1051DR. A. I. SIMEY: THE COMMON COLD, ETC.

framework of people who lived in Britain during thepre-Norman period. When a continental cartoonistseeks to represent John Bull he always emphasisesthese new facial characteristics. Such changes in theform of the facial bones, like contraction of the palate,which they usually accompany, are not the result ofa nasal obstruction such as might be caused byenlarged adenoids or tonsils ; the cause lies deeper.The incidence of irregularities in the growth of theface follow the same laws as hold for all abiotrophicstructures such as the appendix, the sclerotic coatof the eye, the thymus, and the tonsil. Furtherresearch will likely prove that the disorders of growthwhich overtake all of these structures are linkedto a disturbed action of lymphocytes and of all theconstituent elements of the lymphoid tissues. Dr.W. Cramer has become convinced that lymphocytesare actively concerned in assimilation of food andin the nutrition of tissues, and that the nature of thedietary does directly affect their activities. It seemsto me very probable that a fuller knowledge of thelife-histories of lymphocytes, particularly of theoffice they perform in growing tissues, will go far toexplain the disharmonies which civilisation is producingin the bodies of some of us. But the problem ofexplaining why some members of our communityare highly susceptible to these new conditions, whileothers are less so, and why the majority remainunaffected, will still remain.

CONCLUSION.

I have touched only the fringe of a great subject;I have left undiscussed the numerous imperfectionsand disharmonies which civilisation has made manifestin structures concerned in the maintenance of posture,26and in those which are concerned with the circulationof blood and with the duties of respiration. I havesaid enough, I believe, to convince you that Metchni-koff was right when he declared that civilisationhad launched man on a great experiment. From thisexperiment there is no turning back. We cannotreturn to the conditions of human life which pre-vailed in this country 6000 years ago ; there are morepeople in one of the lesser Jback streets of Londonthan could find an existence in the whole length andbreadth of the Thames valley if we returned to themanner of living of our distant ancestors. We cannotgo back; we must go on. Seeing how differentlywe are now circumstanced in every relationshipof life-in food, in drink, in shelter, in warmth, inoccupation, and in amusement-the wonder is,not that structural imperfections and functionaldisharmonies should develop in a proportion of ournumbers, but that so many of us should escape harmaltogether and enjoy good health. It says much forthe adaptational reaction which is inherent to thehuman body that it withstands the artificial conditionsof modern civilisation as well as it does.

How are our bodies to be protected against these illswith which civilisation threatens them ? Metchnikoff,a declared and open rebel against Nature, hoped thatscience might discover some short cut for man’sescape, some way of speeding up the evolutionarymachinery of his body, and so making it perfectlyfitted for the life which ever-advancing civilisationis forcing on mankind. I also believe that sciencewill find a means of escape, but not by Metchnikoff’sway. The solution of our problem is a fuller know-ledge of the use and working of those parts of ourbodies which are most apt to give way under ourmodern ways of living-the use of such structuresas the great bowel. And when we have replaced ourignorance by real knowledge we shall then be in aposition, not to adapt our bodily structures toour mode of living, but our mode of living toour bodily structures. This seems to me the bestway out.

26 I have discussed the Imperfections of Man’s PosturalStructures in Brit. Med. Jour., 1923, i., 451, 493, 545, 587,642, 669.

An AddressON THE PROPHYLAXIS OF THE

COMMON COLD AND FEBRILECATARRHS.

Delivered before the Medical Officers of SchoolsAssociation on Nov. 6th, 1925,

BY A. I. SIMEY, M.D. CAMB., F.R.C.P. LOND.,MEDICAL OFFICER, RUGBY SCHOOL.

IN this paper I use the terms " common cold"and " febrile catarrhs " to indicate all those affectionsof the respiratory passages ranging from the commoncold or coryza, on the one hand, to the diseases knownvariously as febricula, " flu," P.U.O., "

chill," and" influenza " on the other hand, which, howevermuch they differ in their manifestations, have thisin common, that they are all infections, and all

begin in the upper respiratory passages, causingmalaise, often pyrexia, and a set-back in the normalhealthy progress of adolescence. I intend, also, todeal with the prevention of these diseases in schools,especially the boarding schools, in which infectionis so much more likely to spread, because the pupilsfeed, work, and sleep in common dining-halls, studies,class-rooms, and dormitories. Moreover, it is inthese schools that great difficulty is experienced infinding adequate sanatorium accommodation for thepatients, who so often require skilled nursing andattention in large numbers at the same time. I shallalso use the term "influenza" looselv to cover allthose febrile manifestations to which I have alreadyalluded.The appearance of these diseases in epidemic form

is a matter of very great importance to schools fortwo main reasons: 1. Because, even though theyrun a normal uncomplicated course, they interferewith the work of the individual, whilst if complications arise they may jeopardise his future healthand even his life. 2. Because they disorganise thewhole life of the school, and are most expensive bothas regards time and money. The work of a schoolmedical officer would be reduced by one-half atleast if such epidemics could be eliminated.

