Australian Medical Journal: (February, 1902)

INTERCOLONIAL

MEDICAL JOURNAL OF AUSTRALASIA.

VOL. VII. No. 2. FEBRUARY 20, 1902.

Mrigin at Articteo. AN ANALYSIS OF SEVEN HUNDRED CONSECUTIVE

CONFINEMENT CASES.

By H. OSBURN COWEN, M.B., C.M. Glas., of Eaglehawk, Victoria.

[Read at the Sixth Intercolonial Medical Congress, Hobart.]

A perusal of the paper on Midwifery, read by Dr. Purdy at the

Brisbane Congress, suggested so many points of contrast with my

own practice, that I have thought it well to submit for the considera-

tion of this section a record of similar results arrived at by dissimilar

methods. The conditions and circumstances of my work were as follows :-

(1) A working-class neighbourhood, chiefly mining.

(2) No trained midwifery nursing.

(3) Responsibility has been assumed for all cases in which I have

been present before the delivery of the placenta.

(4) No time limit post-partum. Personally, I do not think the

statutory thirty days sufficient, as I have known cases in which, had

death occurred six or eight weeks subsequently, it would have been

as clearly due to the confinement as if but one week had elapsed.

(5) Miscarriages before the fifth month have not been included, though no fatality has occurred from this cause, as I consider them a

factor in a somewhat different equation.

(6) The cases have been taken in the course of a mixed general practice, and,. with very few exceptions, in spite of post-mortem

work, or the currency of a septic case. I feel some diffidence in

stating this condition, in view of the recent researches by the

Committee of the Melbourne Women's Hospital.

GENERAL PRINCIPLES.

In the general conduct of a case, my aim is asepsis for myself and

antisepsis for my patient. I rely more on nailbrush and soap than 1 F

58 Interco(lomal Medical Journal. Feb. 20, 1902

on any antiseptic, though I invariably, have a second bowl ,containing lotion beside me. After a post-mortem, and during the currency of a septic case, I take the additional precaution of submitting my hands and forearms to the routine detail required for surgical asepsis.

No emollient is used, and no ante-partum douching, unless there is a suspicion of specific disease, or I find that the nurse has been " trying the pains." The vulv ✓ are bathed with antiseptic lotion before each examination, and, more frequent/y, before the birth of the head. In primiparm especially, this can he done without exciting comment while one is attempting to save the perinwum.

I practise infrequent vaginal examinations, and am old-fashioned enough to think that abdominal palpation, in spite of all that

, is claimed for it, can never take their place. In at least 90 per cent. of cases, the condition of the maternal soft parts is of more import-ance to , the accoucheur than the position of the child.

I have discontinued the practice of post-partum douching, unlesa there is some obvious indication for it, when I do it myself, using separate tubes for the vagina and uterus, and a rubber reservoir, Higginson's syringe has been discarded as a dirty and dangerou instrument, over which one can exercise no efficient control.

For the rest, it is well for us to bear in mind that it is a natural

and not a morbid process with which we have to deal, and that Nature has provided very efficient safeguards for the parturient

woman in the way of secretion, contraction, and direction of flow. It is for us to do our utmost to avoid contaminating those secretions, or unnecessarily interfering with those processes.

PRESENTATIONS, &C.

In the series of 70o cases, the large proportion of 184 were primiparw ; the explanation being that, in my neighbourhood, a considerable number of the subsequent confinements are attended by midwives.

Of the presentations, 684 were cephalic ; of these, forty were noted as being occipito-posterior. This, however, cannot be taken as the full number of such positions, as some may have rotated before my arrival. My limited experience of occipito-posterior, positions inclines me to question the approximate accuracy of Dr. West's estimate, that not more than 4 per cent. terminate with the face to the pubes. Of my last sixteen cases, I find it noted that no less than seven terminated in this way, I am not at all satisfied

i nter. Med•" 11 Analysis of Seven Hundred Confinement Cases. 59 Feb. 20, 1902

with my practice for the correction of these positions. In the large

majority, I have found manual rotation difficult, and that the head

tends to resume the vicious position. I have not attempted rotation with the forceps on, notwithstanding Smellie's " great joy," as I do

not know what damage the blades may be doing in positions in which I am not accustomed to handle them. Still, it seems feasible that,

with the vertex below the brim, and a pair of straight blades, the

position might safely be corrected, and I shall be glad of expressions

of opinion and experience on this point. In view of the relative frequency of this position, and the much greater relative delay and

difficulty which it entails, the question of its forcible correction seems

to me to be most important.

