Showing papers in "BMJ in 1907"

A Report ON CLINICAL EXPERIENCES WITH SPINAL ANALGESIA IN 100 CASES, AND SOME REFLECTIONS ON THE PROCEDURE.

Abstract: I. CLINICAL. AT the outset of this communication I wish to disclaim all intention of advocating the immediate or general introduction of spinal analgesia. This essay is only intended to be a report on a series of 100 cases in which the procedure was employed tentatively during the last year the ordinary course of hospital study, with some flections on its many aspects. I have approached subject without any prepossessions and with a dueeense

Report c. an investigation on the regeneration of nerves, with regard to surgical treatment of certain paralysis.

Abstract: IN connexion with recent discussions on this subject, may I be permitted to state briefly the results of a considerable hoopital experience of some of the commoner varieties of this class of Injury, treated both by conservative and operative measures? Attempts at reduction have habitually been made under general anaesthesia at tbe earliest moment possible. In the femur, fractures of the shaft have been transverse, short oblique, or torsion (spiral) fractures.. The, reslt, by extension, etc., has been nearer perfection the more the fracture approached the transverse; In the latter the displacement is seldom marked, and the result consequently perfect in some of them. In the second class I have been astontshed at the difficulty and frequent impoesiblblty of reducing (and more so of maintaining reduction of) the longitudinal displacement by extension; this did not sonrpriseme, bowever, after experiencing the extreme difficultteo of doing so by open operation combined with extensiQn in many cases with apparently little shortening; as a consequencea useful, though not perfect, limb with a varying amount of shortening has usually resulted. The large majority of these fractures have been in cl¢lldren. With splral fractures my own experiences and those of others h%ve led me to the conclusion that never, by other than operative measures, can the fragments be placed or maintained in even approximately good position. Persistence in conservative methods has here usually led to shortening of aboout 1 In., often more, eversion, deformity, ap4 pain in varying degrees for as long as I have been able to watch the patients (over geveral months), involving frequently In the poor the necessity for seeking a less aetive occupation. In one or two cases the patient has perhaps been able to hobble with a stick or crutch at the end of three or four months, and these distressing tallures are not an uncommon sight in hospital practice, and possibly frequent In infirmaries. We have only to contrast a confident expectation, warranted by experience, of a perfect restoration of function with no shortening at all In ten weeks at the outside by operative measures; I will only mention a case of a spiral fracture with nearly 3 In. shortening after extension, who, after operation, was running upstairs under seven weeks later with no limp. Little need be said about conservative treatment In Pott's fracture, for the deplorable stiffnees, deformity, and inability to resvime active life, which result at least for several months, If not permanently, In so many cases, have led most surgeons to consider operation the method of choice in these Injuries. In fractures of the bones of the leg,;if transverse, lateral displacement can sometimes be reduced by manipulation; rarely is thls so with spiral fractures, especially if shortentng be at all marked. To summarize, convalescence In cases operated on has taken about half the time in fractures of the femur, and In fractures of tibia aud fibula about two thirds the time necessary for an inferior functional result in those treated conservatively; while aching, pain, and stiffness marked features in the convalescence of the latter class of case, is conspicuously absent throughout the whole treatment in cases operated on. Among fractures of the humerus I need only mention the rotatory, angular, and longitudinal displacements, delayed union, and paralysis due to interference with the functions of the brachial plexus and musculo-spiral nerve, which sometimes have resulted from conservative treatment (not necessarily from neglect of treatmwent), and compare ttieir imperfect or delayed functional recovery and painful convalescence, extending into months or years, with the moral certainty of complete functional recovery in siU to eight weeks when operated on at once. Secondary operations, necessitated by some of the above fatlures, have demonstrated clearly to me the greatly increased difficulties Involved in addition to a farther retarded period of convalescence. The prevention of these failures is always vastly preferable to the cure. Finally, in separation of the lower epiphysis. of the humerus, foitoiie fiexton has certainly sucoeeded in a few cases, and those not the wrorst; but, with .thes.e fewr exceptions, the only results wbich could justify our taking a pride In the patients have been attained by levering the lower fragment into position, without violenee, through a posterior incision, apposition being maintained by full flexion. By this method less renewed haemorrhage and swelllng is -caused, and the subsequent joint movements, taking all cases, is infinitely better. In conclusion, the risks of operation are summed up im sepsis only. I have never seen supppation result from operative interference in fractures, while as to the disadvantages of leaving plates, screws, wires, etc., In the bone,, I have come across no single instance In which any subsequent trouble has atsany time necessitated. the subsequent.removal of them. Such an operation, if necessary,. would, in any case, be the simplest procedure,

Functional albuminuria in athletes

Abstract: must be applied. This varies, of course, for each. fracture, but the guiding principle is the following: The splints are meant to retain the fractured ends of the bones in their proper position after they have been reduced and correctly fixed. They are not supposed to rectify an imperfectly-corrected displacement by either constantly forcing or pulling the bones into position. This. is a very important point. If the fractured ends have been more or less satisfactorily interlocked, very little pressure is required to keep them in position, and consequently a spliat may be put on so as to be comfortable to the patient without any special pressure being applied; that is to say, to -keep the bones in line and prevent the displacement from mechanical causes rather than to keep them forcibly, in, apposition and violently oppose muscular contraction. The question of massage in the after-treatment of fractures has been much discussed, and more or less general agreement has been come to. It is quite evident that the sooner movements and massage can be begun, the quicker will the function of the limb be restored so long as no displacement of the bones occurs during the manipulations. My own belief is that the fractured ends ought to be left quite still for eight or ten days after the injury, ,except in the case of fractures of the forearm where the fingers can be left out and moved from the first. By that time the bones will be more or less stuck together with fairly firm material, so that a certain amount of force would be necessary to displace them; and from that time onwards the splints may be taken off once or twice a day, and massage and careful active and passive movements of the neighbouring joints and muscles carried out so as to prevent the occurrence of stiffness. In most cases, provided the patient does not put any strain on the part, the splints may be left off entirely in from three to four weeks. I do not at all approve of treating fractures without any splints, or of looking on massage as a panacea of primary importance and reduction and retention as of quite minor value.