It would appear logical to begin by a descriptionof the various forms of the disease as met with bymedical officers of schools, and the different typeswhich it assumes in different epidemics-e.g., thecatarrhal, the anginoid, the intestinal type, and soforth. But I take it that all of us know it, with allits protean manifestations, and that we are agreedthat the phenomena of this disease are due to micro-organisms, and that they are acutely infectious.The question as to the particular organisms con-

cerned has not been finally settled, but we know,

that when cultures are made from the sputum ormucus of affected patients a variety of organisms are

: usually isolated which, if not the prime or deciding,

cause, are, at any rate, aiders and abettors or accom-plices of the arch-offender, who or whatever he may

L be. Their entry into the body is by the upper respira-

tory passages. As to predisposing causes we can say: little. It is well known that the vigorous and healthy, are attacked almost as readily as those who have a. less healthy constitution, though deformities of the. nasal septum and turbinate bones, and the presence,

of unhealthy adenoid and tonsillar tissues no doubt: weigh to some extent in the balance.’ PREDISPOSING CAUSES.

. What we know about predisposing causes is very

- little, and the prevention of the disease depends’

largely on the degree of immunity in any com-

munity for the time being. I do not mean to say1

that it counts for nothing if a child sits in a draught,,

or goes about in wet clothes or imperfectly clad, forthese conditions temporarily depress vitality, but in

1052 DR. A. I. SIMEY: THE COMMON COLD, ETC.

the majority of our patients we cannot, as a rule,lay much stress on any of those conditions as a

contributing cause.Some blame the inclemency of the weather, and

lay stress on seasonal incidence ; others point out acertain periodicity in the waves of visitation ; butwhilst there may be some ground for both of thesesuggestions, the probability is that we can say littlemore than that the bodies of mankind have beendiscovered to be a first-rate culture medium bycertain bacteria, which go on increasing in numbersand in virulence until the soil is temporarily exhaustedor otherwise made untenable for their activities.No doubt climate and season are a small factor in

their environment which influence the outbreak anddecline of epidemics, but it is more likely that thebacteria are themselves the victims of their ownactivity, and require either fresh feeding-ground ora rotation of bacterial crops before they can thriveagain in the same host.

ATTEMPTS AT LOCAL ANTISEPSIS.

Attempts have been made to make the human soiluntenable by disinfecting the upper respiratorypassages by means of sprays, gargles, nasal douches, &c.But there are two considerations which, to my mind,make it most improbable that these measures can beof any avail.

1. The disinfectants used, if strong enough to killthe germs, will damage the epithelium with whichour throats and nostrils are provided to deal withinfection.

2. Even if strong enough, their contact with themicro-organisms is so short (for they are soon washedaway or diluted) that the protection is likely tolast for a question of minutes only. In this connexionI have noticed that where there is much nasal catarrh,constitutional symptoms do not develop so often orso severely. For by the catarrh Nature fixes andlocalises the disease to the naso-pharynx and " dealswith it," so to speak, in situ. A common history toobtain at the outset of an attack of influenza is thatthe patient has recently had an ordinary cold forsome time without feeling ill, but when the catarrhceased constitutional symptoms with malaise andpyrexia first appeared. A remedy for colds much inuse at one time was the " carbolic smoke-ball." Itsvirtue, no doubt, consisted, not in the antisepticpower of the carbolic acid, but in the fact that itproduced an aseptic irritation of the nasal mucosaand caused an excess of mucus to be formed whichdealt with the invading infection there and then.With the same object in view, some medical

officers have tried to educate their pupils to breathehabitually and entirely through their noses byteaching them a kind of " nasal drill." This expedientis difficult to carry out effectively and has not metwith signal success: it has psychical rather thanphysical results.

