 
liquid through narrow interstices or channels. 

This penetration is controlled by surface tension, and 
by ac?sorption — i.e., surface condensation. 

It is familiarly exemplified in the wetting of porous clay, 
of a sponge, or of blotting-paper. 

By acfsorption is meant surface condensation, as dis- 
tinguished from absorption into the mass of a substance. 
The use of charcoal as a decoloriser is an example. 

(h) Imbibition by osmosis — i.e., diffusion across a 
boundary surface — a well-known phenomenon observed in 
animal and vegetable tissues, especially the latter. 

An attractive illustration of diffusion is easilv shown. A 



404 The Pathologij of CEdema and Dropsy. 

3 per cent, solution of gelatin is allowed to solidify in the 
bend of a U-tube. In one limb of the tube is placed a 
dilute solution of potassium ferrocyanide ; in the other limb 
a dilute solution of ferric chloride. Dissociation occurs, 
and the ferric ion and the ferrocyanogen ion, respectively, 
travel in opposite directions, and, after some hours, meet 
in the middle of the bend, and form a beautiful blue septum 
of precipitated Prussian blue. 

(c) Molecular imbibition (Fick) — i.e., increase of volume 
due to localised taking up of water by a mass of substance, 
whether a living cell, or such colloid substances as gelatin, 
agar, or fibrin. 

For this condition the term turgescence seems to me 
appropriate, leaving imbibition restricted to the first case. 

Turgescence is independent of osmotic pressure, and it 
is unnecessary to introduce the conception of a semi-per- 
meable membrane or surface. 

It is to the factor of turgescence that I desire to specially 
invite your attention. 

All animal and vegetable cells can be regarded as 
" organised hydrosols " — i.e., mixtures of colloid proteins, 
carbohydrates, fats, and lipoids, with water — susceptible 
of being influenced by mechanical, physical, and chemical 
agencies. Each and all of these factors impress the ana- 
tomical, chemical, and colloidal mechanisms of the cell 
(Mott). 

In the normal organism there exists among the indi- 
vidual organs and tissues a certain turgescence ratio ; a 
dynamic equilibrium ; and this exhibits surprising varia- 
tions in amount. 

For example, the muscles are far and away the most 
hydrophile of the tissues, whereas the colloids of the blood 
have a very small capacity of turgor. Hence it is that 
even a large excess of water when introduced into the 
blood-vessels, quickly passes out and is excreted by the 
kidneys. 

In this connection the researches of Martin Fischer, 



By De. Walter G. Smith. 405 

Professor of Physiology in Cincinnati, 3' into the determin- 
ing factors of oedema are important and illuminating, and 
are reckoned by Wolfgang Ostwald as the most suggestive 
addition made to one of the fundamental problems of 
general biology and pathology. 

Fischer seeks for the cause of dropsy not in the vessels 
but in the tissues themselves. The problem of oedema is 
essentially a problem of the tissues, and the play of the 
drama is shifted from the vascular system to the con- 
stituent cells of the various organs. 

Klemensiewicz also lays stress upon the factor of the 
tissue-cells in his excellent article on the lymph in Krehl 
and Marchand's Allgem, Pathol, Bd. II., 1912. 

The influence of various electrolytes, acids, bases, and 
salts in solution upon the turgor of such substances as 
fibrin, gelatin, and agar is very considerable, and is easily 
demonstrable. [Experiments demonstrated with lami- 
naria tents, and with gelatin.] The water in colloid 
" gels " is held with great tenacity, and can be expressed 
from them only by enormous pressure. This is a highly 
important fact. 

How stands the case with oedema fluids? Such fluids 
react acid to phenolphthalein, even after the CO2 has been 
removed, and it has, moreover, been shown that the 
amount of CO 2 in these fluids is much in excess of that in 
venous blood (Strassburg : Ewald) — i.e., there is an in- 
crease of acidity On the other hand, it has been shown by 
Araki and Zillessen that every deficiency in oxygen supply 
is followed by increased production of acids. Even CO2 
and very dilute solutions of acids lead to extreme swelling 
of colloid materials, and since lowered oxidation goes hand- 
in-hand with insufficiency of the heart, severe anaemias, 
and certain cachexiac, we see a reason for the frequent 
occurrence of dropsical swelling in such cases. 

Hoppe-Seyler has shown that oedema-fluid may contain 

' Das Odem von Dr. Martin H. Fischer. Translated from the American 
edition, 1910, by Drs. Schorr and Wolfgang Ostwald, Dresden, 1910. 
Nephritis. Dr. Martin H. Fischer. New York. J. Wiley & Sons. 1912. 



406 The Pathotogy of CEdemn and Dropsy. 

not only lactic acid, but also traces of valerianic, succinic, 
and butyric acids. 

I show you a simple experiment which illustrates, by 
analogy, the mode of production of a wheal — i.e., a local- 
ised oedema, such as that caused by a nettle sting. 

A drop of dilute formic acid is inserted by a hypodermic 
needle beneath the surface of a layer of gelatin "gel," 
and the specimen is placed under water. After some time 
a rounded hillock projects above the surface at the point of 
injection. Moreover, if the ions of certain electrolytes can 
induce oedema by producing turgor of the tissue-cells, it 
ought to follow that ions of other electrolytes which lessen 
turgor of cells would reduce oedema. Such is found to be 
the case, whereas non-electrolytes have no such influence. 

To sum up. — The blood- and lymph-stream carries fluid 
to and from the tissues, but what these take up or give 
back to it is their own affair. Only in so far as the circula- 
tory system brings to the tissues substances which directly 
threaten their existence, or, in so far as they neglect to 
carry away the metabolic products of the tissues which by 
their accumulation may injure the tissue can the circula- 
tion be said to exert a compel] ing influence on the water- 
combining capacity of the tissues (Fischer). Upon this 
water-fixing power of the colloid tissues much depends. 
Blood is essentially a hydrosol, and the water of the liquor 
sanguinis cannot be considered "free" in the same 
sense as the water in a weak crystalloid saline solution, 
such as a dilute solution of NaCl. 

Clinical Illustrations. 

Renal Drop.^y. — Here we have to consider two different 
types :— 

(a) The dropsy following on acute nephritis — say, post- 
scarlatinal. 

In all probability this is due to increased permeability 
from the action of toxins on : — 
(i.) Renal glomeruli. 

(ii.) Subcutaneous capillaries (Senator), and 
possibly 



By Dr. Walter Gr. Smith. 407 

(iii.) Increased adsorption — i.e., holding back of 
water by the tissue-cells. 

(h) Chronic Bright's disease. 

High blood-pressures is evidently not the leading factor, 
for, as we all know, dropsy is usually much less marked 
(or may be absent) in interstitial nephritis with raised 
blood-pressure than it is in the large white kidney with 
lower blood-pressure. Ascites and hydrothorax are not so 
common in renal as in cardiac disease. 

We must further distinguish between the drojDsy due to 
primary uncomplicated renal disease and that associated 
with the secondary morbid cardiac conditions so often 
superadded to the renal affection. 

It is, I think, a clinical fact that oedema of the lung is 
at least as common in renal as in cardiac dropsy, and this 
points to a chemical rather than a mechanical explanation. 
As Cohnheim said years ago : — " A man does not die of 
oedema of the lung, but he gets oedema of the lung because 
he is dying." 

Moreover, extensive renal dropsy is frequently met with 
apart from any discoverable abnormality of the vascular 
system. The exact pathology of renal dropsy still remains 
an aggravating puzzle. 

Yet we may assign as probable events : — 

(a) Ketention (from unknown causes) in the tissues of 
crystalloids — e.g., NaCl — i.e., substances of low molecular 
weight and easy dissociation, circumstances which conduce 
to osmotic attraction of fluid from the blood. 

(5) Cohnheim laid great stress upon increased permea- 
bility, which appears to vary in different parts of the body. 
For, according to Schmidt's analysis of transudates from 
different parts of the body of a patient who died of 
nephritis, the following sequence obtains — 

The proportion of protein varies in descending order, 
thus : — 

Pleura ^ peritoneum* >cerebro-spinal >• sub- 
cutaneous. 
(Wells, Chem. Pathol., 1907, p. 296.) 

(c) Turgor of the tissue-cells, due to acidity. 



408 The Pathology of CEdema and Dropsy. 

Von Jaksch has found that the " alkalinity " of the 
blood is constantly and markedly depressed in severe renal 
inflammations. The urine is often strongly acid, and 
several observers state that they have found in the blood 
of nephritic patients substances which dej^ress some of the 
oxidative processes of the body. Fischer holds that all the 
changes that characterise nephritis are due to a common 
cause — the abnormal production or accumulation of acid in 
the cells of the kidney. It is very unlikely that this is the 
sole factor, but whatever may be the ultimate fate of this 
theory it undoubtedly demands consideration and gives 
food for thought. 

Fischer explains the occurrence of the familiar clinical 
phenomenon termed " pufl'y eyelids " in renal disease on 
the grounds that he has shown the tissues in this region 
not only to be especially sensitive to slight variations in 
acidity, but also to possess an enhanced attraction for 
water as compared with other colloids. 

Much confusion in renal pathology has arisen from 
ignoring the assured fact that the excretion by the kidneys 
of water and the excretion of substances soluble in water 
are two entirely independent processes. From the 
behaviour of the kidney towards the excretion of one 
chemical substance we have no right to infer what may 
happen in the case of another soluble substance. The two 
processes are frequently associated, but do not run on 
parallel lines. 

It is worth noting that in complete suppression of the 
urine, say, by calculous obstruction, dropsy may be en- 
tirely absent. 

Tre.^tment of Nkpttrttir. 

A cursory reference to text-books on Medicine will 
quickly show how little satisfactory arc our ideas upon the 
tlierapeutics of nephritis. 

It is quite impossible in tlu! time at my dis|X)sal lo enl(M' 
fully upon such a complex subject. 



By Dr. Walter G. Smith. 409 

One point, however, clearly emerges from the foregoing 
observations, and it is strongly urged by Martin Fischer. 

It consists in the " avoidance, as far as possible, of every 
condition that favours the abnormal production or accumu- 
lation of acid in the kidney ' ' (Fischer) 

This is the key to several of our recognised procedures 
or lines of advice. 

Thus, restriction of proteins in diet is advisable, not, as 
is usually said, to avoid over-burdening the excretory 
function of the kidney, but rather because, as is well estab- 
lished, appreciable amounts of acid are produced in the 
metabolism of proteins. 

Hence, also, why highly acid wines, such as sherry, are 
so injurious, and the percentage of alcohol is of less sinister 
importance than the degree of acidity. 

The ill effects of hard muscular work, especially when 
performed under insanitary conditions, and exposure to 
chill or extreme cold, circumstances which lead to in- 
creased production of acids in the body, find, similarly, 
their explanation, and also account for the resultant albu- 
minuria. 

Conversely, we can readily see the advantages to be 
derived from a more liberal vegetarian diet and from the 
use of alkalies and their salts. 

Fruits and vegetables, moreover, are rich in the very 
classes of salts which act most powerfully in reducing the 
solubility of proteins in acids, and thus tend to diminish 
the albuminuria, so far as it arises from dissolution of the 
renal tissues. Plenty of water is beneficial to nephritic 
patients, and it should be conjoined with the administra- 
tion of properly selected salts, especially NaCl and 
Na2 CO3, not the bicarbonate. " The milk diet has, not 
without reason, enjoyed the popularity that it has ob- 
tained. By giving milk we give a patient a very useful 
balanced ration of fat, carbohydrate, and protein. But we 
do more than this — we give water and salts. The water 
helps to wash out poisons, and the salts contained in the 
milk have a concentration which just suffices to do away 

* 2d 



4l0 The PatJiology of Oedema and Dropsy. 

with the effects of giving an equal amount of water pure ' ' 
(Fischer). 

On the other hand, the use of nitrites to reduce blood- 
pressure is to be deprecated in cases of arterio-sclerosis 
associated with chronic interstitial nephritis. 

Fischer states that he has several times observed alarm- 
ing falls in the urinary output, and once a complete sup- 
pression of urine, followed by death of the patient eight 
days later, after the adoption of such a treatment. It is 
unjustifiable to reduce general blood-pressure by nitrites 
unless we take care that we do not at the same time reduce 
the blood-supply to the kidney down to a dangerous level. 

As Sir W. Osier aptly puts it : — " A man's life may be 
said to be a gift of his blood-pressure, just as Egypt is the 
gift of the Nile. I am sure that in many cases more real 
good can be done by regulating the patient's diet and habits 
of life than by tinkering him with powerful but dangerous 
drugs." 

Fischer's rule for treatment of nephritis may be baldly 
summarised in these words : — Give alkali, salts, and 
water. 

For full details, illustrated by clinical cases, I must con- 
tent myself with directing your attention to Fischer's 
monograph on Nephritis (1912), and also to a paper by 
him on the treatment of nephritis published in the " Trans- 
actions " of the Association of American Physicians 
(1912). 

Heart Disease. — In the text-books and in current 
clinical teaching the effects of so-called " back-pressure " 
are set forth as the main cause of dropsy and other secon- 
dary troubles, and this one-bar tune is played upon with 
monotonous iteration. This view is as old as the time of 
Lower, who flourished in the latter part of the seventeenth 
century. 

Upon closer consideration we may recognise two classes 
of cases (H. J. Starling). 

{a) Those in which the arterial pressure is normal. 

(6) Those, chiefly occurring in older subjects, in whom 



By Br. Walter G. Smith. 411 

the pressure is high, and may amount to over 200 mm. of 
Hg. 

H. J. Starling claims to have shown by his measurements 
of arterial pressure in cases of heart disease that in no case 
of cardiac disease, however severe the symptoms, and how- 
ever marked the failure of compensation, was the blood- 
pressure in the arteries below the normal. 

How is this surprising fact to be met? 

Why is it that in cases of heart disease we find a normal 
arterial pressure even where there is considerable over- 
distension of the veins? 

Professor Ernest Starling's answer is this : — The whole 
vascular system is subordinate in its activity to the needs 
of the master-tissue of the body — viz., the brain. 

To meet these needs a certain height of arterial pressure 
is essential in order that the medullary centres shall receive 
a proper supply of blood and of oxygen. Failing this 
supply, death soon follows. 

What, then, is the result of temporary failure of the 
heart-pump ? 

So soon as the arterial pressure falls so low as to cause 
an ischaemia appreciable by the vasomotor centre, the 
latter at once sends down by all the vascular nerves im- 
pulses which bring about universal vaso-constriction. If 
this is not sufficient to raise the arterial pressure, increased 
respirations and expiratory convulsions occur, and tend to 
force the blood from the veins into the heart, thereby in- 
creasing the output of the latter. 

Bolton's important experiments {Journ. of Pathol., 
IX.) on the relation of cardiac dropsy to that of local 
venous obstruction have shown that oedema may occur 
under conditions in which the capillary pressure is cer- 
tainly not higher than in the normal animal. That is to 
say, increased transudation under normal pressure may 
arise from altered permeability of the capillary endothe- 
lium as a result of defective nutrition. 

So we are led to see that " the production of dropsy in 
heart disease is by no means simple. It involves a compli- 



4l2 The Patholocjy of CEdema and Dropsy. 

cated series of interacting mechanisms all of which tend 
to the death of the organism" (E. StarHng). It will 
follow from these considerations that the treatment of car- 
diac dropsy rests upon a wider basis than purely hydraulic 
or mechanical factors. We must take into account not 
only the dynamics of the vascular system, but also the bio- 
chemical conditions of the different tissues themselves. 
But time forbids my pursuing this theme. 

a One more example — the last I shall weary you with — 
in illustration of the principles referred to in my paper may 
be cited from ophthalmology, and I hope my ophthalmic 
friends will pardon an intrusion into their province. 
I refer to the production of glaucoma. 
In the last edition of Sir H. Swanzy's admirable text- 
book, the chapter on Glaucoma opens with this state- 
ment : — " The primary cause of glaucoma remains to a 
great extent obscure. ... It probably has its origin 
in some vascular derangement of the uveal tract. 

But may not this be putting the cart before the horse? 
All the symptoms of the disease depend upon increased 
ocular tension, and innumerable experiments have been 
devised to elucidate its cause. 

Further on, in alluding to secondary glaucoma following 
on serous cyclitis or iritis, he quotes Priestley Smith's 
significant opinion that, in such cases, the increased ten- 
sion is due to diminished filtration power of the eye, and 
perhaps to tissue-changes around the filtration angle. 

Does not Priestley Smith's view suggest colloid chemical 
changes as an important factor, and can any observations 
be adduced in favour of this hypothesis, as against the 
views based upon exaggerated lymph- or blood-pressure? 

It has been demonstrated by Hofmcister and others 
many years ago, and by Martin Fischer more recently, 
that the turgescence of colloids such as gelatin, agar, car- 
tilage, and fibrin can be markedly affected by various elec- 
trolytes, and that there is no essential difference between 
the relations of fibrin and gelatin to water. 

" Thi>^ Section was not read before the Academy owing to lack of time. 



By Dr. Walter G. Smith. 413 

Fischer has, likewise, shown that the water-combining 
capacity of muscle, and of the eye-ball, respectively, cor- 
responds with that observed in the case of fibrin and 
gelatin. 

Muscular tissue can, from a dilute acid solution, take up 
more than twenty times its weight of water. Now the eye 
is composed of a number of different colloid substances, 
with different water-absorbing capacities, and Fischer set 
himself to examine how far the ocular tissues responded to 
solutions of various electrolytes. 

If an extirpated eye be placed in a very dilute solution 
of acid, so weak that the sour taste is scarcely perceptible, 
the eye-ball becomes stony hard, just as in the worst 
glaucoma. 

Conversely, other electrolytes cause shrinkage of the 
eye-ball, or will counteract the tension produced by acids. 

Moreover, Fischer and Thomas {Annals of Ophthalmol., 
Jan., 1900) have utilised these observations therapeuti- 
cally, for they claim to have shown that the injection of a 
few (5-15) drops of J-J molecular solution of sodium citrate 
(i.e., 4.05 to 5.41 per cent.) under the conjunctiva of 
human beings affected with glaucoma will, within five 
minutes, relieve the pain, and lower the tension to the 
normal level or even below it. I do not for a moment 
imagine that such crude experiments give the key to the 
puzzle of glaucoma, but I do not think that they suggest a 
promising field of investigation to pathologists and ophthal- 
mologists. 