The part played by pediculus corporis in the transmission of relapsing fever.

Abstract: appoarance of the first symptoms of obstruction the temperature rose. Operation. On examination of the abdomen, whioh w#s still diste)nded and tender on pressure generally, a small area of distinctly treater tenderness was discovered in the left iliac region; it was distinctly dull on percussion. This suspicious area was closely watched during the next three, or four days, during which time it became visibly larger till it formed a somewhat oval putch measurlig about three inches in its long diameter. It was excwsssvely tender on palpation, pitted slightly on pressure, and the patient now referred most of hls pain to this region. Synchronous with this all the symptoms of acute obstruction returned. The vomiting became persistent, the vomited matter being almost black in colour. DlstressiDg hiccough supervened which nothing seemed to, relieve. The abdomen was rigid and much distended, and waves' of peristalsis could be seen through the abdominal wall, evidently indicative of an obstruction,fairly low down. The patient complained of pain acoompanying each act of micturition. Examination of the urine, however revealed nothing of sfgnificance. On rectal examination there was great tenderness, especially in the neighbourhood of the prostate, which, however, was not enlarged. The rectum was emply and much ballooned ; the temperature was 1000 and the pulse about 120, 'very small, and almost thready in character. A consultation was held, and it was decided to open the abdomen immediately in the left iliac region. An incision was accordingly made in the long axis of the dull area, and by carefully working deeper an abscess was opened into and about a teacupful of zetid pus evacuated, such as one finds in purulent appendicitis. 'As adhe6ions bad apparently formed shutting off the cavity it'was deemed inadvisable to attempt to explore further. The cavity was therefore washed out and a large drainage tuba iDserted. Advantage was also taken of the anaesthesia to make a more thorough4 examination of the iectum, but nothing pathological could be diecovered. The vomiting and hiccough parsisted at Intervals during the next few days, the latter being particularly distressing. The patient could get very little sleep, and was slightly delirious part of the time. He continued to suffer a good deal from shaTp spasms of abdominal pain, and there was still visible peristalsie. A fresh complication supervened in the shape ot a septic pericarditis, and the outlook for tbe pstient seemed very grave. The bowels became more and more loose, till there was persistent diarrhoea. The evacuations were very light, almost clay-czloured, and very offensive. The abdomen still remained distended and nearly immobile, and there was great tenderness, especially in the neighbourhood of the wound. Then gradually the severity of the symptoms began to abate. Vomiting and hiccough disappeared, and he was able to get better sleep. He continued, however, for some time to have frequent sharp spasms of pain, but these gradually disappeared also. The motions then became occasionally formed. and gradually the diarrhoea ceased, giving place to copious, fullyformed stools, which in time assumed a normal aspect. The wound was kept open for some time, and then allowed to heal up.

The evolution of the stethoscope

Abstract: PARIS. Professor Calmette of Lille on Early Diagnosis of Tubercle by Ophthalmo-reaction to Tuberculin.-X Bays fothe Detection of Tubercle as an Aid to Meat Inspection. [N the BRITISH MEDICAL JOURNAL of June 15th a summary was given of the experiments by M. Vallee (Alfort) in regard to the early diagnosis of tubercle in cattle by the \"cuti-reaction,\" or Inoculation of tuberculin on the 'scarified skin. Professor Calmette (Lille) has made experiments to see if the healthy mucous membranes, and especially the conjunctiva, would show an analogous reaction after contact with tuberculin. Professor Calmette, in a recent number of the Presse Mddicale, describes the first series of experiments which he has ~carried out in collaboration with his pupils, MM. Breton and G. Petit in the hospitals at Lille. The experiments were made on 25 patients (children and adults), of whom 16 suffered from taberculous and 9 from non-tuberculous affections. In order to avoid the irritating effects of glycerine on the conjunctiva they used exclusively dry tuberculin precipitated by alcohol at 950 in a 1 per cent. solution in sterilized distilled water. The solution was always freshly prepared, and one drop was placed in the conjunct'ival sac-in one case five hours after the instillation, in some cases even after three hours; all the tuberculous patients showed a very apparent congestion of the palpebral conjunctiva, which becam'e bright red, and was the seat of more or less intense oedema. The conjunctiva swelled, became red, and was covered with a slight fibrinous exudation. The injection of the blood vessels increased gradually, and was accompanied by secretion of tears. In six hours the fibrinous secretion became more abundant, and collected in filaments in the lower conjunctival sac. The reaction reached its maximum in six to ten hours. The patients felt no pain, but only a 'little discomfort with slight ,sensation of burning and some disturbance of vision in ratio to the abundance of the exudation. There was no ehemosis. The rectal temperature was not appreciably altered. The intensity of the reaction could easily be appreciated by comparison with the non-inoculated eye. The congestion gradually disappeared in children after .eighteen hours, and in adults in from twenty-four to thirty-six hours. In healthy persons or patients with non-tuberculous diseases the instillation of tuberculin produced, as a rale, no effect, but sometimes one to three hiours afterwards a slight redness was observed, which soon disappeared, and was not accompanied by either tbrinous secretion or-tears. The reaction was positive in 16 cases of pulmonary or pleuritic tubercle and in tuberculosis of bronchial ganglia. The reaction was negative in the following' cases: Sciatica and hysterical hemianaesthesia, Bright's disease, tabes with inco-ordination, lymphangitis with wound of the forearm, mitral and tricuspid incompetence, mental confusion, cerebro-bulbar 'sclerosis, influenza, acute rheumatism with mitral endo--carditis. This phenomenon, which Professor Calmette proposes to call the \"ophthalmo-reaction to tuberculinj\" appears to be very sensitive. It deserved to be studied, he thought, by clinicians because it was extremely easy to show; it appeared much sooner than the cati-reaction, which required forty-eight hours, and it caused no pain nor durable discomfort. It, moreover, did not appear 'to give rise to any of the drawbacks or dangers attending the injection of tuberculin under the skin. Professor Calmette hoped that by this method it would be possible to make a positive early diagnosis of tuberculous affections, and to prove the' definite cure of old tuberculous lesions. At a recent meeting of the socidt6 de Biologie, Dr. Maurice Letulle communicated the first results of his use of the ophthalmo-reaction of Calmette; 65 tuberculous cases all gave a positive reaction witih the exception of five, four of whom were very gravely affected or moribund. At a recent meeting of the AcadAmie des Sciences, MJ. H. Martel made a communication on the result of the inspection of tubercullous meat byradioscopy and';radiography. Cattle anld pigs had, he said, this peculiarity that thleir tuberqculous lesions were easily inlvaded by deposits of lime salts. Healthy ganglia onlys gave a slight shadow, while the tuberculous ganglia were projected in the form of a granular spot of greater or less extent, according to the degree of invasion. This method was valuable, as it enabled tuberculous foci to be discovered which were not even suepected in the absence of a previous tuberculin test on the living animal.