Again, it has been suggested that all pupils shouldhave their throats and nasal passages disinfectedperiodically by passing through a chamber in whicha saturated spray of some vaporised disinfectant iscirculated. I think this measure also is open to thecriticism that the effect is too temporary and super-ficial to be efficacious.

PRINCIPLES OF PROPHYLAXIS.The prophylaxis of these diseases then resolves

itself into the following rules: 1. Keep out ofinfection’s way. 2. Raise the immunity of the body.Let us deal with these separately.

1. Avoidance of Infection.-How can school-childrenkeep out of infection’s way ? This is a large and far-reaching question. The infection is usually broughtinto schools at the beginning of a term by boys orgirls who have left home with a cold or cough whichseemed too trivial to detain them, or who during thelast week of the holidays have gone through a con-centrated tour of amusements at kinemas, theatres,dances, &c., and return to school somewhat tiredand out of sorts, with the diseases under questionincubating in their systems.

The way to tackle this source of infection is to" educate " the parents, or rather take them intoour confidence, and point out the folly of indulgenceof this kind. I have found it of no avail to send outa printed form, such as : " You are requested notto send your boy back to school with a heavy cold."To be of any use, a special communication must besent periodically, written in reasonable terms, withexplanations, and an appeal for cooperation on thepart of the parents. Moreover, in schools situated inor near a town there is a constant-risk of the infec-tion being introduced by day-boys or boarders whomust needs enter ’shops, hotels, and other townbuildings to replenish their wardrobes, meet theirparents, or go to theatrical or musical entertainments.This is to a certain extent avoided by stringent rulesas to bounds and hours, and by providing the schoolwith a food-shop of its own ; but, inasmuch as thestrength of a chain is that of its weakest link, allsuch efforts at surveillance and restrictions mustalmost inevitably break down, as it is enough thatone pupil introduce the infection for the whole schoolto be exposed to its attack.But if we ask for preliminary care on the part of

parents we, too, must leave no stone unturned toavoid infection when the pupils assemble at thebeginning of each term. Precautions should be takenby school authorities to ensure that all school pre-mises are in as suitable condition as possible forpupils who have come from comfortable home-quarters to the severer rigour of the school establish-ments. In addition to the thorough routine cleaningand ventilation of school premises, all class-roomsand other meeting places should be warmed by thelighting of fires a few days before the pupils return,and the school routine should be entered upongradually, not plunging at once into early hours, butgradually training the pupils to adapt themselvesto their change of environment. No doubt, colds

and febrile catarrhs spread much more quicklyamongst boys and girls when living in their schoolcommunity because they are packed into closequarters both by day and night.

It is, in my experience, chiefly in the big dormitoryand small study where.two or more boys live andwork together that infection most easily spreads.Stated in other terms this means that they are over-crowded, and no doubt in a sense they are so, butit would be neither possible nor desirable to houseboys at school as young men live.at the universities-i.e., each with his own sitting-room and bedroomquite apart from that of his neighbours. Such anarrangement would materially alter the value of ourboarding-schools in which close contact and publicityof life are important social and moral factors. I amquite sure that, even in dormitories where amplespace (according to the accepted doctrines) is allowed,infection is carried directly from boy to boy.

There are only two remedies for these difficulties :—

(a) To rebuild or rearrange existing accommodationso that there are far fewer boys in each dormitory,after the plan adopted in some fever hospitals, whereseparate infections are nursed in the same wardwithout obvious ill-effects. But so long as boys areboys the theory would utterly break down in practice.There is all the difference in the world between sickpatients in bed in a ward under supervision andhealthy children in a dormitory with little or modifiedrestraint. But this does not mean that we should notbe strict as to the spacing of beds and ventilation indormitories. On the contrary, the minimum spaceprovided should at least be in accordance with theusually accepted rules, and great care should betaken that the ventilation is as good as possible.