I should have hesitated to bring forward Fischer's views 
were it not that in a recent paper {Proc. Royal Soc, Series 
B., Vol. 85, 1912), Leonard Hill and Martin Flack put for- 
ward somewhat similar views. They suggest that the in- 
creased tension in glaucoma is due to increased imbibition 
and secretion of fluid, resulting from an altered metabolism 
of the ocular tissues, leading to compression of the veins 
and to a rise in the capillary venous pressure, and, there- 
fore, ocular pressure. 

What may be the intimate nature of the chemical altera- 



414 Gyncccological Urology. 

tions in the eye-tiyues that induce glaucoma is still an 
enigma. 

The circulatory conditions in the eye resemble those in 
the intracranial cavity, with the exception that the intra- 
ocular pressure is much higher than the intra-cranial pres- 
sure, and, therefore, is not affected by changes in the 
general venous pressure. 

REFERENCES. 

Bolton, C. An Exi)eriinental Study of the Pathology of 
Cardiac Dropsy and its Relation to that of Venous Obstruction. 
Journ. of Pathol, and Bacieriol. Vol. XIV. 1910. 

Beciihold, II. Die KoUoide in Biologic u. Medizin. Dresden. 
1912. 

Fischer, Martin. Das Odem. Dresden. 1910. Nephritis. 
1912. 

Krehl und Marchand. Handbuch der allgem. Pathol. 
Leipzig. 1912. 

Lazarus-Barlow. General Pathology. 2nd Edit. 1904. 

OsTWALD, WiLHELM. Gi'undriss der allgenieinen Chemie. 
1909. 

Starling, E. The Fluids of the Body. 1909. 



Art. XIX. — Gyncecological Urology.^ By M. J. Gibson, 
M.D. ; Master of the Coombe Hospital ; Gyn.TCologist 
to the Richmond Hospital, Dublin ; President of the 
Obstetrical Section of the Royal Academy of Medicine 
in Ireland. 

I HAVE to thank you sincerely for the honour you have paid 
the Coombe Hospital and me. In seeking a subject for this 
address which would relate to both obstetrics and gynae- 
cology, I decided on a review of some of the urological sub- 
jects with which we are constantly brought in contact. It 
is apparent that much of the work done in urology by the 
members of this Section is not reported. One explanation 
may be that there is still some doubt as to whether the 
gynaecologist, in dealing with such work, is going outside 

• Read before the Section of Obstetrics in the Royal Academy of Medicine 
in Ireland on Friday, November 7, 1913. 



By Dr. M. J. Gibson. 415 

his own province. There are, however, many conditions 
of the urinary system which demand our attention and our 
treatment. Some of those of which I have had experience 
I wish to review in the hope that further information may 
be obtained from the experience of the members of this 
Section. 

Bladder troubles are present in the histories of our 
patients to nearly as great an extent as menstrual troubles, 
back-ache, and inter-menstrual discharge. One recognises 
that in many cases these troubles are regarded as being 
associated with the different affections of the genital tract, 
and that the cure of the genital trouble will be followed by 
the disappearance of the urinary symptoms. In some cases 
this conclusion is correct, in others it is false. It was the 
fashion as long as the urine contained neither blood nor 
pus to treat such cases gynsecologically. They must, how- 
ever, be considered as due to affections of the urinary 
system until a complete examination has proved otherwise. 

I do not propose to consider in detail the modern de- 
velopments in cystoscopic work which have made it pos- 
sible for us to attain more exact knowledge of these con- 
ditions. They have, however, served to show still more 
convincingly the intimate connection existing between 
gynaecology and many diseases of the urinary tract. 

Among the interesting conditions of the bladder with 
which we have to deal are those arising in connection with 
pregnancy. In general the condition of the bladder during 
pregnancy, owing to its congestion and oedema and stretch- 
ing of its walls, predisposes it to infection. The pressure 
of the pregnant uterus or of the head of the child can make 
spontaneous evacuation of urine difficult, and bring about 
incomplete emptying of the bladder. In some cases, owing 
to straining, small quantities of urine are expelled fre- 
quently, pointing to a relative incompetence of the sphincter 
control. In this way micro-organisms readily effect their 
•entrance. In cases of neglected retroversion of the gravid 
uterus at the end of the third month, the pressure of the 
cervix in conjunction with the congestion and stretching of 



416 Gyncccological Urology. 

the region of the internal sphincter leads to retention, 
which is followed by incontinence. Unless proper treat- 
ment is provided infection occurs, which, with the over- 
distension, may lead to more or less extensive destruction 
of the bladder wall. In fatal cases death is nearly always 
due to complications involving the urinary tract. Exten- 
sive pyelonephritis, peritonitis from rupture of the bladder, 
septicaemia or pyaemia are present. Puerperal cystitis is 
further predisposed to by the trauma to which the bladder 
is subjected during labour, and, in addition, we have the 
infected state of the urethra and its neighbourhood soon 
after labour. 

Our observations in cases where catheterisation was re- 
quired at this time showed how readily the urine could be 
rendered purulent. But in these cases the ordinary sym- 
ptoms of acute cystitis are often absent. The origin of 
many cases of bladder trouble may thus be traced to infec- 
tion during pregnancy or the puerperium. 

In post-operative cystitis, according to Baisch, the pri- 
mary infection is staphylococcal, sometimes streptococcal. 
Super-imposed, may be a Bacillus coll infection, if it be 
not already present before operation. Regarding the pre- 
vention during operation, efforts should be made to pre- 
vent infection of the connective tissue about the bladder, 
and careful technique in closing the peritoneum over the 
bladder should be employed. When the catheter must 
be used, the bladder should be douched with a 2 to 5 per 
cent, solution of boric acid. ThiK, with urinary antiseptics, 
is likely to be successful in mild cases where the bladder 
has not been much disturbed. But after the radical 
operation for cancer of the cervix, cystitis is almost invari- 
able in spite of these precautions. Douching should be 
employed here for what it is worth to keep the cystitis in 
control. Five to ten cubic centimetres of a 1 per cent, 
solution of collargol injected into the empty bladder and 
afterwards washed out has been recommended for these 
cases. 

The symptoms vary in degree. The insensitiveness of 



By Dr. M. J. Gibson. 417 

the bladder during the first week, particularly after a cancer 
operation, is very marked. Many patients have an over- 
distended bladder without knowing it, and only partially 
empty it when passing w^ater. When this is overlooked the 
cystitis does not heal, and patients should not be allowed 
to leave hospital until they are capable of completely 
emptying the bladder. 

In dealing with inflammation of the bladder, we fre- 
quently see the cystitis colli in which the inflammatory 
changes are localised to the trigone. This may be a result 
of a more diffused cystitis which has become chronic, or of 
gonorrhoeal extension (the cystitis colli gonorrhoeica) , or 
extension from a urethritis due to some other cause, or as 
a result of tying in a catheter. 

In cases of cystitis colli gonorrhoeica one frequently finds 
numbers of polypi of various sizes growing from the 
mucous membrane around the edge of the sphincter. 
These may become impacted in the sphincter and cause 
obstruction. 

In treating cystitis colli the only satisfactory method is 
the direct application of nitrate of silver, protargol, &c., on 
wool through the urethroscope tube. Attempts to cure 
this condition by douching are fruitless ; in fact they 
usually aggravate it. The condition is recognised with the 
cystoscope. 

The cystitis in old women is mainly due to an ascending 
infection. The shrinking vaginal wall pulls the outer lips 
of the urethra apart. The elasticity and capacity of the 
bladder are reduced. The micro-organisms, and particu- 
larly the colon bacillus, ascend to the bladder along the 
continuously urine-bathed urethra. 

Other conditions are paracystitis, which may cause a 
localised cystitis, pericystitis with adhesion formation 
between the serous coat of the bladder, the omentum, the 
appendix or the intestine, which may prevent complete 
evacuation. 

Cystocele, predisposing as it does to retention of urine 
and cystitis, should always be corrected as early as pos- 



418 Gyncecological Urology. 

sible. The rupture into the bladder of a parametritic 
abscess is followed as a rule by healing, but when the rup- 
ture is from a pyosalpinx or ovarian abscess, healing occurs 
only when the tube or ovary is removed. 

Stone in the bladder is rare, but foreign bodies resulting 
from operation, criminal abortion, masturbation, &c., are 
fairly common. 

Vesico-vaginal fistulae after labour or after operation 
are due to necrosis of the bladder wall or insufficient re- 
pair of a wound. After suturing a wound the bladder 
should be distended with fluid to test it. For the accurate 
localisation of such a fistula, and particularly its relation 
to the ureters, cystoscopic examination, having previously 
plugged the vagina, is most valuable. In extensive cases 
the distension of the bladder with air must be employed. 

Urethrocele, the sac formed in the posterior third of the 
urethra, due to injury to the muscle during labour, leads to 
retention of a small quantity of urine in the sac. Some of 
this urine is expelled every time the patient strains or 
coughs, and is in this way a cause of very troublesome in- 
continence. 

Urethritis is generally secondary to cystitis or to trau- 
mata or to gonorrhceal infection. Gonorrhopal urethritis 
does not tend to extend to the bladder. One should, there- 
fore, avoid any local treatment of it, especially in the early 
stages. It soon becomes chronic, and invades Skene's 
ducts. It may be localised or diffused, which condition, if 
present, can be settled only by the urethroscope. We 
sometimes find the wall of the urethra uniformly thick- 
ened. Stricture, though rare, is sometimes present. 
Stricture may also be due to tuberculosis, syphilis, or in- 
jury during labour. 

In many cases a pyelitis demands our care. It must be 
regarded to a considerable extent as a clinical entity — a 
clinical condition embracing those causes of infection of the 
renal pelvis where evidence of involvement of the paren- 
chyma is wanting. Only exceptionally do patients die as a 
result of a simple pyelitis. There must, naturally, there- 



By Dr. M. J. Gibson. 419 

fore, be considerable difficulty in deciding in any given 
case of pyelitis as to whether the parenchyma is also in- 
volved, and, if so, to what extent. Post-mortem examina- 
tions, owing to the low mortality of cases regarded clini- 
cally as pyelitis, have helped to throw very little light on 
this matter. There are, however, quite a large number of 
cases recorded, where, on splitting the kidney at operation 
during life, the inflammation appeared macroscopically to 
be limited to the renal pelvis. Of the microscopic con- 
dition of the parenchyma there is no mention. 

Acute pyelitis may be sero-fibrinous, diphtheritic, puru- 
lent or gangrenous. Chronic is described as proliferating, 
granular or cystic. In but few cases is the cause other 
than an infective process. The Bacillus coli, typhoid and 
paratyphoid bacillus, influenza bacillus, the Bacillus pyo- 
cyaneus, the Bacillus proteus, the gonococcus, strepto- and 
staphylococci, and the pneumococcus, have all been shown 
to be capable of causing infection of the renal parts. In 
the vast majority of cases the offending micro-organism is 
the Bacillus coli. 

We know that the introduction of microbes into the 
healthy bladder will not cause cystitis. The intravenous 
injection of Bacillus coli will not cause pyelitis. Micro- 
organisms cao pass over the mucous membrane of the 
renal pelvis without causing pyelitis. Cases are recorded 
where pyelitis is present on one side and bacteriuria with- 
out pyelitis on the other. 

Among the predisposing factors which allow of the in- 
vasion of the tissues of the renal pelvis are the congestion 
and oedema of the tissues during pregnancy and the puer- 
perium, lowered vitality induced by traumatism or old- 
standing inflammatory conditions, obstruction to the 
passage of urine from the renal pelvis to the ureter or from 
the ureter to the bladder. The patient's powers of resist- 
ance will naturally also play an important part. 

The infection may be ascending or descending. In 
favour of ascending infection are the sudden appearance 
of the symptoms of pyelitis in patients known to have 



420 Gyncecolocjical Urology. 

cystitis, the presence in the ureter above a site of compres- 
sion, of urine which is clearer than that below. Infection 
reaching the renal pelvis through the lymphatics is ob- 
served in pyelitis secondary to a septic focus in the pelvis. 
Such a mode of infection is observed in the localised in- 
flammation of the bladder wall corresponding to a uni- 
lateral parametritis. Again, if the micro-organisms in the 
bladder invade the tissues about the openings of the ureters 
they may make their way to the wall of the ureter, and 
eventually reach the renal pelvis, travelling in the lym- 
phatic spaces. Probably the most frequent form of ascend- 
ing infection is that through the lumen. Normally, this is 
prevented by the very complete closure of the ureteral 
orifices w^hen no passage of urine into the bladder is taking 
place, and the jet-like manner in which the urine is ex- 
pelled. It has been shown that the movements of the 
ureter present definite stages comparable to intestinal peri- 
stalsis. They are dependent on the integrity of the mus- 
culature. The sphincter mechanism of the orifices may be 
overcome by forcible contractions of the full bladder, 
accompanied by spasm of the sphincter urethra?. Again, 
injury to, distortion or rigidity of, the edges of the orifices 
may lead to incompetence. Regurgitation from the 
bladder may thus occur with the danger of ascending in- 
fection should the bladder contents be septic. These facts 
explain why the results of implantation of the ureters still 
attached to the trigonal region are more satisfactory than 
when the cut ends alone are available. 

The ejaculation from the ureter is interfered with by 
the existence of some unusual resisting force or by a lesion 
involving the muscular layer. Among these conditions wo 
find tumours pressing against, or growing in the wall of 
the urethra; stricture, stone or foreign body impacted in 
the urethra, paralysis of the bladder, over-stretching of the 
bladder during pregnancy, tumours of the bladder situated 
in front of the orifices of the ureters, stricture or stone in 
the ureter, ureterocele, compression of the ureter from a 
tumour or the uterus, contractions of the tissue surround- 



By Dr. M. J. Gibson. 421 

• 

ing the ureter from processes such as parametritis and 
appendicitis, an abnormal angle of junction at the pelvis of 
the kidney whether due to floating kidney or other cause, 
calculus, tumour, or spurs in the renal pelvis. The over- 
stretching of the renal pelvis alone or with the ureter, in- 
jures the functioning power of the musculature. Wertheim 
has shown that after operations for cancer of the cervix 
urine may be locked up in the renal pelvis even though no 
injury has been inflicted on the ureter in the surgical sense. 
Its extensive detachment from its tunica adventitia leads 
to loss of the peristalsis. That there is no obstruction in 
many cases has been proved by the sound. 

Anatomically we know that there is some degree of 
narrowing, firstly, where ureter and renal pelvis meet, 
secondly, at the pelvic brim, and thirdly, where the ureter 
traverses the bladder wall. That the intrapelvic course of 
the right ureter to the bladder is not as direct as that of the 
left is given as one of the causes of the greater frequency 
of right-side pyelitis. During pregnancy the usual position 
of the uterus favours pressure on the right ureter more fre- 
quently. It has been shown in cases of chronic ureteritis, 
in which degenerative processes following on inflammation 
resulted in failure of the motor mechanism of the ureter, 
that, although the lumen of the ureter was actually some- 
what dilated, the pelvis of the kidney could not empty 
itself satisfactorily and had become enlarged. As to 
whether an acute ureteritis can cause obstruction, one 
cannot definitely say, but there is no doubt that one finds 
a very sluggish action of the ureter in cases of inflamma- 
tion of the tissues surrounding the ureteral orifices. 

Whether, in cases of obstruction, the pent up urine 
becomes infected, or whether in the majority of cases the 
urine from the kidney is already infected, is naturally diffi- 
cult to determine. But that the latter is the more probable 
is borne out by the known frequency with which bacteria 
are found to exist in the female urinary tract. 

Descending infection may be due to a septic focus near 
the renal pelvis or infection of the renal pelvis through its 



422 Gyn<xcological Urology. 

lymphatic vessels or hsematogenously. The hcDmatogenous 
is the most frequent of these modes of infection. It may 
be due to a septic focus, such as the uterus, a joint, &c., 
and it is the invariable path in tubercular pyelitis. The 
intimate relationship between the lymphatics of the colon 
and renal pelvis on the right side explains pyelitis following 
inflammatory conditions of the colon. The healthy intes- 
tinal wall efficiently prevents the passage of bacteria from 
its lumen. This property can be maintained in spite of 
considerable interference with the circulation through its 
blood-vessels. In cases of strangulated hernia the fluid in 
the hernial sac is sterile unless the bowel has become gan- 
grenous. But accumulation of large quantities of hardened 
faeces renders the wall pervious to the colon bacillus, pro- 
bably by causing superficial ulceration with resulting in- 
fection of neighbouring viscera. Pyelitis may be caused 
by advanced constipation, whether the infection spreads 
through tissues poisoned by an ulcerated process or through 
the lymphatic channels. 

Pyelitis complicating acute or chronic gonorrhoea is rare. 
This is probably due to the fact that gonorrha^al urethritis 
does not usually extend to the bladder. While in the male, 
infection from the blood may occur, in the female gonor- 
rhoeal pyelitis is practically always an ascending infection. 
The trigone being most affected, the ureteral orifices may 
be deformed. 

Chronic pyelitis may be present without any subjective 
symptoms. The urine is cloudy, but since pyelitis is 
so often associated with cystitis, this fact loses much of 
its value as a point in differential diagnosis. When 
the condition is acute the onset is marked by such 
features as fever, rigors, severe pain in the back and 
front of the lumbar region on allected side, sometimes 
radiating towards the bladder, rapid pulse. Cases without 
fever, or in which at the onset the temperature gradually 
increases, are the exception. The fever is usually re- 
mittent. Symptoms due to the toxa^iiia may be present, 
vomiting, diarrha3a, neuritis, mental disturbances, &c. In 



By Dr. M. J. Gibson. 423 

a number of cases the symptoms of cystitis are most promi- 
nent. As regards the urine, the quantity is at first 
diminished, then markedly increased. The pale, yellow, 
watery colour is characteristic in the later stages. The 
reaction depends on the bacteria present. Only in cases 
where, in association with a small amount of pus, a large 
amount of albumen is present, is one justified in diagnosti- 
cating involvement of the renal parenchyma, and in such 
cases tube casts are usually present. In none of our cases 
has there been much blood in the urine. It is only likely 
to be present in quantity in cases of pyelitis complicating 
chronic renal disease. The pain is chiefly due to the in- 
flammation and distension of the renal pelvis. Stretching 
of the kidney capsule due to swelling of the kidney may 
account for some of the pain. The radiation of the colicky 
lumbar pain to the bladder is to be explained by the con- 
tractions caused in the effort to overcome the distension of 
the renal pelvis. Such contractions pass along the ureter 
to the trigone. In acute cases it is sometimes possible to 
demonstrate in the blood the presence of the bacteria caus- 
ing the pyelitis. 