There were three face and brow presentations and two of the

whole vertex, in which neither brow nor occiput showed any ten-

dency to engage. I can find very little as to this condition in the text-books, but I am quite clear that these were the two most diffi-

cult cases to deliver which have occurred in my practice. Both

were large square-headed children ; in both, the head remained high,

and the forceps showed an inveterate tendency to slip. Ultimately,

version was performed, and both children were born dead. Look-

ing back, I cannot but regard the failure with the forceps as fortu-

nate, since delivery by that means must have involved serious injury

to the soft parts.

There were fourteen presentations of the breech, one of the funis,

two mixed (one arm and head, and one hand and breech), and two

transverse.

Of three cases of placenta previa, two were partial and one

central, the latter accounting for the only maternal death in the series.

Of eight cases of twins, two were premature, and in two the

second child was stillborn.

ACCIDENTS.

Of three cases of eclampsia, one occurred during labour, one six

hours, and one sixty hours subsequently. The two post-partum

cases were very severe, but one has a much freer hand in treatment

when delivery has not to be considered. Of the various methods of treating eclampsia, I much prefer the

Preventive. I have notes of a case ,in which a woman came to

engage me only three days before her confinement occurred, corn F 2

60 Intercolonial Medical Journal. Feb. 20,190

plaining of loss of sight, shortness of breath, epigastric pain and

swelling of the legs. Vision was so much affected, that she even had

to feel for the food on her plate, and out of doors she saw a " cloud

of moving specks, just like a lot of sandflies." She was markedly

anxmic, and had a soft, rapid pulse. The urine was loaded with

albumen. It seemed to me that she presented all the conditions for a bad, and if it did supervene, a probably hopeless eclamptic attack.

I at once put her on milk diet, and a diuretic and sedative, and prescribed complete rest.

When called to her confinement, I gave a hypodermic of morphia, and, as soon as I had made an examination, put her under chloro-

form. Twitching of the corners of the mouth was observed, but nothing general developed. She was delivered instrumentally, and

made a good recovery as far as the confinement was concerned, though it was months before her renal and cardiac symptoms entirely disappeared.

Eighteen children were born dead, but of these six had been dead

for some time; one was hydrocephalic, two were the second of twins,

and one was born before my arrival, leaving only six which could fairly be attributed to difficult and retarded delivery.

In six cases only has there been serious post-partum hemorrhage,

two occurring in the one individual ; on the second occasion in spite of careful preliminary treatment for three months with ergot and

strychnine, the exhibition of ergot when the os was dilated, and con-stant control of the uterus from the moment the head was born.

In 684 head presentations, forceps were applied rob times, or, on an average, once in six-and-a-third labours. During the first four

years covered by the series, forceps were used in fifty-seven cases out of 291, and during the second four years, in fifty-one cases out of 393 —the former representing a frequency of one in five, or 20 per cent.; the latter, one in seven and three-quarters, or 13 per cent. Of 184

primiparx, sixty-five were forceps cases, an average of one in less

than three, or 35 per cent; but for the first four years the percentage was 40, and in the second it fell to 3o per cent. Even these per-

centages sound high, but not when compared with Dr. Purdy's

figures, which show sixty-four applications in eighty-five primipar, equalling 75 per cent.