(b) To make the best use of what space is availablein studies and dormitories. Here, I think, a greatdeal could be done if more attention were paid totidiness both of place and person. In my opinion,pupils should be paraded every morning to see thatthey begin the day, at any rate, tidy in appearanceand apparel, and their quarters should likewise beinspected daily by a specially selected master or

1053DR. A. I. SIMEY : THE COMMON COLD, ETC.

officer to see that they are kept clean and well venti-lated. This is especially necessary where boys liveand sleep in the same room, and every attemptshould be made to keep such rooms free from unneces-sary furniture, draperies, and other dust-collectingmaterials. The condition of class-rooms and othermeeting places likewise requires special attention tosee that they are kept clean, warm, well ventilated,and adequately lighted.In the holidays following an epidemic, special care

should be taken to begin cleaning and decoratingoperations early. I do not think that the burningof sulphur or formalin, as usually employed, has anygermicidal action whatsoever, and I regard it as anunnecessary performance in which far too muchtrust is placed by the public and ourselves.My impression is that girls’ schools suffer less from

influenzoid epidemics than boys’ schools of the samegrade. If this is so, I have little doubt that it is dueto the greater care spent upon tidiness and generalsupervision of living quarters rather than to theirbeing less closely packed. I feel sure that 100 tidypupils will occupy the same space as 80 untidypupils without a corresponding increase in theincidence of febrile complaints. There are manyother small but important considerations which I mustpass over, such as the kind and amount of food, thelaundry arrangements, the hours of sleep, &c., whichbear indirectly on our subject.But there is one small detail to which insufficient

attention is usually given in schools, and that is theprovision of adequate foot-gear. I cannot explainwhy cold and damp feet should predispose to catarrhalconditions any more than coldness and dampness ofany other part of the body, except that it is moreoften overlooked. One of the inconveniences ofadolescence is a tendency to poor circulation in theextremities, and this can to a certain extent be over-come by seeing that pupils are well shod and thattheir boots and shoes are kept in good repair.

2. Raisirzg the Im3tinit,y.-There are some indi-viduals who seem to have a high natural immunity toinfections of all kinds ; some children, even beforepuberty, will pass through epidemics of differentkinds unscathed, and it is possible that, with puberty,most people acquire a still greater degree of naturalimmunity. A second class, possessing less naturalimmunity, suffer from occasional attacks of influenza,but acquire after each attack an immunity whichlasts them for a considerable length of time. Thereremain, however, a large number of persons of schoolage who acquire only a very short-lived immunityafter an attack of influenza, and succumb wheneverthe so-called " wave " passes over their neighbour-hood.

In a school of 600 boys I have known 200 to beon the sick list at one time, and a total of over 300cases in a term, which implies the loss of about4000 school days in a term of 12 weeks.

PROPHYLACTIC TACCINATION.

It seems to me that the longer the epidemic laststhe greater is the virulence of the infection and themore serious the nature of the complications. Con-sequently, it behoves us as medical officers to leaveno stone unturned, at whatever cost or trouble. tostamp out or mitigate the disease and its sequelae,and I would like to direct attention to the questionof raising the immunity of the community by prophy-lactic vaccination.There has so far been no combined attempt on the

part of medical officers of schools to tackle a givenepidemic systematically by methods and on lineson which they have previously arrived at agreement.At present the question is in a state of chaos, and Ido not think that we could arrive at any certainconclusions if we had before us to-day all such evidenceas can be collected, because of its fragmentary anduncoordinated nature.

There is on the one hand : 1. The evidence ofindividual patients who think they have or have notbenefited by a "

course " of prophylactic vaccines,

and who swear bv or belittle this form of vaccinationaccording to the result they imagine it has producedin themselves. 2. There is the evidence of medicalmen who have dealt with communities such as a

detachment of troops, schools, and other societies,whose evidence, if we were able to collect it, wouldin some cases be enthusiastic, in others lukewarm,but in no case convincing, because the methods havenot been carried out oi. a large enough scale and withsufficient control material.What is wanted is a combined test-effort on the

part of medical officers of schools to tackle theproblem thoroughly by agreeing as to the method ofpreparation and details of administering a vaccineat a time chosen by the doctors calculated to immunisepupils against a likely, or one may say, almost certainoutbreak of influenzoid epidemic at a given season-e.g., the coming Lent term.

It may be argued that as the organism responsiblefor influenza is not certainly identified, this form ofprophylactic vaccination is unscientific, but we docertainly know that certain accessory organisms playa not unimportant part both in the disease as weknow it and in its complications. Indeed, there maypossibly be no one particular responsible germ, butthe disease may be due to the combined activity ofseveral organisms, some of which we know-forinstance, the virulent form of streptococcus so

frequently isolated from otorrhoea following influenza.If, then, we can raise the immunity of the body againstone or more such organisms we are immunising inpart or in whole against the complex disease.