The diagnosis is established by the cystoscope and 
catheterisation of the ureters, but in cases with character- 
istic symptoms it is often possible to dispense with their 
aid. With the cystoscope, in cases where there is much 
pus, the stream of turbid urine may be observed. One can 
also note whether the volume on the diseased side seems less 
than on the healthy side, and whether the intervals during 
which no urine escapes are longer. Catheterisation of the 
ureters gives accurate information as to the site of an ob- 
struction and the existence of urine pent up in the renal 
pelvis. For example, Stoeckel has shown that in cases of 
pregnancy pyelitis the usual site of obstruction is about 
thirteen cms. above the opening of the ureter at a point 
corresponding to the level at which the ureter crosses the 
pelvic brim. In a few cases the obstruction in the ureter 
was rendered passable by pulling the uterus forward and 
to the opposite side. Urine pent up escapes from the 



424 Gyyicecologicat Urology. 

catheter in a continuous stream or in very raj^idly succeed- 
ing drops which can often be converted into a continuous 
stream by compression of the kidney. In cases of renal 
pelvis obstruction the functional activity of the kidney is 
usually decreased, but recovers when the obstruction is 
overcome. The extent of the involvement of the kidney 
parenchyma is consequently a matter of uncertainty. But 
when a pyelitis fails to get well in spite of treatment the 
probability of pyelone2)hritis should not be overlooked. 

Pyelitis may be simulated by any of the acute inflamma- 
tory processes, such as appendicitis, pyosalpinx, sub- 
phrenic abscess, pneumonia, gall-bladder trouble, twisted 
ovarian cyst, &c. I have also seen it mistaken for puer- 
peral sepsis. 

x\n acute., pregnancy pyelitis can very much resemble 
pneumonia, as in one of my cases ; against it are the pulse 
and respirations, which are less frequent than in pneu- 
monia, and the absence of sputum. The patient frequently 
will complain that the pain extends to the lower abdomen, 
and although it is aggravated by the respirations, it is more 
so by movement. The more commonly intermittent tem- 
perature and the tenderness of the kidney are to be noted. 
In the diagnosis from appendicitis the tenderness over the 
ureter about M'Burney's point is not accompanied by the 
same rigidity as acute appendicitis. Difficulty in diagnosis 
should exist only when one of these conditions complicates 
pyelitis. 

Before leaving this I would again point out that bladder 
symptoms are not always present. This is so in many 
cases of descending infection, and we also know that cys- 
titis need not be present when the urine is purulent and 
contains Bacillus coli. Therefore, in cases of fever during 
pregnancy or puerj)erium, even when there are no bladder 
symptoms, the urine must be microscopically and, when 
possible, bacteriologically examined. 

As regards the outlook, here, as elsewhere, one finds that 
most strains of staphylococci and streptococci may invade 
the livin<' tissues under favourable conditions. This is only 



By Dr. M. J. GiiBsoN. 425 

exceptionally so with the Bacillus coli. But one must re- 
cognise that the virulence of different strains of strepto- 
and staphylococci varies considerably. Prolonged reten- 
tion of purulent urine in the renal pelvis leads to poisoning 
of the cells of the kidney parenchyma. Their resistance 
may diminish to such an extent that even the Bacillus coli 
is enabled to gain a footing and cause a suppurative pyelo- 
nephritis. The outlook in pyelitis is most favourable from 
a life point of view where the infecting micro-organism is 
the Bacillus coli. The outlook is much graver when the in- 
fection is strepto- or staphylococcal. The Bacillus coli par- 
ticularly tends to persist, and even years after an acute 
attack of pyelitis other attacks can follow and lead to 
pyonephritis. Pregnancy pyelitis usually subsides after 
delivery, and only rarely appears during the puerperium. 
Opitz, amongst 53 cases, found that in only 20 did the 
pregnancy pursue a normal course, 23 came into labour 
prematurely, and 10 had labour induced. 

In managing pyelitis in general as it affects the female 
one should adopt an expectant line of treatment unless 
urgent symptoms have developed. Kest, light diet, anti- 
septics, particularly salol and urotropin, alkaline or acid 
fluids, according to the reaction of the urine and the par- 
ticular micro-organisms which it contains while still 
within the urinary tract. The administration of large 
quantities of fluids seems undesirable in cases of obstruc- 
tion, as it may lead to further embarrassment of the renal 
pelvis. In pregnancy pyelitis one tries, in addition, the 
effect of making the patient lie on the healthy side. This 
in some cases may relieve the compressed ureter. 
Opinions differ concerning the value of vaccine treat- 
ment. The results of such general treatment are good. 
It particularly assists in tiding a case of pregnancy 
pyelitis to the time labour sets in. The pyelitis usually 
disappears spontaneously in the puerperium. Local 
treatment is indicated in acute cases of pyelitis by the 
patient's general condition, or the severity of the lumbar 
pain suggesting excessive distension of the renal pelvis. In 

2 E 



426 OyyicBcologicat Urology. 

some acute cases it is indicated when conservative treat- 
ment has failed. Catheterisation of the ureter, with or 
without washing out of the renal pelvis by injecting 8 to 12 
c.cms. of silver nitrate solution, one in a thousand, or a 5 per 
cent, solution of protargol, slowly along the catheter, yields 
good results. Its immediate escape is allowed. Prolonged 
drainage by means of a catheter reaching to the renal 
pelvis is advised in severe cases. It is said that the 
catheter may be left any time up to a week or longer, 
and be reintroduced if symptoms recur after its removal. 
This prolonged drainage has reduced the number o{ cases 
requiring the termination of pregnancy, or, *as may some- 
times be preferred, nephrotomy. We have found simple 
catheterisation of the ureter two or three times weekly, 
depending on the urgency of the symptoms, to be suffi- 
cient in cases of pregnancy pyelitis. In other cases of 
pyelitis, douching the renal pelvis with one in a thousand 
nitrate of silver has given good results. When conserva- 
tive methods and local treatment have failed, and severe 
symptoms exist, we must recognise that we are not dealing 
with the pyelitis only, but also with infection of the kidney, 
and in such cases nephrotomy is indicated. 

As regards ureteral fistulas occurring spontaneously after 
the radical operation for cancer of the cervix, Wertheim 
had G per cent, in 400 cases, of which 52.4 per cent, healed 
spontaneously, yielding in every instance a functioning 
permeable ureter. Only once in a later series of 335 cases 
was spontaneous healing followed by cessation of kidney 
function due to complete obstruction. Weibel maintains 
that mere isolation of the ureter will not cause fistula. In 
the vast majority of Wertheim 's cases it did not, and in 
many of his fistula cases isolation was not done, as they 
were very early. Franz isolates the ureter freely in all 
cases, and has only 5 per cent, of fistulnp. Subperitoneal 
sepsis may help to cause fistuLno, but Weibel states that 
no such sepsis was evident in many of Wertheim 's cases of 
fistul.T. Placing sutures too close to the ureter, and in this 
way dragging and inferf(M*ing with its blood-supply, and 



By Dr. M. J. Gibson. 427 

with the passage of urine, is recognised by Weibel as a 
cause of fistulae. Weibel also maintains that the assistant 
is often responsible in early cases — in holding the ureter 
aside, he injures it. Bumm, Stoeckel and Franz maintain 
that gauze drainage of the pelvis predisposes to the occur- 
rence of fistula. Wertheim always uses gauze drainage, 
and has only 6 per cent, of fistuljje. In Wertheim 's second 
series of 335 cases the percentage of spontaneous fistulae 
was again 6 per cent., but of these only 36.8 per cent, 
healed spontaneously. Of those which do not heal spon- 
taneously, many die from pyelitis. For double-sided cases 
the outlook is bad. For example, in the cases occurring 
spontaneously among Wertheim 's cases, two healed on 
both sides with restoration of function, five persisted on 
both sides, and death occurred in two from recurrence, and 
in three from pyelitis. A study of Wertheim 's results 
shows that narrowing of the ureter with obstruction can 
take place with or without symptoms after both easy and 
difficult operations in cases where the parametrium was or 
was not carcinomatous, where the ureter had or had not 
been extensively isolated, immediately or not for months, 
or even years, after operation, and that pyelitis may follow. 

In treating these cases one must remember that spon- 
taneous healing may occur even after the lapse of several 
months. During the period of waiting, the danger of 
ascending pyelitis is always present, and, consequently, 
Stoeckel advises implantation or nephrectomy after six 
weeks. Wertheim waits for three months, and prefers 
nephrectomy to implantation, as it is safer and simpler. In 
cases of double-sided fistulae Wertheim waits as long as 
possible without allowing pyelitis to set in, and implants 
both ureters in the bladder. 

In cases w^here the ureter was injured unintentionally 
during operation, Wertheim adopted suturing in four 
cases; two healed, one developed fistula and pyelitis, and 
the fourth a simple fistula. When the division was com- 
plete, implantation in the bladder was followed by good 
results. 



428 Gynecological Urology. 

Wertheim resected the ureter in only 1.5 per cent, of 
cases. In these 11 cases implantation was followed by 
good results in 10 cases, as far as healing was concerned. 
One tore out, but in this case there was undue tension. In 
one case successful implantation was not followed by re- 
covery of function. In this case the kidney was found 
atrophied and the ureter closed. One of his cases shows 
that after months stenosis and severe pyelitis may ensue in 
an implanted ureter which had previously acted satisfac- 
torily. Veit states that when a ureter needs resection the 
outlook is always most unfavourable. Wertheim agrees 
with this, and where possible avoids resection of the ureter, 
preferring to free it from the surrounding cancer, and thus 
his immediate results are better. 

Cystoscopic examination in cases of ureter fistula shows 
that the ureter orifice is active without expelling urine 
when it is partially divided. It is not active when it is 
completely divided. In doubtful cases the catheter will 
settle the question. It is always arrested at the site of 
division or accidental ligature. One can also recognise 
soon after operation, before a fistula develops, whether one 
or both ureters have been tied. Again, after im]ilantati()n 
in the bladder, there is no other way of deciding whether 
the ureter and its kidney are acting. 

The usual cystoscopic examination which is carried out 
before deciding on operation in cases of cancer of the 
cervix will show the presence of bullous oedema and the 
cushion-like oedema of the mucous membrane very fre- 
quently. This indicates that either the cancer or the in- 
flammatory process which precedes it has reached the outer 
wall of the bladder. It is not a contra-indication to opera- 
tion. 

Stone in the female ureter is frequently impacted owing 
to the three physiological narrowings, the possibility of ob- 
struction from parametritis or jiaraureteritis, tumours of 
the adnexa), &c. False diagnosis of appendix and adnexjp 
troubles has been made. 

The recognition of displncfMnonts of the ureter due to 



Petrol as a Therapeutic Agent. 429 

parametritis, myomata, carcinoma, over the surface or 
under the base of an intra-ligamentary tumour, often in- 
fluences the success of operations. 

In conclusion I would remind you that kidney tubercu- 
losis in women is frequently overlooked ; they come with 
gynaecological complaints, and often with scarcely any 
bladder symptoms, the urine is slightly turbid, and may or 
may not contain blood. Many of these cases remain un- 
healed, and in them early diagnosis of the kidney involved 
is essential. This can be established only by complete ex- 
amination of the urine, the use of cystoscope, and animal 
inoculation. 

In this review it was impossible to deal exhaustively with 
my own cases without adding too much to its length. I 
hope that gynaecological urology will provide material for 
more complete discussion at subsequent meetings. 

REFERENCES. 
Baisch. Hegar's Beitr. 3. 
Casper. Handb. d. Cystoskopie, 1905. 
Franz. Zeitschr. f. gynakol. Urologie Bd. 1. 
Oppenheimer. Zeitschr. f. urologische Chirurgie Bd. 1. 
Weibel. Zeitschr. f. gynakol Urologie Bd. 4. 
Stoeckel. Veits Handb. d. Gynak. 2. 
Rubsamen. Zeitschr. f. gynakol Urologie Bd. 4. 



Art. XX. — Petrol as a Therapeutic Agent. By G. 
Arbour Stephens, M.D., B.S., B.Sc. ; Hon. Physician, 
Koyal Cambrian Institute for the Deaf ; Appointed 
Surgeon under the Factory Act ; Hon. Med. Officer, 
Swansea Collieries Rescue Station. 

It is hardly necessary to describe the well-known hydro- 
carbon which is in daily use as an important factor of our 
motor traffic. 

Its clear appearance, its characteristic odour, and its 
ready volatility are well known, whilst its properties as a 
cleanser are held in high respect by every practical house- 
wife. 

But up to the present very little has been written on its 



430 Petrol a.s a Therapeutic Agent. 

qualities from a medical point, and although at present 
its internal use has not been put to the test, its external 
value can be spoken of very highly. 

As a scalp cleanser it is of great value, es^Decially when 
the dandriff is excessive, for by removing excess of 
" grease " it allows of the application, if necessary, of 
other drugs, such as mercury in the colloid or any 
other form. Antiseptics are often ineffective in the case of 
scalp trouble because the oily material interferes with the 
approach of the medicament into close contact with the 
offending morhi causa, as, for example, the failure of 
tincture of iodine in ringworm of the scalp, although it 
may be of value in other parts of the body. 

Alopecia areata often yields to treatment when petrol is 
applied thoroughly and frequently, in addition to an anti- 
septic. 

In cases of pediculi capitis petrol is par excellence the 
drug to use, for it not only terminates the life of the para- 
site in quick time, but it has a good solvent effect on the 
nits as well. The volatility of petrol adds to its penetrat- 
ing qualities, and thus gives it a considerable advantage 
over paraffin, whose smell also makes it somewhat objec- 
tionable. 

For wounds of the scalp, petrol is very useful, as it 
enables the surgeon to remove all surgical " dirt " in an 
easy and thorough manner, and oftentimes without having 
to shave the scalp. 

In pustular eruptions of the beard it will be found that 
petrol is of value, especially in cases where the " rash " 
can be traced to such a cause as discharge from the external 
meatus. 

Applied early in cases of barber's rash, petrol is effica- 
cious, and were it used more often as a spray after a public 
shave the customers would be protected. 

Scabies, if taken at the early stages, can be easily checked 
and cured by jietrol, for its penetrating qualities allow of 
its travelling along the path of the acarus and killing it in 
its lair. 



By Dr. G. Arbour Stephens. 431 

An interesting case of a nurse whom I saw with a dry 
eczematous patch on the wrist, and which had resisted 
many treatments, yielded fairly readily to petrol. This 
trouble occurred after she had been nursing a "dirty" 
case of " eczematous " head, and had persisted for nearly 
two years. She had been recommended a^-ray treatment, 
but petrol rendered such a method unnecessary. 

I have found petrol to do good in cases of cracked nipples 
after all other well-known methods of treatment had failed, 
and the mothers on the point of giving- up the nursing of 
their infants. Petrol is not a panacea, but if it does no 
harm it certainly cleanses in a most admirable manner, and 
without much friction, which, in the cases of cracked 
nipples, is a matter of great consideration. 

For soft corns I have used petrol, and its effect has been 
good in many cases, the ease of application recommending 
itself to the patients. Here again it helps to remove the 
mess of sodden skin cells, grease, dirt, and germs, and after 
such a removal nature has some chance to do its healing 
work. 

Burns of all kinds, and especially those produced by the 
spluttering of hot metal at steel, copper, or spelter works, 
are greatly benefited by the early application of petrol. 

At my suggestion, several of the works in this district 
have a quantity of petrol ready at hand in a spray, whence 
it is blown on to the wounds, which are then covered with a 
dusting powder of iodoform, salicylic acid, and boric 
acid. 

Its application by means of a spray lends to the cleanli- 
ness of the method, which, in the case of cuts, is of especial 
value, as it allows of the stitches being put in at the surgery 
without any further preparation. 

The value of petrol in burns is, in my opinion, due to the 
fact that it destroys all germs that have been conveyed from 
the filthy clothes on to the wound, and at the same time 
interferes with the broken-down, half-burnt skin cells, from 
which enzymes have been set free. 

These enzymes, being closely related to ptomains, are 



432 Petrol as a Therapeutic Agent. 

undoubtedly responsible for the poisoning which always 
takes place in metallic burns, whereby the process of heal- 
ing is prolonged for weeks, to the discomfort of the patient 
and the financial loss of the home and the firm. 

In operations I have found petrol extremely useful and 
effective, and possessing none of the irritating and dis- 
appointing qualities of tincture of iodine. 

Before the incision, the part should be well scrubbed with 
cotton wool soaked in petrol, and the instruments, if they 
be suspected, can be thoroughly disinfected by putting 
them in petrol for a few minutes : after the stitches are 
inserted all that remains to be done is to swab with petrol 
and dress with an orthodox dry dressing. 

In one case where I removed a large fatty tumour from 
the labium majus of a woman of fifty, an orthodox dry 
dressing could not be kept in position, so I contented my- 
self by swabbing with petrol and applying clean cotton 
wool, the process to be repeated after each soiling which 
took place at micturition. The wound healed excellently 
and allowed the patient to get up earlier than she could 
have done under most other methods of dressing. 

Internally, my experience of the use of petrol is limited, 
save in the case of pyorrhoea alveolaris, when I have seen 
its application attended by very good results. It allows 
the gums to be cleaned and relieved of decomposing mate- 
rial in an easy and pleasant manner, for its taste is not 
objectionable. 

In these cases it is best applid by soaking small pledgets 
of cotton wool in the i^etrol and applying by means of a 
forceps. 

For operations about the mouth I venture to think its 
use would be of great value ; but at present I cannot speak 
from personal experience. 

One word of warning should be issued as regards the use 
of petrol, and that is, that it should never be handled near 
a fire or a naked light, such as gas, or a candle, or an oil 
lamp, for on account of its great volatility it readily gets 
ignited, and with disastrous consequences. 



PART II. 
REVIEWS AND BIBLIOGRAPHICAL NOTICES. 



A Course in Normal Histology. Part II. By Eudolf 
Krause, a. o. Professor of Anatomy at the University 
of Berlin. Translation by Philipp J. K. Schmahl, 
M.D. New York. London : Eebman, Ltd. No date. 
Koyal 8vo. Pp. x and 406. 

The first part of Professor Krause 's " Normal Histology " 
was recently reviewed in this journal. In it is given a 
concise and useful account of general micro-technique. 

The present volume (Part II.) gives in detail the results 
obtained by the application of the methods described in 
Part I. to the study of the tissues and organs of the animal 
body. A special feature is, that it is illustrated throughout 
by coloured plates. In all there are 98 of these, containing 
'208 figures, and it is not too much to say that it would be 
difficult to surpass them in excellence. They have this 
additional merit also — that they are obviously true to the 
actual preparations from which they have been made, and 
full details of the making of these are given, including every 
step leading up to the final result. A sub-title represents 
the work as " a guide for practical instruction in histology 
and microscopic anatomy." This it undoubtedly is. 