Merycism or rumination in man

Abstract: bone, downwards and slightly outwards along the lower margin of the orbit for about 3 cm. Such an incision will be on the inner side of the sac, and should go right ''down to the bone. The skin and subjacent structures are now reflected off the bone outwards until the lacrymal sac comes into view in the lacrymal groove. It may be recognized by its greyish-blue glistening appearance, but by adopting the above method of procedure it can hardly be missed. The sac is separated from the groove-first on the inner side, then on the outer side-by means of curved scissors and blunt dissector. Care must be taken to dissect the fundus carefully, so as not to injure the internal palpebral ligament-under which the sac extends for a little distance. When the upper part of the sac has been freed, it is drawn out with forceps and its lower attachments are divided with scissors, which are eventually passed down along the duct as far as possible and mad'e to cut across the duct. A free communication is established with the nose, and the mucous membrane of the duct is scraped with a sharp curette, or cauterized with thd electro-cautery. The bleeding during the operation is often troublesome, and it is well to inject some adrenalin and cocaine even when the operation is being performed under general anaesthesia. The use of efficient retractors, such as Axenfeld's, adds materially to the comfort of operating. After flushing the wound or duct into the nose, the incision is sewn up, and healing is almost .certain to take place by first intention. The stitches are removed on the third or fourth day. The line of the incision is hardly perceptible after a month or two. In my experience, there is practically no epiphora after excision of the sac except under some exceptional physical or psychical stimulation. The reason for this is that the previous epiphora being largely the result of excessive secretion due to reflex irritation from the sac and conjunctiva, the normal glandular secretion is not more than can be, removed by evaporation. Such being the case, I have never found it necessary to resort to excision of the lacrymal gland after excision of the sac. Should the epiphora exist, it would not be a menace to the function of the eye as is the epiphora of dacryocystitis; and should the epiphora be distressing to the patient, the lacrymal gland can be removed without in any way endangering the eye, whose surface will still be kept moist by the secretion'of the accessory lacrymal glands, and by the mucous secretion of the conjunctiva.

Bilateral lesion of the auditory cortical centre: complete deafness and aphasia

Abstract: begins at the anterior edge of the coronary vein, then passes forwai ds on the right aide of the auricular septum, telow the foremen ovale, lyin'g close on the auriculov('ntricular septum, which paeses obliquely from left above6to tight below. Just above the place of inEertion of th,e median flap of the tricuspid valve the bundle forms a special knot-like thickening which sends processes down on either aide of the ventricular septum under the endocardium,zemifying in the walls of both ventricles.6 The lard contains not only neive fibres but nerve ganglia, so that conducticn by muscle alone is as yet unproved. i rlanger and others have found that pinching this bundle in dogs increases lhe ventricular pause. A greater tightening of the clamp length* ns the pause till three or four or more auricular contiactiors occur for every one in the ventricle.' A cut through the bundle i's followed by complete diastoleof thevtntricle,andno stimulus can be made to paes from the auricle to the ventricle. What interests us more as pbysicians is that all cases cf true bradyeardia which have come to an autopsy since the band of His was discovered have shown extensive degenerative lesions in its structure.7 I would suggest, then, that tachyeardia Is a pure neurosis, characterized by a great increase *in auricular contractions from distuIbed nervous influences. After a time, from over-exertion, fatigue in the conductivity of the band of His occurs; missed impulses result, causing longer or ehorter delays in the ventricular contraction. When these delays are sufficiently prolonged, cerebral anaemia is caused, followed in due course by the nervous symptoms described. Tachyeardia being a neurosis, it is, like other neuroses, commonly recovered from. The condition may persist for years, and recovery may be complete, or relapses may take place from time to time. In bradycardia we cannot be so hopeful, the ventricular pauses being due to serious structural changes in the band of His. Sclerosis of the vessels, fatty degeneration of the fibres, and an abnormal increase of fibrous tissue in the bundle bave all been found. The condition is never recovered from, and the chances of sudden death from prolonged cessation of the v entricular contraction should not be forgot, en. Life in true bradyeardia, according to Balfour, is rarely prolonged for more than three or Iovr years. As regards treatment, ret, both physical and mental, so far as possible, is of greatest importance. In my case, strict confinement to bed prevented convulsive attacke. In another recorded case the patient \" dodged \" these when threatening by getting up in bed on his hands and knees, and keeping his head down. The head should be kept low, and the foot of the bed raiEed. Any deviation from health, such as indigestion, constipation, gout, iheumatism, etc., should be attended to. Massage also may be employed if the conditions allow. In tacbyeardia I have pushed bromides till bromidjsm was marked, without good results-rather the opposite. They certainly have no effect in controlling the fitg. Nerve tonics, such as valerianate or oxide of zinc, Eeemed to do good. The glycero phosphates or glycero-formates might be tried, but I have no experience of these in this connexion. Stryebnine or nux vomica, atropine or belladonna, and alcohol are better avoided. In bradyeardia strychnine hypodermically, with heart tonics such as digitalis or strophanthus, seem to have been of use. Osler records a case of recovery after treatment with iodide of potassium. With a better knowledge of the causes at work in producing both conditions, it is not too much to hope for more successful methods of treatment in the near futtre.