Stocle Vaccine.-There has lately appeared in printa report of an experiment tried in September, 1919,in a boarding-house of a large public school, whereeach child received five injections in the course ofthe year of the anticatarrh vaccine made in the

inoculation department of St. Mary’s Hospital. Thereport says : " The results were so encouraging thatthe procedure has been continued regularly, and therecord for the past four years shows that not onegirl who had been duly inoculated missed a singleday at school owing to colds or influenza, whereasof those girls who were not inoculated a considerablenumber were confined to bed with colds and influenza,and two contracted pneumonia." " In this house thenumber of girls averaged 40, and they mixed freelywith other uninoculated pupils in their class-rooms.The vaccine here used is composed of Micrococcus

catarrhali8, Bacillu8 pneumon,ice,pneumococcus, Bacillusseptus, Bacillus injT1wnzae, and streptococcus in certaindefinite proportions, and is, no doubt, constantlyreinforced at headquarters by fresh cultures takenfrom well-marked cases of the disease. The recordedresults are excellent, but I would suggest that itwould be still better if those schools which determinedto join in one big concerted experiment should sendto a prearranged laboratory or pathologist culturesfrom the naso-pharynx and throat and specimens ofsputum by a given date, in order to have a vaccineof local origin made for them, leaving it to the dis-cretion of the pathologist to incorporate such andas many strains as his experience led him to thinknecessary.Such a vaccine would combine the advantages of

being easily procurable and of being made from localmaterial. This concerted experiment would have two.sources of control: 1. Those schools which, for some-reason, did not adopt the plan. 2. Those individuals:in any school whose parents preferred not to have.their children inoculated. The best time for adminis-tering the vaccine would be during the Christmas;holidays immediately preceding the Lent term, andagain during the last three weeks of the summer-holidays so as to precede the two school winterterms in which influenza is usnally most prevalent.

I feel that we have before us a great opportunityfor testing the efficacy of vaccine prophylactic treat-ment in the case of a disease which has become anational danger and expense, and that the time hascome to give it a careful trial. I often feel and saythat the value of my work as medical officer of a big.

1054 MR. G. WAUGH : SENSIBILITY OF THE HEART.

public school can only be judged when the boyswhom I have steered through adolescence reach thefourth and fifth decade of their life. The proof ofthis pudding is not in the eating but in the digesting.The success of education at our schools cannot bejudged by lists of scholastic distinctions so much asby the mentality and usefulness of their pupils whenthey attain middle age. The same, I take it, is truein medical ma.tters, and we medical officers of schoolshold in our hands the invisible keys which could openmany secrets of the future health of our patients.

SENSIBILITY OF THE HEART:A HUMAN EXPERIMENT.

BY GEORGE WAUGH, F.R.C.S. ENG.,SENIOR SURGEON, HOSPITAL FOR SICK CHILDREN, GREAT

ORMOND-STREET, AND HAMPSTEAD GENERAL HOSPITAL.

With Notes bySir WILLIAM WILLCOX, K.C.I.E., M.D. LOND.,

PHYSICIAN, ST. MARY’S HOSPITAL, ETC. ;

AND

FELIX ROOD, M.B., B.S. DURH.,HON. ANÆSTHETIST, UNIVERSITY COLLEGE HOSPITAL.

THE opportunity for a comparatively prolongedmanipulation of the human heart in a fully consciouspatient has occurred probably with sufficient infre-quency to justify placing on record this case. Asnearly five years have now elapsed since the date ofthe operation it is possible to add that the health ofthe patient is excellent and fully warranted the riskthat was taken in exposing him to an experimentalprocedure. At the time of the operation his conditionwas one of extreme gravity and apparently hopeless.For obvious reasons, that will be explained later,a general anaesthetic could not be administered.The use of an appropriately planned regional analgesiafor making a flap from the wall of the thorax was notan entire innovation, but there was no precedent toguide us as to the sensitiveness of the visceral peri-cardium and heart to such stimuli that the tearingdown of adhesions, squeezing, and ordinary tactilepressure might evoke. Operations upon the hearthad been done long previously to the discovery ofgeneral anaesthetics, and an excellent resume of thehistory of cardiac surgery from early days is given byBallance in his book " The Surgery of the Heart."But, as a rule, these operations were for severe woundsfrom which the patients were barely conscious and werehurried procedures that were necessitated by suchemergencies. Dobson,l in April, 1924, successfullysutured a wound in the heart under " local anves-