As is natural, the structure of the cell is first dealt with. 
For this purpose use is made of the cells of the liver of 
the salamander and axolotl, of bone marrow, epidermis, 
parotid gland, of the skin of the pike (pigment cell), and 
of the embryo of the horse ascaris for cell division. The 
tissues are then taken up, beginning with the epithelia and 
passing on to the connective tissues, muscle, nerve, and 
blood. This is the orthodox procedure, but it is more than 
usually well done, and the choice in the selection of mate- 
rial is very sound — in many cases strikingly so. 



434 Reviews and Bibliographical Notices. 

The organs are then considered, beginning with those of 
circulation, and passing on through the ductless glands, 
the organs of digestion, of respiration, of urinary secretion, 
and of reproduction to the nervous system and sense 
organs. If any part of the work could be said to be better 
than the others, it is undoubtedly the section on the ner- 
vous system. The methods here are very carefully de- 
scribed in every detail, and the time which they involve is 
well repaid by the beautiful results shown in the illustra- 
tions. Altogether, nothing more useful as a practical aid 
to micro-technique has appeared for a long time, and both 
author and publisher are to be congratulated on the excel- 
lence of the work. The translation is also good, and shows 
little to indicate that Dr. Schmahl is writing in a language 
foreign to him. 



The Nervous and Chemical Regulators of Metabolism. 
By D. Noel Paton, M.D., B.Sc. ; Professor of 
Physiology in the University of Glasgow. London : 
Macmillan & Co., Ltd. 1913. Demy 8vo. Pp. x+ 217. 

From time to time it is imjx)rtant to take stock of our 
knowledge in every department of medical science, even 
when that knowledge is being rapidly added to, and per- 
haps modified by further researches. In the present series 
of lectures Professor Noel Paton has carefully and criti- 
cally compiled all that up to the present has stood the test 
of repeated investigation concerning the function and mode 
of action of the so-called internal secretions. The author 
is himself well known as a worker in this branch of 
physiology, and his lectures in consequence ]X)ssess the 
stamp of personal authority, and should prove of great 
value as a stimulus to future research, more especially as 
he does not hesitate to state his own views and to indicate 
the lines along which more investigation is required. To 
the physician as well as to the physiologist the book should 
prove most useful. Without unnecessary detail a com- 
plete picture is given of the working, as far as we can at 
present understand it, of the various ductless glands. A 



Herman — Maxwell — Handbook of Gynmcology. 435 

special attempt is also made to deal with the inter-relation- 
ships of the glands, and in doing so many facts are adduced 
from clinical observation as well as from animal experi- 
mentation. Criticism of the book in detail is unnecessary, 
and would prove most difficult. We have read it with 
pleasure and much profit, and can strongly recommend it 
to any member of the profession who is anxious to keep 
abreast of modern thought concerning the chemical and 
nervous regulators of metabolism. 



The Student's Handbook of Gynoecology. By George 
Ernest Herman, M.B., &c. ; Consulting Obstetric 
Physician to the London Hospital, &c. Second 
Edition, revised by the Author, with additions by R. 
Drummond Maxwell, M.D., &c. ; Assistant Obstetric 
Physician to the London Hospital. London : Cassell & 
Co. Cr. 8vo. Pp. xiii + 587. 

In the preparation of this revised edition of his work Dr. 
Herman has been assisted by Dr. Maxwell, and six colour 
plates have been added. Much useful information will be 
gleaned from a perusal of the book in which the text is 
well written and the illustrations are carefully drawn. 
Most of the ordinary operations are described, but we are 
surprised that no mention is made of an operation so 
commonly practised as that of Gilliam, and that shortening 
of the utero-sacral ligaments is not deemed worthy of 
notice. Many instruments are illustrated, and we note 
with pleasure a small vaginal clamp for use in Wertheim's 
operation for cancer. 

The number of unfortunate medical men and women 
who have been infected with digital syphiHs would be 
very small if precautions were taken in all cases to inspect 
thoroughly the extern genitals and to wear finger stalls or 
gloves. We are surprised, therefore, to find that Dr. 
Herman advocates the following : — " If by digital exa- 
mination you find enough to account for the symptoms, 
there is no need to inspect the parts or to use a speculum 
or sound." Teaching such as this, which necessitates 



436 Reviews and Bibliographical Notices. 

unseemly groping under the clothes, makes indecent an 
examination which should be strictly practical. 

" The Student's Handbook of Gynaecology " is a con- 
venient size for the pocket, and will be found advantageous 
not only to the student, but to the practitioner who is 
desirous of some knowledge of gynascology without 
reading a large manual. In addition to the six colour 
plates, there are 194 figures in the text. 



Ionic Mediaition : the Principles of the Method and an 
Account of the Clinical Results obtained. By H. Lewis 
Jones, M.D. ; Fellow of the Royal College of Physicians 
of London ; Consulting Medical Officer to the Electrical 
Department in St. Bartholomew's Hospital ; Associate 
of the Institute of Electrical Engineers, &c. London : 
H. K. Lewis. 1913. Cr. 8vo. Pp. viii + 131. 

In writings on the medical uses of electricity, Dr. Lewis 
Jones's name is a hallmark of excellence. " Ionic Medica- 
tion " is a most satisfactory book, not merely giving us 
a reliable account of the remarkable progress of the 
application of " ionic " methods to Medicine, but indicat- 
ing in a clear and convincing way the paths along which 
that progress niay be expected to develop. The physical 
principles involved in the method are fully and yet simply 
explained. References are frequently niade to the 
original papers in which success has been claimed for any 
special line of treatment, and in many cases the author 
attests the value of these methods from personal trial. 
We heartily endorse Dr. Jones's protest against the indis- 
criminate use of ionic jnedication by incompetent persons, 
and often for conditions quite unsuitable for such a mode 
of treatment. 

The range of usefulness of ionic medication is remark- 
able. To the dermatologist its uses in ulcers, cancers, 
warts and corns, as well as in ringworm and alopecia, are 
for the most part w(^ll known. The ])hysician may employ 
the ionic; treatjnent ^\ ith success in neuralgias, niyositis, 
and various arthritides. In ankylosis, sclerosis, keloid 



Paterson — The Surgery of the Stomach. 437 

and scars, it has been invaluable, while the oculist and 
dentist may find in the method a useful adjunct to their 
treatment. The very universality of the method and its 
remarkable success lend it to abuse and quackery, but 
Dr. Jones's book should go far to guide us as to what 
cases are most likely to benefit, and to suggest what form 
of ionic treatment is the most suitable for any given case. 

The author inclines to the view that with improved 
technique the treatment of ringworm by ionic methods 
may become established. Riddell has had very marked 
success. Children are not very good subjects for ionic 
medication, but if success could be ensured — and this 
would seem to be merely a matter of perfecting the 
technique — there are many reasons why this method 
would be preferable to any other existing treatment. 

The niethod of administering a salt internally and 
liberating its ions in the tissues by introduction of an 
electrolysing needle is interesting, and capable of develop- 
ment. There is much food for thought in the book. We 
have no hesitation in heartily recommending it. 



The Surgery of the Stomach : a Handbook of Diagnosis 
and Treatment. By Herbert J. Paterson, M.A., 
M.C., M.B. (Cantab.), F.R.C.S. London: James 
Nisbet & Co., Ltd. 1913. Pp. xiv + 312. With 
Plates. 

In the preface the author tells us that he has attempted to 
give a practical account of ' ' The Diagnosis and Treatment 
of those affections of the stomach which are amenable to 
direct surgical interference." Any one acquainted with 
Mr. Paterson knows the thoroughness with which he does 
anything he undertakes. Those who have not the pleasure 
of knowing him have only got to read this vohime to a])pre- 
ciate his work. His experience in gastric surgery is such 
as fits him well for the task he undertook in writing this 
book. The entire work is eminently practical, and the 
teaching is clear and forceful. He lays great stress in the 
opening chapter upon the importance of takinfj a careful 



438 Reviews and Bibliographical Notices. 

and accurate history of the origin and progress of the 
patient's illness. " Laboratory investigations are an aid — 
and a valuable aid — not a substitute for clinical work." 
The book is decidedly a significant contribution from a 
good, sound, practical surgeon of his own experience in 
connection with this important subject. Our views do not 
coincide in every respect with those stated by the author, 
nevertheless his opinions deserve every consideration. 

We heartily congratulate Mr. Paterson on the success of 
his efforts, and commend the study of the book to every 
physician and surgeon as well as to every general prac- 
titioner. 



Transactions of the American Gyncecological Society. 
Vol. XXXVI., for the Year 1912. Philadelphia : W. J. 
Dornan. 1912. Pp. Ivi + 502, with Index. 

The present volume of Transactions of this well-known 
Society is more than usually interesting, and fully main- 
tains its reputation. Amongst the different articles it 
contains may be mentioned an interesting series on pro- 
lapse of the uterus by such well known gynaecologists 
as Noble, Baldy, Goffe, Polk, and Vineberg. There is 
also another series dealing with uterine cancer, by J. G. 
Clark, Peterson, Taylor, Cullen, and Neel, and several 
interesting papers deal with toxjvmias of pregnancy* and 
eclampsia. The President, Dr. Howard Kelly, in his 
address, gives a most interest uig account of '' The History 
of Vesico-vaginal Fistula." 



Book for Mothers on the Management of Children in Health 
and in Disease. By A. M. Usher. With Introduction 
by Francis B. Rutter, M.D., F.R.C.S. London : 
J. & A. Churchill. 1913. Cr. 8vo. Pp. xi + lOG. 

This is a practical little book written in a pleasant chatty 
style. It is, as its najne ijn])lies, intended solely for the lay 
public, and is written by a lady who does not pretend to 
have any jnedical knowledge. It covers a good deal of 



Stitt — Practical Bacteriology. 439 

ground, and contains many sensible and practical sug- 
gestions, but its great fault is lack of proper arrangement. 
Although it is supposed to be divided into three parts — 
infancy, cbildhood, and youth — they are really very much 
mixed up, and each section lacks any definite arrange- 
ment. But for the fact that there is a good index it 
would be impossible to find anything in the book without 
prolonged search. 

The authoress acknowledges she wrote it in pencil 
during the times she was nursing the youngest of her 
twelve children. It now would be worth her while when 
the baby is grown big, to sit down, without interruptions, 
and systematically rearrange the whole book, taking some 
good text-book as a model. 

The book has the merit of cheapness. It costs only 
one shilling. 



Practical Bacteriology, Blood Work and Animal Parasi- 
tology. By E. R. Stitt, A.B., Ph.G., M.D. ; Head of 
Department of Tropical Medicine, U. S. Naval Medical 
School, &c., &c. Third Edition. London : H. K. 
Lewis. 1913. Post 8vo. Pp. xv. +411. Four Plates 
and 106 other Illustrations. 

Intended primarily for workers in the Tropics, but 
equally useful for those at home, Stitt's handbook has 
been, since its first publication, one of the best of the 
smaller books on the subject. Now, with the appearance 
of the third edition, its value has been considerably 
enhanced. Although not appreciably larger than its 
predecessors, it contains much added information, and 
is now thoroughly up-to-date. Naturally there has been 
less addition to the chapters on bacteria, and more to that 
on protozoa, in accordance with the greater amount of 
attention which has latterly been directed to unicellular 
animals ; and in addition the chapters on the higher 
parasites and disease carriers have been enlarged, so 
that practically all the medically important genera can 
with the help of the book be distinguished and named. 



440 Reviews and Bibliographical Notices. 

Special attention may be drawn to the charts and 
tables, of which those dealing with the condition of the 
urine in kidney diseases and classifying the intestinal 
bacteria are new, all greatly facilitating clinical 
investigation. 



A Manual of Medical Treatment, or Clinical Therapeutics. 
By I. BuRNEY Yeo, M.D., F.R.O.P., Emeritus Professor 
of Medicine in King's College, London ; Consulting 
Physician to KLng's College Hospital ; Honorary 
Fellow of King's College. Fifth Edition, by Raymond 
Crawfurd, M.A., M.D., Oxon., F.R.C.P., Physician 
and Lecturer on Clinical Medicine to King's College 
Hospital, Fellow of King's College, London, &c. ; and 
E. Farquhar Buzzard, M.A., M.D. Oxon., F.R.C.P., 
Physician for Out-Patients to St. Thomas's Hospital 
and to the National Hospital for the Paralysed and 
Epileptic, Queen Square, &c. In two Volumes. Cr. 8vo. 
London : Cassell & Company, Ltd. 1913. Vol. I. 
Pp. XV + 834. Vol. IL Pp. viii + 846. 

With the history of this work before us, adverse 
criticism is quite uncalled for. The first edition ap])eared 
in July, 1893, and was twice reprinted early in the follow- 
ing year. The second edition was published in January, 
1895, and was reprinted on five occasions. The third 
edition came out in August, 1902, and was four times 
reprinted. The fourth edition a])])eared in January, 
1909, and was re-issued in January, 1910, and February, 
1912, and now (in September, 1913) a new edition — the 
fifth — of a deservedly popular work " has been rendered 
necessary by the advances that have been made in 
Medicine since the publication of the fourth edition " in 
1909. 

Dr. Burney Yeo has been unable to share the work of 
revision, the whole of which lias been undertaken by the 
co-editors of the fourth edition. Dr. Raymond Crawfurd 
and Dr. Farquhar l^uzzard. The latter author is 
responsible for the section on Nervous Diseases, Dr. 



Johnstone — A Text-book of Midwifery. 441 

Crawfurd for all the remaining sections. Notwithstand- 
ing Dr. Yeo's disappearance from active participation in 
the bringing out of this new edition, the work retains its 
characteristic form and features, to which it owes so 
much of its success in the past — it remains " Burney 
Yeo's Manual of Medical Treatment." We venture to 
state that it is more than this title implies — it is a very 
excellent " Practice of Medicine," for its pages contain a 
succinct description of the diseases to which the great 
systems of the body are liable, of constitutional diseases, 
and of specific infective diseases. 

The distinctive characters of the present edition are 
the attention which has been paid by the authors to 
recent advances in medical therapeusis, more particularly 
in the domain of vaccine-therapy. For this no doubt 
important addition to the physicians' armamentarium 
the authors show plainly that they hold no retaining 
brief, and the reader may refer with confidence to what is 
said on the subject whenever its merits are discussed in 
connection with any given infective malady. Close 
attention has also been given to the use of x-rsiy photo- 
graphy in diagnosis. 

Enough has been stated to show that this fifth edition 
of a standard work on medical therapeutics has been 
well kept up to date. Accordingly, it gives us pleasure 
to commend it to medical practitioners and medical 
students alike. 



A Text-book of Midwifery for Students and Practitioners. 
By R. W. Johnstone, M.A., M.D., F.R.C.S. Edinburgh 
Medical Series. Illustrated. London : Adam & Charles 
Black. Pp. xxvi + 485, with Index. 

This is a clearly written and short work on midwifery 
intended for students and practitioners. It is divided 
into eight sections dealing successively with anatomy, 
the physiology of pregnancy, of labour, and of the puer- 
perium ; the pathology of pregnancy, of labour, and of 
the puerperium, and operative obstetrics. A very good 

2 r 



442 Reviews and Bibliographical Notices, 

description of modern midwifery is given. The illustra- 
tions are clear, though rather diagrammatic. The 
diagram of "footling" presentation is hardly correc' . 
Dr. Johnstone uses a different indicator in the different 
presentations to describe the position of the foetus. The 
occiput in the vertex, chin in the face, sacrum in the 
breech, &c. Surely a student has enough to remember 
without compUcations that are unnecessary. The back 
serves for a common indicator in all these presentations 
and so saves one complication. 

We are sure the book will be found most useful. 



Blood-pressure :fro7n the Clinical Standpoint. By Francis 
Ashley Faught, M.D. ; Instructor in Medicine at the 
Medico-Chirurgical College, Philadelphia. Illustrated. 
Philadelphia and London : W. B. Saunders Company. 
1913. 8vo. Pp. 281. 

Wptat, perhaps, strikes the reviewer most in reading over 
this book is the large number of misprints. The work, 
which is of a rather ambitious nature, has evidently been 
put together with a certain degree of carelessness, and 
indeed one gets the impression that the proof sheets have 
been read over by some one who is quite unacquainted 
with medical terminology. " Bacterial " for " brachial," 
" grandular " for " granular," in speaking of the kidney, 
are but two samjiles out of many that mar the book. Con- 
tradictions in matter of fact are also met with ; thus in one 
place one reads that it is doubtful whether disease of the 
suprarenal glands really causes much change in the blo(xl- 
pressure, and a few pages further on we find it stated 
dogmatically that low blood-pressure is a symptom of 
Addison's disease, owing to the disease of the suprarenals 
that is present. 

While calling attention to these defects in the work, we 
must add in fairness that the author has collected together 
a good deal of information on the subject of blood-pressuro 
in clinical work, though we are of ()})inion that an attempt 
is made to bestow a dignity on clinical sphygmomanometry 



Harrison CripPs — Cancer of the Hectum. 443 

beyond its value. Blood pressure estimations are doubtless 
of much value in many cases, but an attempt to make such 
estimations of diagnostic and prognostic value in cases 
where they are really of little service will only tend to 
bring the whole subject into disrepute. 



WORKS ON DISEASES OF THE RECTUM. 

1. Cancer of the Rectum : Its Surgical Treatment. By 

Harrison Cripps, F.R.C.S. ; Consulting Surgeon to 
St. Bartholomew's Hospital ; Member of Council, 
Royal College of Surgeons. London : J. & A. 
Churchill. 1913. Royal 8vo. Pp. x + 255. 

2. On Diseases of the Rectum and Anus. By Harrison 

Cripps, F.R.C.S. ; Consulting Surgeon to St. 
Bartholomew's Hospital ; Member of Council of the 
Royal College of Surgeons. Fourth Edition. London : 
J. & A. Churchill. 1913. 8vo. Pp. xii + 588. 

1. This book consists of the sixth edition of the author's 
Jacksonian Prize Essay reprinted to include the opening 
address on the Surgical Treatment of Rectal Cancer, 
delivered at the annual meeting of the British Medical 
Association, held at Liverpool in 1912. 

In this edition of the Jacksonian Prize Essay a table is 
given of 445 consecutive cases of rectal cancer in the 
private practice of the author. The chief value of the 
book consists in this table which has been brought up-to- 
date, and the after history of most of the cases traced, so 
that it provides an interesting comparison in the cases 
seeking advice, between those in which radical operative 
treatment is possible, and those too far advanced and only 
suitable for colotomy. The final results of both methods 
of treatment enable one to form an idea of the expecta- 
tion of life in cancer of the rectum. 