I do not propose to deal at length with the very difficult question

of forceps delivery. It will be seen from the above figures that my

tendency has been to a greater conservatism in their use, to the

Inter. Med. Jul] Feb. 20. 1902

Analysis of Seven Hundred Consecutive Cases. 61

advantage, I am fully persuaded, of both mother and child. In my

last loo cases, which include twenty-eight primiparae, I find I have

only used forceps eight times, six being in primiparw, and yet I do

not hesitate to assist when I find that Nature is not effecting

progress. Milne Murray's aphorism is excellent—" Only apply the

forceps when the danger of delivery is less than that of delay "—but

what a rare amount of wisdom and experience its true interpretation

requires ! I learn from a friend, recently in residence at the Rotunda, that

the use of the forceps is much less frequent there than it was a few

years ago, and I hope that Dr. Jellett will see fit to include in his

most valuable appendix, statistics as to the condition and frequency

of forceps application, and the percentages of injury and morbidity which it carries with it. Of this I feel sure, that forceps are used

too early, and much too often, and that this is a factor in the main-

tenance of the high puerperal death-rate. We have been too ready

to take advantage of the immediate immunity afforded by antisepsis, and to lose sight of the more remote effects. Still, it must not be

forgotten that it is to the abuse of forceps we owe the development

of gynaecology. I retain my preference for the Barnes-Simpson

pattern, with all-metal handles, using a tractor when required. I

do not secure the handles in any way, the screwing down of the

head in the ordinary axis-traction instrument constituting my

personal objection to its use. In primiparpe, I always remove the

blades when the head is well down on the perinxum, and I further

seek to avoid rupture by following the head down with the perinaum

until I see that its largest diameter is about to engage, when I tilt the

occiput backwards, and slip the perinum over it in the absence of a

pain. The question as to removal or non-removal of the blades at

this point seems to me to be simply one of gradual versus rapid

dilatation.

THE MANAGEMENT OF THE THIRD STAGE.

This, more than anything else, marks the dividing line between

safe and dangerous midwifery. In it lies the key to the prevention

of post-partum hxmorrhage, and in the great majority of cases,

of puerperal sepsis also. Antiseptic precautions may carry the

accoucheur safely through many an error in the use of the forceps,

but they will not save him from the consequences of want of thought

and want of patience in the delivery of the placenta. So far as I

62 Intercolonial Medical Journal. Feb. 20, 1902

am aware, it is only within the last few years that the necessity for a more rational and deliberate treatment of the placenta has been borne in upon the profession at large. Crede's method had become

a positive fetish, and comprised all that was worth knowing about

the third stage of labour. It was indeed all that I carried away of the teaching in my own student days on the subject. And yet, practised as it has so generally been without limitation as to time and force, I take it to have been the most important factor in the

maintenance of the puerperal death-rate. It is not I think gener-ally remembered that, shortly before his death, Crede recommended a lapse of thirty minutes before his method was to be attempted.

My own practice is to follow down the uterus after the birth of the head, and then, with the hand over the uterus, to watch rather than control it for twenty minutes. I am sure I did harm, in my earlier

cases, by trying to maintain contraction of the uterus at this stage ;

it is not Nature's way ; it is goading the jaded steed, which only asks

rest, and it will do all that is required. I have not seen hour-glass contraction since I abandoned this procedure.

After a few pains, the uterus will be found to rise above the pubis, this signifying, according to Professor Byers, that separa-

tion of the placenta had been effected. Then, during a pain, with

the whole hand square above the fundus, I follow down the uterus,

and it is not until I have repeated this manoeuvre without success that I attempt expression by Crede's method. In more than 95 per

cent. of my cases, nothing further has been required. If, however,

after the lapse of half an hour, further attempts at expression give

the impression of organic immobility, which one soon comes to recognise, I do not hesitate to remove the placenta manually. I

find that this has been done twenty-five times in all, including the removal of retained membrane, and I shall be interested to learn

how this percentage of 3+ compares with the practice of others. With careful preparation of the hand and forearm, I have found the

procedure both safe and satisfactory, and I am convinced that the

warnings of the older text-books, as to the very grave danger of

the proceeding, have often tempted the attendant to employ force sufficient to detach the main body of the placenta from an adherent