Remarks ON IDIOPATHIC DILATATION OF THE COLON

Abstract: or outside the bowel. The origin is mysterious. possible that these nine cases from St. Thomas's Hospital and some borrowed cases from other sources, together, may justify the belief that the condition ages arises through a congenital nervous defect. pathic dilatation and hypertrophy becomes then name for the disease. But the striking point to is the importance of an early diagnosis, because case there is a period, short or long, during which can be effected by surgical treatment. The life, in all these cases is precarious, and the final toxaemic stage sets in so rapidly and unexpectedly

Two new genera of nematodes occasionally parasitic in man.

Abstract: and intestinal haemorrhage were regarded as the result of tuberculous ulceration of the intestines, and probably of tuberculosis ,more or less generalized throughout the body. Tuberculous ulceration of the intestines is, in our experience at least, hardly ever accompanied by profuse intestinal haemorrhage; but Professor Oeler speaks of having had several fatal cases from this 'cause. The occurrence of profuse haemorrbage of the stomach without haematemesis was presumably explained by the pressure exerted by the growth against the cardiac orifice, and to some extent by the presence of the oesophageal growth, conditions which would-make vomiting impossible. Much stress cannot be laid on the obstructive influence of the latter, inasmuch as there was at no time any recognizable dysphagia. The same argument might, indeed,' be raised with regard to the gastric growth; but it seems reasonable to believe that the gastric growth, which, did not quite reach the cardiac orifice, did not obstruct that orifice when the stomach was passive, but that in vigorous contraction of the stomach, such as would induce vomiting in a healthy person, the cardiac orifice became obstructed by the pressure of the growth. In otler words, that the obstruction was valvular. BIBLIOGRAPHY. Borst: Die Lehre von den Geschuiilsten, ii, 541. Clement: Virch. Arch, cxxxix, 35. Deetz: Virch. Arch., clxiv, 381. Flitterer: Journ. Amer. Med. A 88oC., Chicago, October 15th, 1O;. Griffiths: Journ. Path. and Bacteriol., Edinburgh and London, 1901, vii. 449. Hebb: Westminster Hosp. Rep., 1895, ix. 316. Hewlett, A. W.: Journ. Exper. Med., New York, 190)-1901, v, 319. Keith, R. ).: Trans. Path Soc., London, 1905, lvi, 365. Klein: Lancet, 1899, Ii, 1297. Moore. F. Craven: Medical Chronicle, Manchester, 1899, 5. Osler, W.: Principles and Practice of Medicine, 1905, sixth edition, P. 340. Robson, A. W. Mayo: Med.-Chir. Trans., London, 1896, lxxix, 1F9. Rolleston and Trevor: Journ. Path. and Bacteriol., Edinburgh and London, 1906, x, 418. Speese: Univ. Penn. Med. Bull., 1£07, XiX, 700.

Fracture of the fifth metatarsal bone.

Abstract: French surgeons of the early part of the last century for its recognition, and also for. the term by which it is generally known, \" reduction en bloc \" or \" en masse.\" Luke, in this country, first described it in the Traneactions of the Medico-Chirurgical Society, vol. xxvi, p. 159. Examination will show that the inguinal region and' the rings are free, but a lump will be felt behind the abdominal wall. It has only been recorded in connexion with old inguinal herniae. In the reduction the hernia would have disappeared without the characteristic gurgle, and symptoms of obstruction would remain. Instances 'of it are rare, and the following case, which was under my care in St. Thomas's Hospital, is a good example:

Remarks ON SOME POINTS IN THE PATHOLOGY AND TREATMENT OF ADHERENT PERICARDIUM.