We cannot but regret that the author has not brought 
the text of the book up-to-date. 

2. This book is the fourth edition of the author's work 



444 Reviews and BihliogTaphical Notices. 

on Diseases of the Rectum and Anus reprinted to include 
the opening address on the Surgical Treatment of Rectal 
Cancer, delivered at the annual meeting of the British 
Medical Association, Liverpool, 1912, and including the 
sixth edition of the Jacksonian Prize Essay on Cancer. 
The author publishes two new editions of his books in a 
simple way by mcluding one in the other. The value of 
the book would have been enormously increased if the 
author had brought it up-to-date in other respects, for 
beyond adding details of clinical cases, the illustrations 
have not been improved, and the text is far from beiiag 
up-to-date. 



Preventive Medicine and Hygiene. By Milton J. 
RosENAU. With Chapters on Sewage and Garbage, by 
George C. Whipple ; on Vital Statistics by Cress y L. 
Wilbur ; and on Prevention of Mental Diseases by 
Thomas W. Salmon. New York and London; D. 
Appleton & Co. 1913. Eoyal 8vo. Pp. xxxiii + 1074. 

This excellent treatise covers the entire field of hygiene 
and sanitation, and will make the reader conversant with 
the latest views and practice. 

In his preface the author claims an unusually wide ex- 
perience : — 

" During twenty-three years of varied experience in 
public health work it has been my good fortune to have 
served as quarantine officer, in epidemic campaigns, in 
epidemiological investigations, and in public health labora- 
tories, at home, on the Continent, and in the Tropics. 
The fruits of these experiences are reflected in this b(K)k, 
which may be taken as representing my personal views 
gained in the field, in the laboratory, in the class-room, 
and in administrative office." 

His book fully justifies this claim, and deserves a con- 
venient place on the reference shelf. There is a full and 
clearly printed index which fills forty pages. 



PART III. 
MEDICAL MISCELLANY. 



Reports, Transactions, and Scientific Intelligence. 

^ 

KOYAL COLLEGE OF SURGEONS IN IRELAND. 

The Winter Session of 1913-1914 was formally opened on 
Wednesday, Oci>ober 25th, by the President, Mr. Richard 
Dancer Purefoy, in the presence of members of the Council 
and of the Professors of the Schools of Surgery. 

The President, in the course of his inaugural address, said 
that it was a pleasure for the members of the Council to be 
there, as they all took the deepest interest in the progress of 
the students and the welfare of the school established for 
their benefit. He had the honour for ten years of being a 
professor, and his classes had always treated him well, sym- 
pathetically, and indulgently. The students would find 
when they came to seek appointments that the fact that 
they had their names decorated by a long list of prizes 
would be of no small advantage. Continuing, the President 
alluded to the departure of Professor Geddes, who had con- 
ferred lasting services on the school. His great energy and 
his thoroughness in everything largely contributed to the fact 
that they had now a dissecting-room a credit to the College, 
and which would bear comparison with any dissecting-room 
in the Kingdom. Professor Geddes had obtained a very fine 
appointment in the Land of the West, and they all wished 
him the utmost success that any man could desire to 
achieve. He was not the first great distinguished Scots- 
man whose reputation had been made in this school, 
for it had proved the starting-point of the career of many. 
They had thought now, however, that it was time for an 
opportunity to be given to one of their own countrymen, 
and he was sure from their attitude that what the Council 
had done met with approval. Professor Evatt, who began 
work now, was no stranger, as he had worked in the school 
before, and the laurels he had won in another sphere would 
not be less lasting and abundant than those he would earn 
there. 



446 Royal College of Surgeons in Ireland. 

The President then distributed the following prizes and 
certificates : — 

Systematic Anatomy. — H. M. Alexander, first prize (£2) 
and medal; K. Elmes, second prize (£1) and certificate. 

Practical Anatomy. — First Year — H. Graham, first prize 
(£2) and medal; H. M. Alexander, second prize (£2) and 
certificate. Second Year — J. A. M'Kinnon, first prize (£2) 
and medal; D. J. Steele, second prize (£1) and certificate. 

Practice of Medicine. — Robert P. Weldon, first prize 
(£2) and medal; second prize, no award. 

Surgery. — Trevor S. Smith, first prize (£2) and medal; 
W. Lumley, second prize (£1) and certificate. 

]\Iidwifery. — G. M. C. Powell, first prize (£2) and medal; 
second prize, no award. 

Pathology. — D. V. O'Connor, first prize (£2) and medal; 
J. O'Brien, second prize (£1) and certificate. 

Physiology. — H. M. Alexander, first prize (£2) and 
medal; H. Graham, second prize (£1) and certificate. 

Chemistry. — James F. Seale, first prize (£2) and medal ; 
second prize, no award. 

Physics. — J. F. Seale, first prize (£2) and medal; D. J. 
Steele, second prize (£1) and certificate. 

Dental Anatomy. — T. Edwards, first prize (£2) and 
medal. 

Barker Anatomical Prize. — £26 5s., D. V. O'Connor. 

Carmichacl Scholarship. — £15, C. W. Robinson. 

Mayne Scholarship. — £8, G. E. Popper. 

Gold Modal in Operative Surgery. — No award. 

Silver ^ledals in Operative Surgery. — E. J. Palmer and 
E. O'Connell (equal). 

Stoney Memorial Gold Medal. — J. A. Fretton. 

Practical Histology. — J. A. M'Kinnon, first prize (£2) 
and modal; L. L. Gick, second prize (£1) and certificate. 

Practical Chemistry. — H. L. Moonoy, first prize (£2) and 
medal; W. E. Cooke and J. G. Thornton (equal), second 
prize (£1) and certificate. 

Public Health and Forensic Medicine. — M. Moran, first 
prize (£2) and medal; H. G. Villiers, second prize (£1) and 
certificate. 

Materia Medica. — C. W. Robinson, first prize (£2) and 
medal; M. Moran, second prize (£1) and certificate. 

Biology. — M. J. Briscoe, first prize (£2) and medal; G. 



Royal College of Surgeons in Ireland. 447 

Dunne and J, F. Seale (equal), second prize (£1) and cer- 
tificate. 

Surface and Topographical Anatomy. — J. A. M'Kinnon, 
first prize (£2) and medal ; K. Elmes, second prize (£1) and 
certificate. 

HONOUR CERTIFICATES. 
PRACTICAL ANATOMY. 

Senior. 

First Class Honour Certificates. — Mr. K. Elmes, Mr. C. 
A. M'Cay, Mr. C. W. Kobinson. 

Second Class Honour Certificates. — Miss E. Budd, Mr. 
J. A. Fretton, Mr. B. Hirson, Mr. J. M'Guire, Mr. J. A. 
M'Kinnon, Miss M. M'Mullen, Mr. J. P. Pegum. 

Junior. 
First Class Honour Certificate. — Mr. J. F. Seale. 
Second Class Honour Certificates. — Mr. M. Briscoe, Mr. 
J. C. Rutherford. 

SYSTEMATIC ANATOMY. 

First Class Honour Certificates. — Miss E. Budd, Mr. K. 
Elmes, Mr. H. Graham, Mr. J. A. M'Kinnon, Mr. C. W. 
Eobinson. 

Second Class Honour Certificates. — Mr. B. J. Daunt, Mr. 
J. A. Fretton, Mr. C. A. M'Cay, Mr. W. J. M'Elhinney, 
Mr. J. M'Guire, Mr. B. Hirson, Miss M. M'Mullen, Mr. E. 
Parker. 

DENTAL ANATOMY. 

First Class Honour Certificates. — Mr. L. B. Leonard, Mr. 
T. G. O'Connor, Mr. C. D. Roe, Mr. P. F. Smith. 

Second Class Honour Certificates. — Mr. P. E. Brown, 
Mr. W. S. Canton, Mr. A. B. Cole, Mr. G. A. Fitzgibbon, 
Mr. H. J. Higgins. 

SURFACE AND TOPOGRAPHICAL ANATOMY. 

First Class Honour Certifictes. — Mr. B. Hirson, Mr. 
J. P. Pegum, 

Second Class Honour Certificates.— IMr. H. M. Alex- 
ander, Miss E. Budd, Mr. J. F. Coffey, Mr. B. J. Daunt, 
Mr. J. A. Fretton, Mr. H. Graham, Mr. C. Hewson, Mr. E. 
McCarthy, Mr. C. A. M'Cay, Mr. C. W. Robinson, Mr. 
W. G. Thompson, 



EOYAL ACADEMY OF MEDICINE IN IRELAND. 



President— Walter G. Smith, M.D., F.R. C.P.I. 
General Secretary— J. A. Scott, M.D., F. B.C. S.I. 

SECTION OF MEDICINE. 

President— J. O'Carroll, M.D., F.R. C.P.I. 
Sectional Secretary— F. C. Purser, M.D., F.R.C.P.T. 

Friday, Octohcn- 31, 1913. 

The President in the Chair. 

Pathology and Treatment of Dropsy, in relation to Colloida. 
The President of the Academy (Dr. Walter Smith) read a 
paper upon this subject, in wliich he developed some recent 
views upon the causation and pathology of oedema and drop- 
sical effusions. 

The chief factors of oedema are these : — 

(I.) Vascular — i.e., blood-vessels and lymph-vessels. 

(a) Increased supply or inflow of transudate. 

(b) Obstructed or diminished outflow through — 

(i.) Lymphatics, 
(ii.) Veins and capillaries. 
(II.) Osmotic pressure. 

(III.) Physico-chemical alterations in the blood. 
(IV.) Alterations in cell nutrition: — 

{a) Blood-vessels and lymph-vessels. 

(b) Tissue cells. 

(c) Nervous influences. 
(V.) Turgescence of cells. 

Special emphasis was laid upon the condition of watery 
turgescence of cells, and illustrative experiments were shown 
in favour of the hypothesis of Martin H.Fischer (Cincinnati) 
that even a very slight degree of, or increase in, acidity leads 
to turgor of cells. 

Renal and cardiac dropsy were respectively discussed, 
mainly from the colloid chemical point of view, and the bear- 
ings of this idea upon treatment were pointed out. 

[This connniim'cation a])pear8 in full at page 395.] 

The pREsn)ENT renuu'ked that the paper was a most valu- 
able one, and rare in the histoi*;^' of the Academy. Referring 
to the possibility of a'deina occurring witiiout any discover- 



Section of Medicine. 449 

able fault of the kidneys or heart, he directed attention to a 
form of acute moderate dropsy met with in alcoholic cases 
without any sign of renal difficulty when examined by ordi- 
nary methods. This condition was found to clear up rapidly 
after a few days' rest. The rarity of oedema in cases of mitral 
stenosis, and its frequent occurrence in connection with 
mitral regurgitation, was a matter of interest. With regard 
to the evil effect of saline purgatives in Bright 's disease, it 
struck him that possibly it might be that the normal tendency 
of the kidney to get dropsical itself may be increased by the 
absorption of the salt — sulphate of magnesium — which was 
so often administered in cases of dropsy. He was also struck 
by the evil effect of normal saline injections in inflammatory 
conditions, especially in acute pneumonia. 

Professor Thompson inquired if all oedema included in the 
definition meant accumulation of fluid in the tissue spaces. 
He pointed out that tissue fluid was different from the fluid 
present in the lymph channels. The imbibition idea was not, 
he thought, brought home so closely to the circumstances as 
one would like, and it must be admitted that there were 
other factors which were potent in causing oedema. Altera- 
tion in capillary pressure certainly produced no influence on 
increase of fluid in tissues, except in the case of the liver. 
He considered that alteration in the capillary pressure 
without alteration in the cell walls had no influence in the 
production of oedema. 

Drs. Parsons, Crofton, and Bewley also spoke. 



LITERARY INTELLIGENCE. 

Messrs. J. & A. Churchill of London announce the 
following new editions : — The Diseases af Children. By 
Sir James Frederic Goodhart, Bt., M.D., LL.D., F.R.C.P., 
Consulting Physician to Guy's Hospital ; and George 
Frederic Still, M.D., F.R.C.P. ; Professor of Diseases of 
Children, King's College. Tenth Edition. Revised. With 
42 Illustrations. 16s. net. A Short Practice of Midivifery for 
Nurses. By Henry Jellett, M.D. (Dubhn), F.R.C.P. I., 
Master of the Rotunda Hospital, Dublin. Fourth Edition. 
Revised. With 6 Plates and 169 Illustrations. 7s. 6d. net. 
Lectures on Medicine to Nurses. By Herbert E. Cuff, M.D., 
F.R.C.S., late Medical Superintendent, North-Eastem Fever 
Hospital, London. Sixth Edition. 29 Illustrations. 3s.6d.net. 



SANITARY AND METEOROLOGICAL NOTES. 

Vital Statistics. 
For jour iveeks ending Saturday, November 1, 1913. 

IRELAND. 

The average annual death-rate represented by the deaths — 
exclusive of deaths of persons admitted into public institutions 
from without the respective districts — registered in the week 
ended November 1, 1913, in the Dublin Registration Area and 
the twenty-six principal provincial Urban Districts of Ireland 
was 17.2 per 1,000 of their aggregate population, which for the 
purposes of these returns is estimated at 1,199,180. The 
deaths registered in each of the four weeks of the period 
ending on Saturday. November 1, and during the whole of that 
period in certain of the districts, alphabetically arranged, 
correspond to the following annual rates per LOOO : — 



County Boroughs, &c. 



27 Town Districts 



Dublin Reg. A.rea 

Dublin City 

Belfast 

Cork ... 

Londonderry 

Limerick 

Waterford 



Week ending 



Oct. 
11 



Oct. 
18 



17.1 



16.0 



Oct. 
25 



Nov. 
1 



Average 
Rate 
for 4 
weeks 



17.8 



17.2 

— • 



17.0 



18.9 
20.8 
1G.7 
24.5 
7.6 
12.2 
15.2 



17.7 


19.0 


21.2 


19.5 


20.3 


23.5 


14.6 


15.1 


13.4 


13.6 


20.4 


16.6 


14.0 


il.4 


17.8 


8.1 


10.8 


10.8 


3.8 


30.4 


11.4 



19.2 
21.0 
15.0 
18.5 
12.7 
10.5 
15.2 



The deaths (exchiding those of persona admitted into public 
institutions from without the res])cxitivo districts) from certain 
epidemic diseases registered in the 27 districts during the week 
ended Saturday, November 1, 1913, were equal to an annual 



Sanitanj and Meteorological Notes. 451 

rate of 2.0 per 1,000. Among the 102 deaths from all causes in 
Belfast were 5 from scarlet fever and 6 from diarrhoeal diseases. 
Included in the 14 deaths from all causes for Londonderry 
were one from measles, and 4 from diarrhoeal diseases. Two 
of the 7 deaths from all causes for Galway were from 
whooping-cough. Three of the 7 deaths for Kilkenny were from 
diarrhoea and enteritis of children under 2 years of age ; and 
2 of the 6 deaths from all causes for Clonmel were from enteric 
fever. 

DUBLIN REGISTRATION AREA. 

The Dublin Registration Area consists of the City of Dublin, 
as extended by the Dublin Corporation Act, 1900, together 
with the Urban Districts of Rathmines, Pembroke, Blackrock, 
and Kingstown. The population of this area is 403,000 ; 
that of the City being 308,187, Rathmines 38,769, Pembroke 
29,942, Blackrock 9,161, and Kingstown 16,941. 

In the Dublin Registration Area the births registered 
during the week ended November 1 amounted to 202 — 108 
boys and 94 girls, and the deaths to 174 — 85 males and 
89 females. 

DEATHS. 

The deaths registered, omitting the deaths (numbering 10) 
of persons admitted into public institutions from localities 
outside the Area, represent an annual rate of mortality of 
21.2 per 1,000 of the jDopulation. During the forty -four weeks 
ending with Saturday, November 1, the death-rate averaged 
20.4, and was 1.3 below the mean rate for the corresponding 
portions of the ten years, 1903-1912. 

The total deaths registered, numbering 174, represent an 
annual rate of 22.5 per 1,000. The annual rate for the past 
forty-four weeks was 21.8 per 1,000, and the average annual 
rate for the corresponding period of the past ten years was 22.8 
per 1,000 of the mean population for all deaths registered. 

The deaths included one from dysentery, 2 from diphtheria, 
one from influenza, 2 from measles, and 14 deaths from 
diarrhoea and enteritis of children under 2 years. In each of 
the 3 preceding weeks deaths from diphtheria had been 
2, 2, and ; deaths from influenza had been 0, one, and ; 
deaths from measles had been one, one, and 2 ; and deaths 



452 Sanitary and Meteorological Notes, 

from diarrhoea and enteritis of children under 2 years had 
been 13, 15, and 13. 

Of 31 deaths from tuberculosis (all forms) 18 were attributed 
to pulmonary tuberculosis, 2 to tubercular meningitis, 4 to 
abdominal tuberculosis, 2 to tuberculosis of joints, one to 
tuberculosis of kidney and bladder, and 4 to disseminated 
tuberculosis. In each of the 3 preceding weeks, deaths from 
all forms of tuberculosis had been 23, 18, and 25. 

There were 11 deaths from cancer, or malignant disease. 

The deaths of 2 infants were caused by convulsions, both 
being under one year of ago. There were 6 deaths of infants 
from congenital debility, one from congenital malformations, 
and 7 deaths from premature birth. 

The 12 deaths from pneumonia included 7 from broncho- 
pneumonia, one from lobar pneumonia, and 4 from pneumonia 
(tyi)e not distinguished). 

Fourteen deaths were caused by organic diseases of tho 
heart. There were 14 deaths from bronchitis. 

Two deaths were assigned to accidental violence or 
negligence. 

In seven instances the cause of death was " uncertified," 
there having been no medical attendant during the last illness. 
These cases include the deaths of 2 infants under one year of 
age, and the deaths of 3 persons aged 65 years and upwards. 

Fifty-four of the persons whose deaths were registered 
during the week were under 5 years of age (30 being infants 
under one year, of whom 13 were under one month old), and 
38 were aged 65 years and upwards, including 20 persons aged 
70 and upwards ; among the latter were 20 aged 75 years and 
upwards. 

STATE OF INFECTIOUS DISEASE IN THE DUBLIN 
REGISTRATION AREA AND IN BELFAST. 