thesia." Another type of operation was for suppura-tion within the pericardium when simple incisionswere made to establish drainage. In this particularcase an exploratory pericardiotomy was carried outwith a purely regional and local analgesia in the hopeof discovering a lesion that could be benefited bysurgical treatment upon a patient who was so normallyconscious that he has forgotten none of the detailsof his experiences throughout the operation at thepresent day. The lesion found was a fibroplastic ipericarditis binding tightly the whole of the heartmuscle to the parietal pericardium with small lacunarspaces containing serous fluid intervening at intervals.The length of time taken to free the whole of the heartfrom its attachment to the pericardium was from10 to 12 minutes, and the whole operation occupiedabout 35 minutes. At no stage of the operation didany stimulus that was applied produce any sensationthat the patient was able to record in consciousness,and throughout most of the proceedings he chattedwith his nurse. Neither is this the sequence ofamnesia, as he can relate fully all the ordinary detailsof the operation that he observed at the present day.

1 Dobson : Brit. Med. Jour., 1924,

Lennander (Upsala) and A. E. Barker (London)showed 25 years ago by operations upon the conscioushuman subject with local infiltration of the abdominalwall only that the alimentary tract deriving its nerve-supply from the vagus and sympathetic nervous

systems was totally insensitive to all forms ofstimuli except traction. The visceral layer ofthe pericardium and the heart in the human beingderiving their nerve-supply from the same sourcesare shown by this operation to possess the sameimmunity to the stimuli applied in this case. Itwas further noted during the whole time when theheart was being manipulated that its beat wasentirely unaffected in any way that could be recog-nised by the hand of the surgeon, an observationnaturally of great relief to the operator. Therewas no subsequent reaction when the operation hadbeen completed : actually the patient had 12 hoursnatural sleep immediately afterwards and the pulse-rate fell within the same period from 148 to 130beats per minute. Such knowledge may extend con-ceivably the sphere of utility of cardiac surgery.The pathological condition that was revealed at

the operation fully explained the absence of anypathognomonic clinical signs for detecting its presence,as well as a reason for the cardiac shadow, examinedbeforehand on two occasions by X rays, showing littleor no variation from the normal. The parietal peri-cardium, which was fully a quarter of an inch thick,clamped the heart like the case of an oncometer,and thus rendered the occurrence of enlargementor displacement impossible. This condition has beenfound not infrequently in the post-mortem room incases of acute pulmonary disease as a lesion, thepresence of which had not been detected before-hand. It is possible that the lives of some of thosepatients might have been saved by the procedureadopted in this case, which enabled a systematicand painless investigation of the pericardial contentsto be carried out without the added risk of a generalanaesthetic to a patient already desperately ill.The purely medical aspects and clinical difficulties

of this case were under the supervision of Sir WilliamWillcox. I must express my thanks to him, to Dr.E. F. Furber, and to Dr. G. P. Selby (the father ofthe patient) for their unwearying skill and assistancein helping towards a successful termination ; and notleast to Dr. F. Rood for an induction of analgesiathat by its perfection gave courage and confidencethroughout an anxious procedure.

Details of Case.C. P. S., aged 21 years, an officer in the R.F.C.,

was sent to me on Dec. 2nd, 1920, suffering from anintractable neuralgia of the median and ulnar nervesand an axial causalgia of the phantom limb of a highamputation of the left arm. He had been shot downwhen flying behind the German lines, and in additionto many injuries a virulent spreading sepsis of acompound fracture in the region of the left elbow-joint ultimately necessitated amputation. Ten dayslater a violent secondary haemorrhage had beenarrested by an urgent application of a mass ligatureto the bleeding-point as he was lying in bed almostdead. (It is pleasing to put on record that he receivedevery possible attention at the hands of the Germanmedical service, and when the surgeon in charge ofthe hospital learned that the patient’s father was amedical man he took the trouble to write a full technicalaccount of the progress of the case on the back ofeach letter that the patient was permitted to writehome.) The symptoms suggested that the medianand ulnar nerves had been included in this ligatureas well as the blood-vessels. But the causalgia wasby far the more formidable sequela, and during itsagonising spasms clonic convulsions of the shouldergirdle muscles occurred as well as pink macularareas of vaso-dilatation over the same region.At the first operation on Dec. 15th, 1920, the

median and ulnar nerves and the brachial vesselswere found to end in a cone-shaped terminationdistal to which the nerves expanded into large