Abstract: 2. Drugs. In some cases severe symptoms are for the time greatly relieved by nitrites. But their effect is usually transient. Still, I have known men made much more comfortable by small doses of nitroglycerine given for a week or two. For a more permanent effect small doses of potassium iodide have been highly recommended. But I do not think that any drug approaches calomel. Given in small doses of 1 gr. or j gr. every night for a short time and repeated at intervals, it sometimes is of very great use. It is not its purgative effect that is needed; it is really what is called an alterative. Every one appreciates its effect on the spirits, and I believe this to be chiefly an effect on the blood pressure, for it is known that melancholy is a state in which the pressure is high. Alkalies act chiefly by increasing the flow of urine, and this, especially in cases complicated-for this is my view of the position-by nephritis, is often of great importance. 3. Diet. I think that diet is perhaps even more important than either habits or drugs. I have not any doubt that in some cases a very light diet acts like a charm. Let me give an example:

Preliminary note on the life cycle of a species of herpetomonas found in culex pipiens

Abstract: IT 15 well known many insects are Infected with harmless flagellate organisms the majority of which are very imperfectly known, the adult forms having alone been described. A large number of these parasites belong to the genus Herpetomonas, and are characterized by the absence of an undulating membrane, the flagellum passing out directly from the anterior end. Excepting a short account of Herpetomonas 8subulata by L6ger,' which I shall refer to later, the only description of the'development of one of these parasites is that of Herpetomnoas mu3cae domeeticae by Prowazek,2 who in addition to giving a detailed account of its strueture, mentions three possible methods of infection and a complicated process of propagation. In December, 1905, when feeding mosquitos (Culex fatigatns) on cases of kala-azar, it was found that a small percentage of the females were infected with flagellates very similar to the cultural forms of the LeishmanDonovan body, and a little later Christophers saw similar parasites in the males of Culex fatigane and certain developmental stages in the larvae. As far back as 1898 Ross found these flagellates in the larvae, nymphs and adults of Culexfatigana, and since then L6ger and others have found similar parasites in the intestinal tracts of many insects. The similarity between the developmental forms of the Leishman-Donovan body in the bedbug (Cimex rotundatus) and these flagellates of insects has led to the careful investigation of the life-cycle of a species of Herpetomonas found in Cule.x pipiens. Having seen certain stages of these flagellates in the larvae and the mature parasites in the faeces of the adult mosquitos, I concluded that the larvae probabjy became infected by ingesting the flagellates passed into the water. The hind gut of a larva was dissected out, the anterior portion isolated, spread out on a slide with two fine needles, and stained deeply with Giemsa's stain. Lying apparently in the gut, and in many cases close up to the nuclei of the intestinal cells, there were a number of round and oval parasites (Fig. 1), measuring from 4 & to 8 u in length and from 3 u to 5 p in breadth; their protoplasm, stained deep blue, was granular, and contained a few vacuoles. The macronuclei, which were circular in sbape, staining light pink, and containing a number of fine chromatic granules, were usually seen lying at one end, while the micronuclei, staining almost black, were rod-shaped, and situated at the periphery or the centre of the parasites. Many of these cells, which were much enlarged, were seen in all stages of simple longitudinal division (Figs. 3a, 4a, and 5a), and in some the macronuclei and micronuclei had divided a number of times and arranged themselves along the periphery, and on the protoplasm dividing from four to six parasites were produced (Figs. 3b, 4b, and 5b). All these changes were seen taking place while still attached to the wall of the hind gut; some of the parasites had already flagellated, and were lying in pairs (Fig. 8b) with flagella of varying length, and had undoubtedly resulted from the longitudinal division of the round and oval parasites. In the nymphs some of the free forms had increased considerably in size, their macronuclei and micronuclei dividing again and again, resulting in the formation of rosettes (Figs. 6a, 7, 8a, and 9). In the older nymphs the individuals had flagellated, and the rosettes were beginning to break up, and in the adult mosquitos the parasites were Eeen. as elongated spindles with oval macronuclei and rod-shaped micronuclei lying between' them and the anterior ends, from which long wavy flagella protruded (Fig. 11). From this short description it will be seen that this parasite has a stage in its development when it is very similar in form to the Leishman-Donovan body, and, further, that it multiplies by longitudinal division and multiple segmentation* as that parasite does in the human tissues. When free in the hind guts of the larvae and nymphs it further multiplies in a similar manner to the Leishman-Donovan body in the bedbug. Though there are still some gaps in the life-cycle of the Herpetomonas of Culex pipiens, enough is already known to compare it shortly with Herpetomoonas muscae domesticae. Prowazek regards the parasite of the house fly as a bipolar flagellate in which the body has become bent so that the two ends have fused, the two flagella remaining distinct. Excepting the forms showing longitudinal division, I have never seen a single parasite with two flagella; further, there is at present no evidence of the bipolarity of any flagellate. In addition to the motile forms, Prowazek describes gregarine-like parasites, and believes their appearance confirms L6ger's view of the relationship of these flagellates 'to the gregarines. I have frequently noticed these so-called gregarine-like forms both in the development of this parasite and in that of the Leishman-Donovan body, and they-appear to represent either parasites whose flagella have not yet developed or have not been sufficiently stained. Prowazek does not mention any stage in the development of Herpetomonam muscae domesticae similar to that of. my parasite in the hind gut of the mosquito larvae. He describes a process of copulation in the parasites of the house fly prior to which there is a marked reduction in the flagellate apparatus, and two similarly constituted forms are then seen lying side by side. The macronuclei and micronuclei of the two parasites then unite to form a single macronucleus and micronucleus, and later a permanent cyst is formed which is passed out in the faeces of the fly. Prowazek also mentions three methods of infection: (1) The indifferent individuals from the cysts may be again taken up by flies; (2) the sexually differentiated forms copulate, forming a permanent cyst, which is passed out in the faeces and may be ingested by other flies; (3) sexually differentiated forms penetrate into the ovaries, where they undergo autogamy and infect the next brood, but no description of the parasites in the eggs is given. I have sojfar been unable to observe any sexual process in my parasite and the examination of ovaria and eggs has proved negative. I have also been able to follow some of the stages in the life-cycle of a species of Crithidia found in a small Homoptera. In the mid gut of the young nymphs of this water-bug there were similar round and oval bodies (Fig. 12) apparently lying in the epithelial wall with circular macronuclei and rod-shaped micronuclei. Longitudinal division was also observed resulting in masses of round and oval forms attached to the epithelium, but there was no evidence of multiple segmentation. While still attached flagellation takes place, and these parasites are then seen undergoing equal and unequal longitudinal division resulting in forms of all sizes. The adult parasite is a long, sickle-shaped organism (Fig. 13) with both ends attenuated, the anterior being prolonged as a rudimentary undulating membrane along which the flagellum is attached. This parasite is very similar to Herpetomonas subulata described by LUger from Tabanus glaucopis and Haematopota italica, of which he recognizes two types:

ON THE DUTY OF RESTORING HEARING BY OPERATION IN CHRONIC AURAL SUPPURATION: An Address delivered before the West Kent Medico-Chirurgical Society.

Abstract: The piezence of an undulating membrane, the morenentral position of the micronucleus and the method of dev.lopment of Herpetomonas subulata suggest that, like ne parasite of the water-bug, it belongs to the genus Crithidia. L4ger 1 believes that some of these Crithidla and Herpetomonas found in blood-sucking insects represent stages in the development of haemoflagellates of vertebrates and considers Schaudinn's observations on T. noctuae in Culex pipiens confirm, his opinion. Many parasitologists, however, now believe that Schaudinn was dealing with more than one parasite in Cukvx pipiens, namely, either Leucocytoz\"on ziemanni or Halteridium danilewski, together with the trypanosome of the owl and the Herpetomonas of Culex pipiens; and further, I have often seen maity spirilla of large size with more than one chromatic dot in their protoplasm in the mid guts of Culexpipiene and CulexWatigans. There can be little doubt that the Crithidia of the waterbug is in no way connected with any blood parasite. I shall reserve for a later occasion a complete account of the life-histories of these two parasites.

The rideal-walker coefficient

Abstract: wall by rheumatic poisons. The enlargement probably is present most commonly where there has been pericarditis, because this is the most serious variety of rheumatic infection of the heart. It may be considered virtually to follow pericarditis occurring only in children, becau3e during the growing period the heart is most susceptible to rheumatic poisons. Whether this be the true explanation or not of the cardiac enlargement it seems clear, for reasons already given. that pericardial adhesions cannot be the only factor, or even, it seems to me, the main factor in the production of this enlargement, or of the cardiac failure with which the eulargement is accompanied.-I am, etc., February 2nd. THEODORE FISHER.

REPORT CII. UPON THE BACTERIOLOGY OF THE SUMMER DIARRHOEA OF INFANTS: [Second Communication]

Abstract: ANEuRYSM of the vessels of the foot is of such rare occurrence (Chauvel; quoted by von Bergmann, could only collect the rccords of twenty such), and, when it does occur, is nearly always to be traced to definite trauma, that I have thought tLe history of the following case of spontaneous ar eurysm occurring in my hospital practice worth recording. The patient, a woman aged 53, had noticed a small swelling on the dorsrum of her left foot for over two years. It had until the last four or five weeks given her very little inconvenience, but of late had been enlarging and had given her a good deal of pain. There had never been any ir jury of the foot, and no history of Fyphilis was to be obtained.

The saccular theory of hernia.

Abstract: morbid conditions within the abdomen during the progress of an operation has materially increased our capacity to make a more certain and an earlier diagnosis, and has accordingly equipped us with more efficient therapeutic power. It is, I submit, by a close study of the anamnesis followed by a careful investigation of the parts implicated in the disease, during the life of the patint, that the surest foundations for accurate diagnostic power cin be built. The surgeon, after hearing the detailed story of an Illness has not to wait until death comes to the patient before he can lay bare those pathological processes which have given rise to all the symptoms. He can see and handle the organ or organs affected at the time they are exciting the sufferings of the patient; not at the time, months or years later, when all bounds have been overstepped by the unchecked extension of the disease, in parts laid waste by a late infection. At the time when symptoms are being caused, the pathological changes are open to examination; that is the advantage which comes from a study of the pathology of the living. So far as abdominal diseases are concerned, he is the best diagnostician who spends much of his time in the operation theatre. The lessons there to be learnt are far greater in number and far outweigh in value those that can be learnt in the poet-mortem room, in so far as they bear any reference to the treatment of the living. I would, therefore, urge upon all those engaged in practice the desirability of following their patients to the operation table whenever opportunity occurs. The lessons there to be learnt will in practice be of a value beyond all reckoning, and interest in the daily work will be thereby quickened to an unaccustomed degree.

The etiology and prophylaxis of dracontiasis.

Abstract: ought or ought not to be removed. The microsicopethere and then showed that only the large glands upon the capsule of the tumour contained. growth, and that those nearer the crural arch contained none, so that it was deemed unnecessary to open the abdomen. Mr. Shaw will now demonstrate how quickly sections of ,growth can be cut with a freezing. microtome, and how clear and good the sections are. In my opinion the apparatus he is using is an essential part of the equipment of an operating theatre.