The usual returns of the number of cases of infectious 
diseases notified under the '* Infectious Diseases (Notification) 
Act, 1889," and the " Tuberculosis Prevention (Ireland) Act. 
1908," as set forth in the following table, have been furnished 
by Sir Charles A. Cameron, C.B., M.D.. Medical Superintendent 
Officer of Health for the City of Dublin ; by Mr. Fawcett, 
Executive Sanitary OfiiccM- for Ratlnnines and Rathgar Urban 
District ; by Mr. Manly, Executive Sanitary Officer for 



Sanitary and Meteorological Notes. 



453 



Pembroke Urban District ; by Mr. Mooney, Executive Sanitary 
Officer for Blackrock Urban District ; by the Executive 
Sanitary Officer for Kingstown Urban District ; and b}'' 
Dr. Bailie, Medical Superintendent Officer of Health for the 
City of Belfast. 

'able showing the Number of Cases of Infectious Diseases notified in the Dublin 
Registration Area (viz. — the City of Dublin and the Urban Districts of Kathmines 
and Rathgar, Pembroke, IJlackrock, and Kingstown), and in the City of Belfast, 
during the week ended November 1, 1913, and during each of the preceding three 
w^eeks. An asterisk (*) denotes that the disease in question is not notifiable in the 
District. 



Cities ami> 
UiiBAN Districts 







1 - 


















ki 






fc. a> 


4> 


Week 




O CO 


<t> 


ending 




cstf 


f^ 






■T" « 






m 








ei 

9) 
IS 


Wis 


e3 



o *^ 
X c 

0-i 






CO p 

2 « 

l-l 

8 



a».2 

j-i ^-' 

<D CO 

r^ ♦J 
Xi 



3 



City of Dublin 



llatliininaa and 
Ratligar 
Urban 
District 

Pembroke 
Urban 
Diflbriot 



Blackrock 
Urban 
District 



Kingstown 
Urban 
District 



Oily of Belfast 



Oct. 11 

Oct. 18 

Oct. 25 

Nov. 1 

Oct. 11 

Oct. 18 

Oct. 25 

Nov. 1 

Oct. 11 

Oct. 18 

Oct. 25 

Nov. 1 

Oct. 11 

Oct. 18 

Oct. 25 

Nov. 1 

Oct. 11 

Oct. 18 

Oct. 25 

Nov. 1 



Oct. 11 

Oct. 18 

Oct. 25 

Nov. 1 



64 
60 
65 
42 

1 

10 
6 

4 



1 
1 
1 
1 

80 

119 

97 

92 



a Continued Fever 



Cases of Infectious Diseases under Treatment in Dublin 

Hospitals. 
During the week ended November 1, 1913, 11 cases of enteric 
fever were admitted to hospital, 10 were discharged, and 5G 
cases remained under treatment in hospital at the close of the 
week, the respective numbers in hospital at the close of the 
three preceding weeks having been 63, 67, and 55. 



454 Sanitary and Meteorological Notes. 

Three cases of measles were admitted to hospital, 2 were 
discharged, there were 2 deaths, and 3 cases remained under 
treatment at the close of the week. At the end of the 3 
preceding weeks such cases were 29, 23, and 4 respectively. 

Eighteen cases of scarlet fever were admitted to hospital, 
17 were discharged, and 104 cases remained under treatment 
at the close of the week. This number is exclusive of 14 
patients under treatment at Beneavin, Glasnevin, the Con- 
valescent Home of Cork Street Fever Hospital. At the close 
of the 3 preceding weeks the cases in hospital had been 91, 98, 
and 103. 

Seven cases of dijihtheria were admitted to hospital, 10 were 
discharged, and there were 2 deaths. The cases in hospital, 
which at the close of the 3 preceding weeks had numbered 
39, 48, and 45 respectively, were 40 at the close of the week 
under review. 

In addition to the above-named diseases, 6 cases of pneu- 
monia were admitted to hospital, 3 were discharged, there 
was one death, and 22 cases remained under treatment at the 
end of the week. 

ENGLAND AND SCOTLAND. 

The mortality in the week ended Saturday, November 1, in 
96 largo English towns (including London, in which the rate 
was 14.2) was equal to an average annual death-rate of 13.9 
per 1,000 persons living. The average rate for 16 principal 
towns of Scotland was 14.7 per 1,000, the rate for Glasgow 
being 15.8, and that for Edinburgh, 11.9. 

INFECTIOUS DISEASE IN EDINBURGH. 

The Registrar-General has been favoured by A. Maxwell 
Williamson, M.D., B.Sc, Medical OfBcer of Health for Edin- 
burgh, with a copy of his Return of Infectious Diseases notified 
during the week ended November 1. From this Report it 
appears that of a total of 112 cases notified, 74 were of scarlet 
fever, 24 of phthisis, 5 of diphtheria, 8 of erysipelas, and one 
of enteric fever. Among the 669 cases of infectious diseases 
in hospital at the close of the week were 473 cases of scarlet 
fever, 109 of ])hthisis, 34 of di])htheria, 16 of measles, 2 of 
whooping-cough, 10 of enteric fever, and 10 of erj'sipelas. 



Sanitary and Meteorological Notes. 455 

Meteorology. 

Abstract of Observations made in the City of Dublin, Lat. 53° 20' 
N., Long. 6° 15' W., for the Month of October, 1913. 

Mean Height of Barometer, - - - 29.768 inches. 

Maximal Height of Barometer (23rd, at 9 p.m.), 30.332 „ 

Minimal Height of Barometer (29th, at 4 p.m.), 28.857 ,, 

Mean Dry -bulb Temperature, - - - 50.8°. 

Mean Wet-bulb Temperature - - - 49.0°. 

Mean Dew-point Temperature, - - 47.0°. 

Mean Elastic Force (Tension) of Aqueous Vapour, .334 inch. 

Mean Humidity, - . . _ gy g per cent. 

Highest Temperature in Shade (on 13th), - 64.6°. 

Lowest Temperature in Shade (on 24th), - 30.0°. 

Lowest Temperature on Grass (Radiation) (24th) 28.0°. 

Mean Amount of Cloud, - - - 53.^ per cent. 

Rainfall (on 17 days), - - - 3.760 inches. 

Greatest Daily Rainfall (on 7th), - - .960 inch. 

General Directions of Wind, - - S., S.E.,' S.W. 

Remarks. 

A mild but changeable month. Easterly winds (between 
N.E. and S.E.) prevailed during the first ten days ; southerly 
(between S.E. and S.W.) winds for the most part afterwards, 
except from the 22nd to the 25th inclusive, when light 
northerly winds and calms brought such a reduction of tem- 
perature that the screened thermometer fell to 24° at Birr 
Castle and to 30° in Dublin and at Valentia on the morning 
of the 24th. Notwithstanding this " cold snap " the mean 
temperature of the month in Dublin was 2.6° above the 
average for October. The rainfall was very large — 3.760 
inches — but it consisted largely of heavy splashes, such as 
.960 inch on the 7th, .771 inch on the 5th, .445 inch on the 
27th, .361 irch on the 10th, and .351 inch on the 28th. In 
the week ended the 11th 2.152 inches were recorded ; in six 
days ended the 30th, the measurements totalled 1.173 inches. 

In Dublin the mean maximal temperature was 56.7°, com- 
pared with the average (54.7°) ; and the mean minimal 
temperature was 47.4°, compared with the average, 44.3°. 
The arithmetical mean temperature (52.1°) was 2.6° above the 



456 Sanitary and Meteorological Notes. 

average (49.5°) ; the mean dry-bulb readings at 9 a.m. and 
9 p.m. were 50.8°. In the forty -nine years ending with 
1913, October was coldest in 1892 (M. T. = 44.8°) and in 
1896 (M. T. = 45.0°). It was warmest in 1908 (M. T. = 55.4°) 
and in 1876 (M. T. = 53.1°). In 1912, the M. T. was 54.9°. 

The mean height of the barometer was 29.768 inches, or 
0.072 inch below the corrected average value for October — 
namely, 29.840 inches. The mercury rose to 30.332 inches 
at 9 p.m. of the 23rd, and fell to 28.857 inches at 4 p.m. of 
the 29th. The observed range of atmospheric pressure was, 
therefore, 1.475 inches. 

The mean temperature deduced from daily readings of the 
dry-bulb thermometer at 9 a.m. and 9 p.m. was 50.8°, or 
2.9° below the value for September, 1913. The arithmetical 
mean of the maximal and minimal readings was 52.1°, 
compared with a thirty-five years' (1871-1905) average of 
49.5°. Using the formula. Mean Temp. = Min. + {Max. — 
Min.) X .485, the mean temperature was 51.9°, or 2.6° above 
the average mean temperature for October, calculated in 
the same way, in thirtv-five vears, 1871-1905, inclusive 
(49.3°). On the 13th the thermometer in the screen rose to 
64.6°— wind, S. ; on the 24th the temperature fell to 30.0°— 
wind, W.N.W. The minimum on the grass was 28.0°, also 
on the 24th. 

The rainfall was 3.760 inches, distributed over 17 days. 
The rainfall was considerably above, while the rain -days 
were slightly below, the average. The average rainfall for 
October in the thirty -five years, 1871-1905, inchisive, was 
2.870 inches, and the. average number of rain-days was 18. 
In 1880 the rainfall in October was very large — 7.358 inches 
on 15 days. In 1875, also, 7.049 inches fell on 26 days. On 
the other hand, in 1904 onl\ .454 inch fell on 11 days, in 
1890 only .639 inch fell on but 11 days, in 1884 only .834 inch 
on but 14 days, and in 1868 only .856 inch on 15 days. In 
1911, 3.787 inches were recorded on 20 days, and in 1912, 
1.665 inches on 13 days. 

High winds (force 4 to 7) were noted on 9 days, but attained 
the force of a gale on only 1 day — the 6th. The atmosphere 
was foggy in Dublin on the 8th and 25th. There was a 
lunar corona on the 11th. Lightning was seen on the 20th. 

The rainfall in Dublin duiing the ten months ending October 



Sanitary and Meteorological Notes. 467 

31st, 1913, amounted to 24.742 inches on 157 days, compared 
with 24.323 inches on 171 days in 1912, 16.386 inches on 140 
da>s in 1911, 27.330 inches on 177 days in 1910, 21.106 inches 
on 158 days in 1909, 12.366 inches on 123 days during the 
same period in 1887 (the dry year), and a thirty-five years' 
(1871-1905) average of 23.030 inches on 164 days. 



Mr. C. D. Clark reports that at the Normal Climatological 
Station in Trinity College, Dublin, the mean height of the 
barometer was 29.766 inches, the range of atmospheric pressure 
being from 30.30 inches at 9 p.m. of the 23rd to 28.94 inches 
at 9 a.m. of the 29th. The mean value of the readings of the 
dry-bulb thermometer at 9 a.m. and 9 p.m. was 52.4°. The 
arithmetical mean of the daily maximal and minimal tempera- 
tures was 52.8°. The screened thermometers rose to 65° on the 
13th and 18th, and fell to 30° on the 24th. On the 24th and 
25th the grass minimum was 26°. Rain fell on 16 days to the 
amount of 3.60 inches, the greatest fall in 24 hours being .87 
inch on the 7th. The duration of bright sunshine, according to 
the Campbell-Stokes recorder, was 77.6 hours, of which 10.0 
hours occurred on the 9th. The mean daly sunshine was 
2.5 hours. The mean temperature of the soil at 9 a.m. at a 
depth of one foot was 53.3° ; at a depth of 4 feet it was 54.9°. 



Captain Edward Taylor, D.L., returns the rainfall at 
Ardgillan, Balbriggan, Co. Dublin (height above sea level, 210 
feet), as 4.03 inches on 17 days, the largest measurement in 
one day being .51 inch on the 29th. The rainfall was 1.41 
inches above the average and the rain-days were equal to the 
average. From January 1 to October 31, the rainfall at 
Ardgillan has been 26.56 inches on 151 days, or 3.15 inches 
above while the rain-days were 3 below the respective averages. 
The highest shade temperature in October was 62.9° on the 
13th, the lowest was 30.8° on the 24th. A thunderstorm 
with hail occurred on the 20th. 

Captain E. G. Woods recorded a rainfall of 3.85 inches on 
19 days at Milverton Hall, Skerries, Co. Dublin (190 feet 
above sea-level). This measurement exceeded the average for 
October by 1.01 inches. The rain-days were equal to the 
average. The largest rainfall in 24 hours was .42 inch on the 
7th. Since January 1st, the measured rain at Milverton Hall 

2g 



458 Sanitary and Meteorological Notes. 

was 24.67 inches, or 3.09 inches above the average ; the rain- 
days were 156, or 4 above the average. In October, 1907, 
4.21 inches of rain fell at this station ; in October, 1910, only 
1.33 inches. 

At Stirling, Clonoe, Co. Meath, Mr. J. Pilkington registered 
a rainfall of 4.35 inches on 18 days, the maximum in any one 
day being 1.08 inches on the 5th. From January 1 to October 
31, 1913, rain fell on 158 days to the amount of 26.94 inches. 
This station stands 231 feet above sea-level. 

Mr. T. Bateman reports that the rainfall at The Green, 
Malahide, Co. Dublin, was 3.725 inches on 15 days, the greatest 
fall in 24 hours being .55 inch on the 7th. 

At the Royal Botanic Gardens, Glasnevin, rain fell on 17 
days to the amount of 4.15 inches, the greatest daily fall 
being 1.18 inches on the 5th« 

At the Ordnance >Survey Office, Phoenix Park, Dublin, the 
October rainfall was 4.430 inches on 18 days. The heaviest 
fall m 24 hours was 1.420 inches on the 5th. The total amount 
of bright sunshine was 88.2 hours, the maximal duration on 
any one day being 8.3 hours on the 20th. 

Dr. Christopher Joynt, F.K.C.P.I., registered 3.470 inches of 
rain on 15 days at 21 Leoson Park, Dublin, the largest measure- 
ment in 24 hours being 1.100 inches on the 7th. The ten 
months' rainfall in 1913 at this station amounts to 23.665 
inches on 146 days. 

The rainfall recorded at Cheeverstown Convalescent Home, 
Clondalkin, Co. Dublin, was 5.013 inches on 18 days. The 
heaviest rainfall in 24 hours was 1.380 inches on the 7th. 

Dr. Arthur S. GofE reports that rain fell on 17 days at 
Belfort House, Dundrum, Co. Dublin, the amount being 
5.03 inches, of which 1.20 inches wore measured on the 7th. 
The temperature range was from 66° on the 17th to 31° on the 
24th. The mean temperature in the shade was 52.6°. 

At Manor Mill Lodge, Dundinim, Co. Dublin, Mr. George B. 
Edmondson measured 4.71 inches of rain on 17 days, the 
maximum in 24 hours being 1 .25 inches on the 7th. The mean 
temperature of the month was 51.3^ the thermometer rising 
to 64° on the 13th and falling to 31° on the 24bh. 

Mr. W. J. McCabe, on ])chalf of the Right Hon. Laurence 
P. Waldron, returns a rainfall of 3.97 inches on 18 days at 
Marino, Killiney, Co. Dublin. The heaviest fall in 24 hours 



Sanitary and Meteorological Notes. 459 

was '77 mch on the 7th. The average October rainfall at 
Cloneevin, Killiney, in the 24 years, 1885-1908, was 2.985 
inches on 17.2 days. 

At Coolagad, Greystones, Co. Wicklow, Dr. John H. 
Armstrong, M.B., measured 6.20 inches of rain on 20 days, 
the maximal falls in 24 hours being 1.14 inches on the 5th and 
.75 inch on the 27th. Thunder and lightning occurred at 
2 25 p.m. of the 27th. From January 1 to October 31, 1913, 
the rainfall at Coolagad amounted to 35.11 inches on 166 days. 

Mrs. Sydney O'Sullivan recorded 6.35 inches of rain on 
19 days at Auburn, Greystones, Co. Wicklow, the greatest 
rainfall in 24 hours being 1.36 inches on the 5th. A thunder- 
storm occurred on the 27th, and lightning at 8 p.m. of the 20th. 

Dr. Charles D. Hanan, M.D., reports that 5.96 inches of 
rain fell on 19 days at the Royal National Hospital for Con- 
sumption for Ireland, near Newcastle, Co. Wicklow. The 
maximum in 24 hours was .99 inch on the 5th. The mean 
temperature of the month at the Hospital was 51.2°, the 
extreme readings of the shade thermometer being — highest, 
61° on the 12th and 18th ; lowest, 33° on the 24th. The mean 
maximal temperature was 56.0°, the mean minimum was 46.4 ° 
Hoar frost was observed on the 22nd, 23rd, 24th and 25th. 
Thunder occurred on the 27th and 28th. Lightning was 
seen on the 21st and 28th. 

The Rev. Arthur Wilson, M.A., recorded a rainfall of 7.90 
inches on 24 days at the Rectory, Dunmanway, Co. Cork. 
This fall was 2.12 inches in excess of the average. The heaviest 
falls in 24 hours were 1.53 inches on the 4th, 1.16 inches on 
the 12th, and 1.05 inches on the 10th with thunder and 
lightning. There were many fine, bright warm days during 
the month, which was mild on the whole, although the nights 
of the 14th, 21st, 22nd and 23rd were frosty. The total rainfall 
for the completed 10 months of 1913 is 55.87 inches, compared 
with an average for 8 years of 44.77 inches. A thunderstorm 
with heavy rain occurred on the night of the 4th, and distant 
thunder was heard on the 20th. The average rainfall of 
October for the past 8 years is 5.78 inches. 



PERISCOPE. 

TUBERCULOSIS OF THE URINARY TRACT. 

In a clinical lecture on this subject {The Lancet, August 2nd, 
1913, page 273) Dr. J. Howell, M.A., M.B., M.Ch. Oxon., 
F.R.C.S. Eng., says that the most indicative symptom ex- 
perienced by the patient is " cystalgia," usually a scalding 
set up by toxic and pathogenic irritants which produce an 
oedema, congestion, or a minute ulcerative papillitis on the 
mucous membrane surface at one ureteric orifice, extending 
to the trigone and the urethral orifice, with considerable dis- 
comfort, culminating in severe pain, frequent micturition, 
and urethral smarting. These painful symptoms are greatly 
diminished by cystopurin, allowing of an early and complete 
intravesical examination accompanied by irrigation, not only 
of the bladder, but via the ureter, of the pelvis of the kidney. 
For this irrigation he employs a solution of cystopurin. The 
establishniont of the tubercle bacillus in the mucous mem- 
brane in the bladder is favoured by an antecedent affection 
of the urinary tract. Similarly it is retarded by the diuretic 
and antiseptic action of cystopurin. Cystopurin, a double 
salt of hexamethylene-tetramine and sodium acetate, can 
be employed freely, safely, and effectively in all affections 
of the urinary tract, whether of toxic or of bacterial origin. 
It has the particularly satisfactory result of clearing away 
septic conditions associated with tuberculosis of the kidney, 
so that the true relation of thrombosis to the clinical urinary 
condition can be determined, and the desirability of excision 
of a kidney can be the more accurately gauged. 

THE BRITISH JOURNAL OF SURGERY. 

No apology, in our opinion, is required to accoimt for the 
appearance of this new journal. Its title quite justifies the 
undertaking. In fact, if an apology is to be offered at all 
it should be for the non-appearance of such a journal for 
many years past. The editorial committee contains, 
amongst others, the names of many well-known and eminent 
surgeons in Great Britain, and we are pleased to see that 
Ireland is also represented. The chairman of the com- 



Periscope. 461 

mittee is Sir Berkeley Moynihan, of Leeds, and the 
secretary is Mr. E. W. Hey Groves, of Bristol. The articles in 
the present number are varied and of a very high standard 
of excellence. If we are to judge of the quality of the papers 
promised for future numbers by the eminence of those whose 
names are given as early contributors, then the success of 
the journal is assured. Appropriately enough, we have an 
excellent reproduction of a photograph of the late Lord 
Lister in this the first number. We believe the journal will 
fill a long-felt want, and in our opinion the venture deserves 
the hearty support and co-operation of every surgeon in the 
British Isles and Colonies The publishers are Messrs. John 
Wright & Sons, of Bristol. It will be issued quarterly, the 
annual subscription being 25s. The number before us is 
well printed, beautifully illustrated, and contains over 150 
pages. 

THE " WELLCOME " PHOTOGRAPHIC EXPOSURE RECORD AND 

DIARY, 1914. 

If brevity be the soul of wit, condensation is the essence of 
literature. Especially is it so in these hustling days, when 
leisure is with many people reduced to a minimum quantity. 
It is for this reason amongst others that the pocket guide to 
photography issued under the above title obtains so wide 
a circle of readers. It condenses into one small volume, clear, 
definite, and precise instructions on a very wide range of 
subjects. All the littlo wrinkles and dodges which long 
experience has taught the successful worker are here analysed 
and set forth in simple formulae and exact directions such as 
help the beginner and serve as a useful reminder to the expert. 
Development, toning, fixing, printing, the various processes 
of production in warm tones and colours and the methods of 
dealing with errors of technique are explained, particular 
attention being directed in the 1914 edition to green and blue 
toning and the production of various colours by development 
and other methods. On the subject of exposure this book is 
the last word, containing in addition to its light tables for 
each month and factors for plates and films, the special device 
attached to the cover which tells the correct exposure at one 
turn of the disc. Much discussion has taken place as to the best 
method of calculating exposure, but there is no doubt on the 



462 Periscope. 

subject if you talk to a man who has used the " Wellcome " 
Exposure Calculator. As one such photographer put it, 
paraphrasing an old proverb, " The proof of the exposure is 
in the negative." Three editions of the '' Wellcome " Photo- 
graphic Exposure Record and Diary are published, one for 
the Northern Hemisphere, one for the Southern, and the third, 
a special edition, for the United States of America. The 
" Wellcome " Exposure Record may be obtained from all 
photographic dealers and booksellers, and at all railway 
bookstalls. Price in the Britsh Isles — One Shilling. 

LITERARY NOTE. 

We have received the October number of Lewis's Quarterly 
List of New Books and New Editions added to the Medical 
and Scientific Circulating Library. It contains the books 
which have been published and added to the Library during 
the months of July, August, and September. These are not 
the busiest months for the publisher, and consequently the 
list does not contain quite so many important works as usual. 
Amongst the new books we notice Gordon's Hyde Lecture on 
" The Place of Climatology in Medicine," and Lees' Bradshaw 
Lecture on " Incipient Pulmonary Tuberculosis," also 
*' Diseases of the Stomach," by G. R. Lockwood, Poynton 
and Paine's "Researches on Rheumatism." Amongst the new 
editions of well known books may be mentioned the new 
Gray's " Anatomy," Muir and Ritchie's " Bacteriology," a 
new Binnie's " Operative Surgery" — the sixth, containing 
upwards of 100 new illustrations ; Halliburton's " Physiology," 
&c. Short notices are given to the more important liooks, 
and the list forms a useful guide to the scientific publications 
for the period covered. 

SHRIMPS FROM SALT. 

The strangest entry in the list of new arrivals at the London 
Zoo ap])ears against a collection of Brine Shrimps {Arifwin) 
which, it is stated, were " brod from Tidman's Sea Salt. ' 
This may look like a case of spontaneous generation ; but Mr. 
J. T. Cunningham, who bred the shrim]is, told a representative 
of the Press that the ox]ilanation was sim])leand quite scientific. 
The sea salt is obtained by evaporation, and the minute 
shrimps' eggs that were in the salt water, though dritxl, arc still 



New Preparations and Scientific Inventions. 463 

fertile when^theyjfindjtheir wayfintothe packets with the salt. 
They will remain fertile for a considerable time, and it is only 
necessary to make a solution of the salt of a certain strength, 
and leave it in a warm place until the eggs are hatched and the 
shrimps are seen swimming about in the water. It should be 
emphasised that there need be no fear by users of this salt of 
their finding themselves bathing among shrimps ; the time 
required to hatch them is far longer than any one would care 
to spend in the bathroom. 



NEW PREPARATIONS AND SCIENTIFIC INVENTIONS. 

Cystopurin. 

Messrs. A. Wulfing & Co., 12 Chenies Street, London, W.C, 
have recently introduced under this name a new and effective 
drug, the use of which is indicated in all bacterial affections of 
the urinary tract. Cystopurin is a double salt of hexa- 
methylene-tetramine and sodium acetate, with water of 
crystallisation. Its formula is (CH2)6 Nj — 2CH3. COONa — 
6H2O. In addition to its disinfectant properties, cystopurin 
also exerts a noteworthy diuretic action. Its prolonged use in 
bacteriuria is attended with most beneficial results, and it 
exercises a distinctly sedative action on the urinary tract. 
The sodium acetate in this preparation is a complete innovation, 
and because of its presence the product is able to exert a 
specific action in ammoniacal, alkaline or neutral urine. The 
action of cystopurin is therefore that of hexa methylene - 
tetramine, considerably fortified. By its combination with 
sodium acetate, which is partially or wholly converted into 
sodium carbonate in the body, cystopurin changes the consti- 
tution of the urine and exerts its specific action on the urinary 
tract. It produces a more copious diuresis than hexamethy- 
lene-tetramine, or than other combinations of this salt which 
have been hitherto employed. It is indicated in all affections 
of the urinary tract, embraced by the terms cystitis, pyelitis 
and pyelonephritis. Rapid improvement is noted in chi'onic 
catarrh due to hj'pertrophy of the prostate and tight old- 
standing strictures. Cystopurin plays a special i)art in the 
treatment of gonorrhoea , whether acute or chronic . Cystopurin 
is put up in tablets of 1 gramme, each containing 5 grains of 



464 New Preparations and Scientific Inventions. 

hexamethyleneitetramine. It is sold in phials of 20 tablets 
each. The tablets are readily soluble in water, and the 
solution has a pleasant, slightly saline taste. It is neither 
necessary nor advisable to take a large quantity of water with 
this drug. For adults two tablets three times a day are 
usually adequate. 

" Tabloid " Adjustable Head Dressing (Large Size). 

As a means of fixing dressmgs on the head, the " Tabloid " 
Adjustable Head Dressing, originated and introduced by 
Messrs. Burroughs Wellcome & Co., makes the roller bandage 
an anachronism. This dressing, which is now issued in a large 
size, has been devised for use as a covering in circumstances 
where the primary dressings are of considerable size. It 
consists of a cap, split at one side to render it adjustable, and 
having a back-piece covering the na2)e of the neck. To the 
cap a bandage is attached, while the back-piece carries tapes. 
A pad of double cyanide gauze and a safety pin are enclosed 
with the head dressing for use in first-aid cases. The large size 
" Tabloid " Adjustable Head Dressing is apphed simply by 
shipping the cap over the head, and passing the bandage 
portion round the back of the head, across the forehead, and 
back again to the starting point, where it is fixed with a safety 
pin. The tapes attached to the back-piece are tied under the 
chin, so allowing the bulky dressings to be covered in and 
secured. For use in operations on the eye, ear, nose and 
throat, '* Tabloid " Adjustable Head Dressing, large size, 
allords great advantages over enveloping the head with a 
towel, which is insecure and uncomfortable for the patient 
and, from its bulk, apt to get in the way of the surgeon and to 
be displaced. It also affords a ready means of covering the 
head iia the treatment of ringworm, favus, impetiginous con- 
ditions of the scalp and so forth. Numerous apphcations will 
readily occur to anyone using it. The larger size of " Tabloid " 
Adjustable Head Dressing, fike the smaller, is compressed, and 
the whole package is small enough to go easily into the watch 
pocket. 



INDEX 

TO THE 

ONE HUNDRED AND THlKTY-SlXTfl VOLUME, 



Abel's laboratory handbook of bacterio- 
logy, translated by M. H. Gordon, 
with additions by Dr. Houston, Rev., 
42. 

Actino-bacillosis, Professor Mettam on, 
217. 

Adler, J., primary malignant growths 
of the lungs and bronchi, Rev., 127. 

Allan, R.M., clinical report of the 
Rotunda Hospital from Nov. 1, 1911, 
to Oct. 31, 1912, 1, 51, 81. 

American Pediatric Society, trans- 
actions of the 23rd session and 24th 
session, edited by T. Edford La 
Fetra, Rev., 48. 

American tariff, new, 378. 

Amyloid disease, organs from a case of. 
Sir J. W. Moore on, 209. 

Aneurysm, innominate, Dr. Parsons on, 
215. 

Aneurysm, thoracic, ruptured. Dr. 
Box well on, 215. 

Apenta water in West Africa, 158. 

Armstrong, H.G., a manual of infectious 
diseases occurring in schools. Rev., 
195. 

Auerbach, Dr. S., headache, its varie- 
ties, their nature, recognition and 
treatment. Rev., 39. 

Babies : a book for maternity nurses, 

M. French, Rev., 56. 
Baby, Our, for mothers and nurses, 

Mrs. T. Hewer, Rev., 55. 
Bacteria and blood parasites, diagnosis 

of, E. P. Minett, Rev., 41. 
Bacteriology, manual of, R. Muir and 

J. Ritchie, Rev., 275. 
Bacteriology, practical, blood work and 

animal parasitology, E. R. Stitt, 

Rev., 439. 
Barbour, A. H. F., gynecological 

diagnosis and pathology, Rev., 353 
Barry, Professor D. J., on the spinal 

cord in relation to the respiratory 

nervous mechanism, 64. 



Batten, F. E., editor of diseases of 
children, by various authors. Rev., 
114. 

Bedside manner, the latest, 148. 

Berkeley, C, the difficulties and 
emergencies of obstetrics. Rev., 261. 

Birt, M. E,, invahd and convalescent 
cookery. Rev., 118. 

Blood-pressure from the clinical stand- 
point, F. A. Faught, Rev., 442. 

Bonney, V., the difficulties and emer- 
gencies of obstetric practice. Rev., 
261. 

Bourne, A. W., synopsis of midwifery. 
Rev., 351. 

Boxwell, Dr., on tubercle of the cere- 
bellum, 212. 

Brickdale, F. A., manual of infectious 
diseases occurring in schools. Rev., 
195. 

British Journal of Surgery, 460. 

Bury, J. S., clinical medicine. Rev., 115. 



Campbell, W. F., the surgical diseases 

of children. Rev., 264. 
Cancer research in Denmark, 312. 
Cerebellum, tubercle of the. Dr. Box- 

weU on, 211. 
Chavasse's, Dr., advice to a mother on 

the management of her children. 

Revised by T. D. Lister, Rev., 263. 
Children, diseases of, B. K. Rachford, 

Rev., 270. 
Childien, diseases of, by various 

authors, edited by A. Gar rod, F. E. 

Batten, and H. Thursfield, Rev., 144. 
Christian Science, a ploii for the 

thorough and unbiased investigation 

of, by an enquirer. Rev., 259. 
Chundra, J. L., laws of sexual philo- 
sophy, Rev., 129. 
Clavicle, right, case of puncture wound 

over, H. Stokes on, 251. 
Clinical diagnosis, C. P. Emerson on, 

Rev., 125. 



466 



Index., 



Congenital cystic kidneys, Dr. H. 

Stokes on, 217. 
Congenital cystic kidneys, Dr. O'Farrell 

on, 217 
Congenital cystic kidney from a calf, 

Professor Mcttam on, 217. 
Cookery, invalid and convalescent, 

M. E. Birt, Rev., 118. 
Crawford, Dr., on tumour of the 

mesentery, 216. 
Creatin, formation of, in the animal 

body, Professor W. H. Thompson on, 

63. 
Cripps, H., cancer of the rectum, its 

surgical treatment, Rev., 443. 
Cripps, H., diseases of the rectum and 

anus. Rev., 443. 
Cystic tumour, congenital. Dr. vS. 

SheiU on, 57. 
Cystopurin, 463. 

Diseases, infectious, a manual of, H. G. 

Armstrong and F. Brickdale, Rev., 

195. 
Diseases of the mouth. Professor F. 

Zinsser, translated and edited by 

J. B. Stein, Rev., 205. 
Dor man, W. J., transactions of the 

American Gynaecological Society, 

Vol. XXXVI., Rev., 438. 
Drew, G. A., a laboratory manual of 

invertebrate zoology. Rev., 347. 
Dropsy, pathology and treatment of, 

Dr. W. Smith on, 448, and 395. 
Dublin University Calendar for the 

year 1913-1914, to which are added 

the ordinary papers set in the year 

1912-13, Vol. I., Rev., 346. 
Dublin University Calendar, Vol. III., 

Rev., 38. 
Dudley, E. C, editor of the practical 

medicine series, Rev., 268. 
Dysentery, treatment of by injections 

of emetine hydrochloride, J. H. C. 

Thompson on, 102. 

Ehrlich's aldehyde reaction in hepatic 

congestion, 357. 
Electrocardiography, clinical, T. Lewis, 

Rev., 128. 
Embryology, human, manual of, edited 

by F. Kcibel and F. Mall, Rev., 113. 
Emerson, C. P., essentials of medicine, 

Rev., 124 ; and clinical diagnosis, 

Rev., 125. 
Endocarditis, malignant, Dr. T. G. 

Moorhoad on, 216. 
Enteric fever, two unusual cases of, 

Sir J. W. Mooro on, 66. 



Epilepsy, idiopathic, in children, the 
recognition and treatment of, J. N. 
Greene Nolan on, 92. 

Epilepsy, value of luminal and crotalin 
in, 355. 

Ergot and its preparations, 233. 

Examinations, examiners and exami- 
nees, Sir W. Osier on, 313. 

Exhibit at the International Congress 
of Medicine, 237. 

Eye, diseases and injuries of the, W. Y. 
Sym, Rev., 272. 

Eye, diseases of the, G. E. de Schweinitz, 
Rev., 272. 

Faught, F. A., blood- pressure from the 

clinical standpoint. Rev., 442. 
Fernie, W. T., Our Outsides, and what 

they betoken, Rev., 348. 
Fetra, L. Edford La, editor of trans- 
actions of the American Pediatric 
Society, 23rd and 24th session, 
■ Rev., 48. 

FitzWilliams, D. C. L., manual of 
operative surgery with surgical 
anatomy and surface marking. Rev., 
265. 
Foerster, A., translator of a text- book 
on gonorrhoea and its complications, 
Rev., 350. 
Food and Feeding in health and disease, 

C. Watson, Rev., 36. 
Foot and mouth disease in man, 

C. M. O'Brien on, 28. 
Forensic medicine and toxicology, C. O. 

Hawthorne, Rev., 200. 
Fox, R. F., the principles and practice 

of medical hydrology, Rev., 266. 
Eraser, E., a manual of immunity for 
students and practitioners. Rev., 47. 
French, M., Babies : a book for mater- 
nity nurses. Rev., 56. 

Garrod, A., editor of diseases of children, 
by various authors. Rev., 114. 

Gibson, Dr. M. J., on gynajcological 
urology, 414. 

Glandos surrenalos ot organes 
chromaffines, M. Lucion and J. 
Parisot, Rev., 267. 

Gonorrhoea and its complications, a 
text- book on, Dr. G. Luys, trans- 
lated by A. Foerster, Rev., 360. 

Gonorrhoea in woman, C. Norris, Rev., 
349. 

Gordon, M. IL, translator of Abel's 
laboratory handbook of bacteriology, 
Rev., 42. 



Index. 



467 



Gout : its aetiology, pathology and 

treatment, J. Lindsay, Rev., 42. 
Grant, Capt. M. F. , hints for regimental 

medical officers of the Territorial 

Force, Rev., 137. 
Gynaecological diagnosis and pathology, 

A. H. F. Barbour and B. P. Watson, 

Rev., 353. 
Gynaecological Society, American, 

transactions of the, Vol. XXX VL., 

W. J. Dornan, Rev., 438. 
Gynaecology, Student's Handbook of, 

G. E. Herman, with additions by 

R. D. Maxwell, Rev. 435. 
Gynaecological urology. Dr. M. J. Gibson 

on, 414. 



Hamman, L., tuberculin in diagnosis 

and treatment. Rev., 116. 
Harrison, Major, a manual of venereal 

diseases, Rev., 121. 
Hart, D. B., guide to midwifery. Rev., 

44. 
Hawthorne, C. 0., forensic medicine 

and toxicology, Rev., 200. 
Hayes, M., on a:-ray diagnosis of 

abnormalities of the intestinal tract, 

143. 
Headache, its varieties, their nature, 

recognition and treatment, Dr. S. 

Auerbach, translated by E. Playfair, 

Rev., 39. 
Health, Public, in Ireland, laws relating 

to, G. T. B. Vanston, Rev., 110. 
Health resorts of the British Islands, 

edited by N. Wood, Rev., 266. 
Heape, W., sex antagonism. Rev., 50. 
Helmitol Tablets (Bayer), 239. 
Hepatic function, tests for, 357. 
Herman, G. E., diseases of women. 

Rev., 208. 
Herman, G. E., the student's handbook 

of gynaecology, Rev., 435. 
Hewer, Mrs. L., Our Baby, Rev., 55. 
Hindhede, Dr. M., protein and nutri- 
tion. Rev., 343. 
Histology, normal, a course in, Part II., 

R. Krause, translated by J. R. 

Schmahl, Rev., 433. 
Histology, normal, a course in, R. 

Krause, translated by P. J. R. 