A Clinical Lecture UPON THE SURGICAL ASPECTS OF HAEMOPHILIA, WITH ESPECIAL REFERENCE TO TWO CASES OF VOLKMANN'S CONTRACTURE RESULTING FROM THIS DISEASE

Abstract: lest, as in this case, the outcome proves the cause to have been, though not organic disease of the valves or vessels, something more definite and dangerous than a mere nerve-storm. In the treatment of aortic disease the primary object to achieve is the establishment and maintenance of sufficie'nt compensation. In the case of our first patient, who suffered recently from rheumatic fever, the chances are that his compensation never became firmly established -that is to Lay, that the length of time over which he rested and the amount of care which wa's taken of him otherwise after his acute illness was not enough to build up his myocardium against the strain of his subsequent life. In addition to this, he has been careless of himself and has indulged in alcohol freely and unwisely. Consequently he comes to us with all the evidences of broken compensation; fortunately for him,.it has not gone beyond moderate pulmonary congestion. Already since his admission the improvement in his condition is marked; the mitral murmurs which he then had have almost disappeared; the cardiac rhythm is regular; the locomotive pulsation in the vessels has -diminished, and there is a distinct though feeble second aortic sound to be hcard in the carotid arteries. There is now no cough and no physical signs in the lungs; the liver dullness has become normal; he is taking food well, and is sleeping comfortably in a normal position the night through. This amelioration has taken place under the influence of complete rest in bed, a simple and moderate diet, regulation of the bowels by means of salines and an occasional small dose of calomel. At first he took a mixture of sodium salicylate, digitalis, strychnine, and ammonium carbonate; this was followed later on by another, which he is still taking, containing dilute phosphoric acid, iron perchloride, nux vomica, and strophanthus.' The only point worthy of comment in the medicinal treatment of a case of this type is the employment of digitalis. The old tradition that digitalis is a dangerous drug in aortic disease clings to many of us so pertinaciously that we hesitAte to avail ourselves of its valuable assistance.. This is not, I venture to think, good practice. The true action of digitalis is that of. a tonic, the best of all we possess, to the myocardium. When compensation is well maintained, its exhibition is never indicated, but whenever this fails, It should be called to the rescue, irrespective of' the nature or situation of tho valvular lesion. Not only so, but at the outset of its administration the drug may be given advantageously in bolder doses. than are customarily employed. Fifteen minims of the tincture every four hours may be ordered with perfect safety, if we are careful to watch its effects and curtail the quantity when we get evidence of saturation. That evidence is forthcoming in an abnormally slow cardiac rhythm, diminished urinary Secretion, and disturbance of the digestive organs. In many instances the good 6ffects of the drug are evidenced only after these physiological effects are produced. No harm ever results if, at this stage, the drug is either temporarily withheld or its quantity diminished to 7 or 10 minims every eight hours. Strophanthus and convallaria arerecommended as valuable alternatives which are better suited to aortic conditions; but though they are useful remedies, their good effect upon the heart falls far short of digitalis, and it is by no means uncommon to find a speedy improvement under the influence of digitalis, when the others have failed to bring about the least response. Another point about the administration of digitalis which is not sufficiently recognized is the safety that may be secured by its combination with nitro-glycerine. In all cases where vascular tension is high the 1 per cent. solution of nitro-glycerine given along with digitalis prevents increase of peripheral resistance, and so robs the digitalis of that influence upon the arterioles on account of which its administration is supposed to be contraindicated. In the case of our second patient, who has likewise improved decidedly since his admission to hospital, the treatment has been somewhat different. His chief complaint, when firit brought here, was of pain in the chest on exertion; shortness of breath, which prevented his lying dowrn in bed at nighft; and recurring anginal attacks of a severe type. This is 'a combination of symptoms with which we are very familiar here, and which is enough of itself to suggest aortic disease. You have satisfied yourselves, I hope, that his case is one belonging to the degenerative type of this ailment, but, in addition to the knowledge you have gained of his present condition from the physical examination you have made, I must remind you that, when first seen, his pulse was one of very high tension. Here we found a leading indication for treatment, and, in accordance with our usual plan in cases of this description, he.was at once put on a mixture of potassium iodide and nitro-glycerine. Both these drugs, and especially the latter, are valuable vaso-dilators, and, under their influence, this man rapidly experienced relief to his breathing and diminution in his precordial discomfort. He was kept closely confined to bed, his diet was simple and mostly sloppy, and every night for a week he was given one grain of calomel, followed in the morning by a moderate dose of ordinary white mixture. After ten days he was so much better that we were able to put him on iodide of iron, strychnine, and strophanthus, and to allow him a greater amount of freedom in regard both to diet and exertion. He has had no recurrence of his anginal attacks since a few days after his admission; he is now able to sleep comfortably in the ordinary recumbent position, and a moderate amount of walking exercise can be indulged in daily without producing either cardiac discomfort or undue physical fatigue. As regards the dosage of the iodide and nitro-glycerine in cases of this description, I am persuaded we often err in making the quantities too small15 gr. of sodium iodide, protected by 2 minims of Fowler's solution,and combined with 2 minims of the 1 per cent. solution of nitro-glycerinemaywith perfect safety be given every four hours. Whenever the pulse becomes soft and begins to quicken, longer intervals should be allowed between the 4oses, and eventually the nitro-glycerine may be wholly withdrawn and the iodide continued in smaller amount, say 5 gt., along with strychnine and one or other of the milder preparations of iron. In regard to calomel, its value is not confined to its aperient effect; it is a useful intestinal antiseptic as well, and also assists in diminishing the tension in the arteries. Obviously the nature of these patients' occupation is inimical to the maintenance of their circulatory balance whep they return to work. We always urge them to find a new field for their labours, in which exposure, muscular strain, and dietetic irregularity will enter less into their daily experience, but it is difficult for most men after middle life to embark upon a new calling, and many'of our cases ultimately succumb to the circumstances of an environment which is unusually trying and hard even for those who are in the possession of full vigour and healthy organe.

A case that seems to suggest a clue to the possible solution of the cancer problem.

Abstract: ever looms before his vision tI e seductive stock-in-trade of the advertising quack, which invariably contains a certain cure without the knife. The medical man, therefore, becomes in a large number of cases the dernier re8sort of the cancer-stricken pationt. The circle is maintained in all its viciousness, ignorance of the possibility of cure and of the conditions governing it and fear of receiving a sentence of death, leading to procrastination, which itself is the cause of the impossibility of cure. In addition, the early manifestations of cancer are apparently so harmless that the sufferer has every inducement to believe what he hopes, and what his friends, if he consults them, are sure to tell him: that his ailment must be a trivial one. These are the chief causes of delay among educated people who know something of cancer and its common situations. Among the poorer and less educated classes unadulterated ignorance plays the greater share. They do not commonly regard anything which causes no pain or feeling of illness as of any consequence whatever, and these symptoms are conspicuous by their absence in early cancer. The everyday reply of the poor at hospital, with advanced cancer of the breast, uterus, and even tongue, to the question, "Why did you not apply sooner ?" is, "As I felt well and suffered no pain, I did not think it could be anything serious," "I thought it was only a cold," or something equally absurd. It is manifest that such a state of affairs can only be dealt with by improved education, and by this is understood not an attempt to make of the public amateur doctors, judges of their own complaints and of their own symptoms, but a dissemination of knowledge in the following two particulars: first, in that of tbe possibility of cure in early cancer; and, secondly, in that of the fact that early cancer produces no symptoms of pain or ill-health, and that in the latter half of life any deviation from normal health in certain organs-to wit, the mouth, digestive tract, uterus, and breast, must carry with it the determination to immediately exclude or confirm cancer, if the patient means to make a bid for his life. It is very little to know. In the case of other diseases, such, for instance, as typhoid fever, tubercle, etc., plain facts, requiring no medical training, have become common property, and are acted upon to their advantage by the educated public. There does not seem to be any a priori reason why similar and just as simple knowledge should not be disseminated with regard to cancer. In my recent book, The Control of a Scourge; or, How Cancer i8 Curable, I have endeavoured to instil into the public mind in regard to this disease a view more hopeful and more consonant with the generally accepted opinion among modern surgeons of the possibility of cure in early cancer than exists to-day; and I have adduced evidence to show that this opinion has a convincing foundation in actual practice. I have indicated there some of the lines on which education in this matter might, in my opinion, be put a step further. The general practitioner, who is constantly in touch with the public, has the largest opportunity of helping education forward, and he should lose no occasion of impressing upon his patients the cause of the generally fatal character of cancerous disease, and of the possibility of securing vastly better results in its treatment than do actually obtain at the present time. Then it is obvlous that medical and surgical nurses might easily be equipped with the knowledge of these elementary facts aboutcancer. They are almost as ignorant as lay women. Not only have I witnessed the experience of nurses themselves applying with advanced and inoperable cancer, but convereations with them in hospital have demonstrated that they regard cancer as inevitably fatal. This is not to. be wondered at when we consider the numbers they see who perish of it in our hospital wards, and that those in whom the disease does not recur after removal escape their subsequent cognizance. Owing to its sites of eleation in women, nurses are no doubt frequently c3nsulted by their own sex about early cancer, when from readily intelligible motives the patient liesitates to approach a medical man. It is essential, tberefore, that their knowledge sbould be accurate, and the necessary information c 'uld be easily imparted to them byr including in their syllabus of lectures one on the elemeutary facts of this disease. Midwives mighot be similarly instructed. They are brought daily into close contafl with the ignorant classes, the most difficult of all to get at, and tLey no doubt are consulted frequently on matters outside their immediate calling, amongst others on early cancer. Their information, therefore, should also be accurate, and in like manner there would be no difiSculty in including in their repertoire a little elementary knowledge of cancer. We might reasonably go even a step further in our endeavours to lighten the load of cancer mortality. Lectures might easily be provided for clergymen, clergymen's wives, district visitors, and thoEe generally who are constantly in touch with the poor and ignorant classes on this subject as well as on others in which the possession of accurate knowledge would furnish the means of rendering valuable assistance in the Eaving of human life. Such lectures have long been in vogue to provide for surgical emergencies where skilled assistance is not immediately to hand. We might anticipate far more tangible results from a similar spread of information in regard to those dieeases in which ignorance of the most elementary facts leads to disastrous and irremediable consequences. Among such none plays a more conspicuous part than cancer. The above are some of the means whereby might be substituted sound knowledge for the despair and ignorance which hold the public in their grip, and it cannot be questioned that there would result an appreciable control of the ravages of this deadly disease. Until education has been tapped our presenit means, and at present our only means, of dealing with eancer have not been exbausted. In conclusion, it may be safely asEerted that the early recognition of cancer will not be a matter of indifference whenever, if ever, the cause of this disease is discovered and methods more scientific than eradication by the knife are found for dealing with it; for it is not to be supposed that whatever means the future may have in store for combating this disease, it will be a matter of no importance whether, for instance, a woman suffering from cancer of the breast presents herself for treatment when the disease is early and limited or when she is the victim of its later stages, with secondary deDosits in the thorax and liver. At all events, there are abundant reasons now for an endeavour to bring the lay knowledge of cancer into line with present surgical views of it, and to convince the public that a considerable share in the possibility of cure rests with them, and that it varies inversely with the delay in seeking advice.