Schmahl, Rev., 118. 
Horn, Dr., report on certain out- 
breaks of yellow fever in West Africa, 

1910-1911, Rev., 46. 
Hornsby, J. A., the modern hospital, 

Rev., 206. 
Hornsey, G. W. C, on tho every- day 



application of certain preparations 

of spleen, pancreas, &c., 253. 
Hospital, modern, J. A. Hornsby and 

R. E. Schmidt, Rev., 206. 
Hurry, J. B., vicious circles in disease, 

Rev., 41. 
Hydrology, medical, the principals and 

practice of, R. F. Fox, Rev., 266. 
Hygiene, elementary, lessons on, W. T 

Prout, Rev., 55. 
Hyperthyroidism, polo ligation for, Mr. 

W. Pearson on, 19, 138. 

Immunity, a manual of, for students 

and practitioners, E. Eraser, Rev., 47. 
Infants, breast feeding of. Dr. E. Webb 

on, 147. 
International Congress (Third) of 

occupational diseases, 159. 
Intestinal stasis, some cases of, W. I. de 

C. Wheeler on, 141. 
Ionic medication, the principles of the 

method, by L. Jones, Rev., 436. 
Irish medical student, diary of an, 1831, 

1837, edited with notes by T. P. C. 

Kirkpatrick, 360. 

Jellett, H. M., Clinical Report of the 
Rotunda Hospital from Nov. 1, 1911, 
to Oct. 31, 1912, 1, 58, 81. 

Johnstone, R. W., a text-book of 
midwifery for students and practi- 
tioners. Rev., 441. 

Jones, L., ionic medication, the prin- 
ciples of the method. Rev., 436. 

Keibol, F., editor of manual of human 
embryology, Rev., 113. 

" Kepler " malt extract with glycero- 
phosphates, 392. 

Kerr, Le Grand, the surgical diseases of 
children. Rev., 264. 

Kirkpatrick, T. P. ('., on the diary of 
an Irish medical student, 1831-1837, 
360. 

Krause, R., a course in normal histo- 
logy. Rev., 118. 

Krause, R., a course in normal histo- 
logy, translated by P. J. R. Schmahl, 
Rev., 433. 

Labour, some sequelae of, Dr. B. 

Solomons on, 144, 180. 
Larynx, carcinoma of the, Dr. Stokes 

on, 211. 
Lee, B. de J., the principles and practice 

of obstetrics. Rev., 44. 
Lett wick, R. W., tabular diagnosis, 

Rev., 351. 



468 



Index. 



Lewis's pocket case book, 50. 

Lewis, T., clinical electrocardiography, 
Rev., 128. 

Lindsay, J., gout, its aetiology, patho- 
logy and treatment. Rev., 42. 

Lister, T. D., re visor of Dr. Chavasse's 
advice to a mother on the manage- 
ment of her children. Rev., 263. 

Liston Victoria Jubilee Prize, 359. 

Literary intelligence, 159, 449. 

Literary notes, 80, 158, 194, 276, 462. 

Liver function, tests for, Dr. Nesbitt on, 
67, 327. 

Lucien, M., glandes surrenales et 
organes chromaffines. Rev., 257. 

Luys, Dr. G., a text- book on gonorrhoea 
and its complications. Rev., 350. 

Lyth, E. 11., influence of thermal 
environment on the circulation and 
the body heat. Rev., 119. 



Madill, D. G., the clinical report of the 

Rotunda Hospital, 1, 51, 81. 
Malignant growths, ])rimary, of the 

lungs and bronchi, J. Adler, Rev., 127. 
Malins, G. H., surgical experiences in 

South Africa, 1899-1900, Rev., 271. 
Mall, F. P., editor of manual of human 

embryology, Rev. 113. 
Management of children in health and 

in disease, book for mothers, A. M. 

Usher, introduction by F. B. Rutter 

Rev., 438. 
Manual of medical treatment T. Burney 

Yeo, Rev., 440. 
M'Ardlc, J. S., on hour-glass contraction 

of the stomach, 393. 
Marriage, the healthy, G. T. Wrench, 

Rev., 264. 
Mayer, T. F. G., West Africa, re])ort on 

certain outbreaks of yellow fever in 

1910 and 1911, Rev., 46. 
McDow(01, Dr. K., " Father of Ovario- 
tomy," A. Sehachner, liriK, 201. 
Medical education and examinations in 

Ireland, 1 91 3-191 4, 293. 
Medical inspection of school children, 

Sir Wm. J. Thompson on, 1(51. 
Medical Museum, Historical, handbook 

of, organised by H. S. Welcome, 

Rev., 120. 
Medicine, clinical, edited by J. S. Bury 

and A. Ramsbottom, Rev., 115. 
Medicine, essentials of, C. P. Emerson, 

Rev., 125. 
Medicine, practical, contributions to, 

Sir J. Sawyer, Rev., 34. 



Medicine, report on, T. G. Moorhead on, 
354. 

Medicine Series, Practical, under the 
general editorial charge of C. L. Mix, 
edited by E. C. Dudley and H. M. 
Stowe, Vol. IV., Rev., 268. 

Merck, Dr. L., 290. 

Merck's, E., annual report of recent 
advances in pharmaceutical chemis- 
try and thera])eutics, 1912, Vol. 
X'XVL, Rev., 347. 

Mesentery, tumour of the, Dr. Craw- 
ford on, 216. 

Metabolism, regulators of, D. N. Paton, 
Rev., 434. 

Mettam, Professor, on congenital cystic 
kidney from a calf, 217 ; actino- 
bacillosis, 217. 

Midwifery, a text- book of, for students 
and practitioners, R. W. Johnstone, 
Rev., 441. 

Midwifery, guide to, D. Berry Hart, 
Rev., 

Midwifery, synopsis of, by A. W. 
Bourns, Rev., 351. 

Milk question, the, M. J. Rosonau, Rev., 
201. 

Minett, E. P., diagnosis of bacteria and 
blood parasites, Rev., 41. 

Moore, Sir John Wm., sanitary and 
meteorological notes, 75, 149, 154, 
218, 223, 228, 277, 282, 381, 38(5. 450 ; 
two unusual cases of enteric fever, (5(5 : 
organs from a case of amyloid 
disease, 209. 

Moorhead, T. G., on malignant endo- 
carditis, 216; some scat t(ired remarks 
on stomach eases, 243 ; report on 
Medicine, 354. 

Motjicr, the pros])eetive, by J. M. 
Slemons, Rev., 208. 

Muir, R., manual of bacteriology, Rev.. 
275. 

Murphy, J. K., editor of the practi- 
tioner's encyclopa^lia of medicine 
and surgerv in all their branches. 
Rev., 200. 

Myocardial degenerations in various 
intoxications, 358. 



" Nauheim " treatment of diseases of 
the heart and circulation. L. Thorne- 
Thorne, Rev., 40. 

Nesbitt, Dr., on tests for liver 
ftinction, 67, 327. 

New preparations and scientific inven- 
tions, 239. 240, 292, 302, 463. 



Index. 



469 



Nolan, J. N. G., on the recognition and 
treatment of true idiopathic epilepsy 
in children, 92. 

Norris, C, gonorrhoea in woman, 
Rev., 349. 



O'Brien, C. M., on foot and mouth 

disease in man, 28. 
Obstetric aphorisms for the use of 

students commencing midwifery 

practice, T. G. Swayne, edited and 

revised by W. C. Swayne, Rev., 269. 
Obstetric practice, the difficulties and 

emergencies of, C. Berkeley and V. 

Bonney, Rev., 261. 
Obstetrics, the principles and practice 

of, J. B. de Lee, Rev., 44. 
O'Farrell, Dr. T T., on congenital 

cystic kidneys, 217. 
O'Kelly, Dr. W. D., on congenital 

sacral tumours, 214. 
Osier, Sir W., on examinations, 

examiners and examinees, 313. 
Outsides, Our, and what they betoken, 

W. T. Fernie, Rev., 348. 



Parisot, J., glandes surrenales et 

organes chromaffines. Rev., 257. 
Parsons, Dr. A., on innominate 

aneurysm, 215. 
Paterson, H. J., the surgery of the 

stomach, a handbook of diagnosis 

and treatment. Rev., 437. 
Paton, D. Noel, the nervous and 

chemical regulators of metabolism, 

lecture. Rev., 434. 
Pearson, Wm., on pole ligation for 

hyperthyroidism, 19, 138. 
Periscope, 50, 80, 109, 148, 158, 159, 

160, 194, 233, 237, 256, 276, 287, 291, 

312, 341, 359, 378, 380, 391, 392, 460. 
Petrol as a therapeutic agent, G. A. 

Stephens on, 429. 
Physiological criteria for medicinal 

substances, 235. 
Pineal body, tumour of the, 358. 
Playfair, E., translator of headache, 

its varieties, their nature, recognition 

and treatment, by Dr. S. Auerbach, 

Rev., 39. 
Pneumonia, ante-mortem thrombosis in, 

356. 
Poisoning, cedar, oil of, 256. 
Poliomyelitis, epidemic, J. A. Ponton 

on, 189. 
Ponton, J. A., on epidemic poliomye- 
litis, 189. 



Practitioner's encyclopaedia of medi- 
cine and surgery in all their branches, 
edited by J. K. Murphy, Rev., 200. 

Preventive medicine and hygiene, 
M. J. Rosenau, Rev., 444. 

Prostatectomy in the aged, 256. 

Protein and nutrition. Dr. M. Hindhede, 
Rev., 343. 

Prout, W. T., lessons on elementary 
hygiene and sanitation with special 
reference to the tropics. Rev., 55. 

Public Health in Ireland, the law relating 
to, 80. 

Public Health in Ireland, law relating to, 
G. T. B. Vanston, Rev., 110. 



Quarterly returns of marriages, births 
and deaths, registered in Ireland 
during the year 1911, Rev., 196. 

Queensland, North, tropical, 291. 



Rachford, B. K., diseases of children, 

Rev., 270. 
Ramsbottom, A., editor of clinical 

medicine. Rev., 115. 
Rectum and anus, diseases of the, H. 

Cripps, Rev., 443. 
Rectum, cancer of the, a short com- 
munication on, Wm. Taylor on, 335. 
Rectum, cancer of the, its surgical 

treatment, H. Cripps, Rev., 443. 
Regimental officers of the Territorial 

Force, hints for, Capt. M. F. Grant, 

Rev., 137. 
Remedies, new and non-official, 1913, 

Rev., 43. 
Rheumatism, acute, use of salicylates 

in, 354. 
Ritchie, J., manual of bacteriology. 

Rev., 275. 
Rosenau, M. J., preventive medicine 

and hygiene. Rev., 44. 
Rosenau, M. J., the milk question 

Rev., 261. 
Rotunda Hospital, clinical report of, 

for one year, Nov. 1, 1911, to Oct. 

31, 1912, H. Jcllett, D. Madill and 

M. Allan on, 1, 58, 81. 
Rotunda Hospital, pathological report 

of the, for one year, Nov. 1, 1911, to 

Oct., 31, 1912, R. Rowletto on 

173, 213. 
Rowlette, R., on Rotunda Hospital, 

pathological report for one year, 

Nov. 1, 1911, to Oct. 31, 1912, 173, 

213. 



470 



fndez. 



Royal Academy of Medicine in Ireland, 
57, 138, 209-217, 448. 

Royal College of Physicians of Edin- 
burgh, 391. 

Royal College of Physicians of Ireland, 
379. 

Royal College of Surgeons of Edinburgh, 
lao, 380. 

Royal College of Surgeons in Ireland, 
445. 

Rutter, F. B., introduction to book for 
mothers on the management of 
children in health and in disease, 
A. M. Usher, Rev., 438. 



Sacral tumours, congenital, Dr. W. D. 

O'Kolly, 214. 
Salvarsan, death from intravenous 

injection of. Rev., 289. 
Sanatorium scaremongers in Dublin, 

288. 
Sanitary and meteorological notes, Sir 

John Wm. Moore on, 75, 76, 149, 154, 

218, 223, 228, 277, 282, 381, 380, 450. 
Sawyer, Sir J., contributions to practi- 
cal medicine. Rev., 342. 
Schachner, A., Dr. E. McDowell, his 

life and work. Rev., 201. 
Schmahl, P. J. R., tjanslator of a 

course in normal histology, Rev., 118. 
Schmahl, P. J. R., translator of " a 

course in normal histology," part 2, 

by R. Krauso, Rev., 433.^^ 
Schmidt, R. -E., the modern hospital, 

J. A. Hornsby and R. Schmidt, 

Rev., 206. 
Schweinitz, G., E. de, recent works on 

diseases of the eye. Rev., 272. 
Sex antagonism, W. Hoape, Rev., 50. 
Sexual y)hilosophv, laws of, J. L. 

Chundra, Rev., 129. 
Sheill, Spencer, Dr., on congenital 

cystic tumour, 57. 
Shrimps from salt, 462. 
Slemons. J. M., the prospective mother. 

Rev., 208. 
Small-pox, how to diagnose, W. 

M'Wanklyn, Rev., 202. 
Smith, Dr. W. G., on the pathology of 

cpdoma and dropsy, chiefly in relation 

to colloids, 3!)."), 448. 
Solomons, Dr. B., on some seqm la> of 

labour, 144, 180. 
Spinal cord in relation to the respiratory 

nervous mechanism, Professor D. J. 

Barry on, 64. 
Spleen, pancreas, &c., every day 



application of certain preparations 
of, G. W. Carnrick Homsey on, 253. 

Sputum, the significance of the presence 
of albumen in, 355. 

Stein, J. B., editor of diseases of the 
mouth, syphilis and similar disea-ses. 
Rev., 205. 

Stephens, G. A., on petrol as a thera- 
peutic agent, 429. 

Stitt, E. R., practical bacteriologj' 
blood work and animal parasitology, 
Rev., 439. 

Stokes, Dr. H., on carcinoma of the 
larynx, 211 ; congenital cystic 
kidneys, 217; a case of puncture 
wound over right clavicle causing 
loss of pulsation in arteries of arm, 
251. 

Stomach cases, 'some scattered remarks 
on, T. Gill man Moorhead on, 243. 

Stomach, hour-glass contractions of 
the, Professor M'Ardle on. 393. 

Stomach, surgery of the, H. J. Paterson, 
Rev., 437. 

Stowe, H. M., editor of the Practical 
Medicine Series, Rev., 268. 

Sumbul, the use of, 109. 

Surgery, operative, with surgical ana- 
tomy and surface markings, D. C. L. 
FitzWilliams, Rev., 265. 

Surgical diseases of children, W. F. 
Campbell and Le Grand Kerr, Rev., 
264. 

Surgical experiences in South Africa. 
1899, 1900, G. H. Malins, Rev., 271. 

Swayne, VV. C, editor of obstetric 
aphorisms for the use of students 
commencing midwifery practice. 
Rev., 269. 

Sym, G., diseases and injuries of the 
eye, Rev., 272. 

Synthetic hydrastinino hydrochloride 
(Bayer), 240. 

Syphilis of the heart, 355. 



" Tabloid," adjustable head dressing 

(largo size), 464. 
Tabular diagnosis, R. W. Leftwick, 

Rcr., 351. 
Taylor, Wm., on a short communication 

on cancer of the rectum, 335. 
Thermal ('uvironment, influrnce of, on 

the circulation and body heat, 

E. R. Lyth, Rev., 119. 
Thom])son, .1. H. C, on the treatment 

of dysentery by injections of emetine 

hydrochloride, 102. 



Index. 



471 



Thompson, Professor W. H., on the 

formation of creatin in the animal 

body ; effects of administering arginin 

with betain and cholin, 64. 
Thompson, Sir William J., on medical 

inspection of school children, 161. 
Thorno-Thorne, L., the " Nauheim " 

treatment of diseases of the heart and 

circulation. Rev., 40. 
Thrombosis in pneumonia, ante-mortem, 

356. 
Thursfield, H., editor of diseases of 

children, by various authors. Rev. 

114. 
Tuberculin in diagnosis and treatment, 

L. Hamman and S. Wolman, Rev., 

116. 
Tuberculosis of the bones and joints, 

type of bacillus in, 341. 
Tuberculosis of the urinary tract, 460. 
Tuberculosis, prevalence of rain-bearing 

winds, 359. 

Usher, A. M., books for mothers on the 
management of children in health 
and in disease , with introduction by 
F. B. Rutter, Rev., 438. 

Vanston, G. T. B., the law relating to 
public health in Ireland, Rev., 110. 

Venereal diseases, a manual of, second 
edition, by Major Harrison, Rev., 121. 

Vicious circles in disease, J. B. Hurry, 
Rev., 41. 

Wanklyn, W. M'C, how to diagnose 

small-pox, Rev., 202. 
Watson, B. P., gynaecological diagnosis 

and pathology, Rev., 353. 



Watson, C, food and feeding in health 

and disease. Rev., 36. 
Webb, Dr. E., on breast-feeding of in- 
fants, 147. 
Wellcome, H. S., organiser of handbook 

of the historical medical museum, 

Rev., 120. 
" Wellcome," photographic exposure 

record and diary, 1914, 461. 
Wheeler, W. I. de C, on some cases of 

intestinal stasis, 141. 
Wolman, S., tuberculin in diagnosis and 

treatment. Rev., 116. 
Women, diseases of, G. E. Herman, 

Rev., 208. 
Wood, N., editor of health resorts of 

the British Islands, Rev., 266. 
Wrench, G. T., the healthy marriage, 

Rev., 264. 



X-ray diagnosis of abnormalities of the 
intestinal tract, Dr. M. Hayes on, 143. 



Yellow fever, report on certain out- 
breaks of, in West Africa in 1910- 
1911, Drs. Horn and Mayer, 1913, 



Rev., 46. 
Yeo, T. B. 
treatment 
Rev., 440. 



a manual of medical 
or clinical therapeutics. 



Zinsser, Professor D. F., diseases of the 

mouth. Rev., 205. 
Zoology, invertebrate, a laboratory 

manual of, G. A. Drew, Rev., 347. 



Printed by John Falconbr, 53 Upper Sackville Street, Dublin. 



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is an efficient, non^toxic 
AN TiShPTlC of known and definite power, 
prepared in a form convenient for immediate use 

It it a saturated solution of boric acid, reinforced 
by the antiseptic properties of ozoniferous oils* 

It \m unirritating, even when 
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It docs not coagulate serous 
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It is quite generally accepted as 
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for use where a poisonous or corro* 
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used. 

It is particularly useful in the 
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Diseases of Children 



W. T. Watt, M. D., Di- 
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weakens and debilitates a 
child rapidly, I have found 
Valentine's Meat- Juice a