portion. It is only in cases in which true expression has been em-

ployed that I find difficulty with the membranes. I then support

the placenta on the palm of the hand, and, waiting for relaxation of

the uterus, use gentle traction in the axis of the canal, always stop-

Inter. Med. Jul.] Analysis of Seven Hundred Confinement Cases. 63, Feb. 20, 1902

ping short at the slightest suggestion of a " give." I prefer this to,

the method of twisting the membranes so commonly recommended,

as this seems to re-inforce the stronger as against the weaker por-

tions, and so to increase the liability to tear.

.As a matter of routine, the placenta and membranes are examined, and if I conclude there has been retention of a portion, I go in

search of it at once. In cases where early escape of the liq. a,mnii suggests that the membranes are unusually friable, additional care

is necessary in the removal of the placenta. In such a case, I have

known the placenta to appear stripped entirely of membranes by its

own weight.

THE POST-PARTUM PULSE-RATE.

On the conclusion of labour there occurs, in a fair proportion of

cases, a phenomenon, to which it seems to me sufficient attention

has not been given. I refer to a marked fall in the pulse-rate. One text-book speaks of this as beginning eight to forty-eight hours after

labour ; another, vaguely, , as being most marked on the second or

third day. I have notes of, its occurrence in nine out of my last zoo

confinements. Of these, three were in first cases, and gave the

following counts :— (r) Ante-partum pulse-rate not recorded, but next morning pulse

was fifty, counted to the full minute, and on the third day it was

fifty-eight.

(2) Ante-parturn pulse-rate sixty-five to seventy; fell to forty-four

within a quarter of an hour after expulsion of placenta.

(3) Very tedious case ; pulse sixty-four before putting on forceps

under chloroform ; placenta was expelled spontaneously, and pulse

fell to fifty-three. Two were second cases, one a third, two fourth, and one sixth. In

the last, the ante-partum pulse-rate was sixty-six, and there was

great distension of the uterus, both placenta and child being very

large ; six hours after the pulse was forty-five, and on the second day sixty. They all gave counts of fifty-three to forty-eight. In one

only was the lowest count noted as occurring thirty hours after, and

in the remaining eight it was just after the expulsion of the placenta, These are cases which almost invariably make good recoveries,

and it may be inferred from this that there is nothing pathological

is the phenomenon. The explanations offered in the books, that

it is due to the mental and physical :rest which follow delivery, and


the sudden diminution in the amount of labour put upon the heart, &c., do not at all satisfy me. These are common to 95 per cent.

of confinements, but the fall in pulse-rate occurs in but a small percentage. I am not prepared to define the true significance of the phenomenon, but I have a suggestion to make as to its occurrence. I premise that the parturient woman has a varying

physiological amount of blood to lose. When this is exceeded, the

pulse rises, and much in proportion to the excess, the heart being spurred to supply the wants of the economy with a diminishing

quantity and quality of blood. On the other hand, when less than

the usual amount of blood is lost, and this has been true of all the cases I have observed, the heart has more blood for distribution than is actually required, and beats more slowly until the status quo is regained. It may be, too, that the infrequency of septic com-

plications in these cases is explained by the engorgement of the circulation reducing absorption to a minimum. I would commend

this subject to the careful consideration of maternity hospital residents, and others, whose opportunities for exact and frequent observations are so much greater than my own.

PUERPERAL SEPSIS.

It is pathetic, in reviewing the medical journals of the past ten years even, to note the elaborate attempts at the classification of puerperal fever. As late as June 1894, the Lancet reports a discus-sion at the Royal Academy of Medicine of Ireland, on the Etiology,

Prevention, and Treatment of Puerperal Fever or Septicaemia. It

was introduced by a gynecologist of world-wide reputation, and in

the course of his remarks, he spoke of the epidemic diffusion and

local prevalence of puerperal septicwmia due to air-borne " germs,"

much as if he were discussing a disease of the nature of measles or

scarlet fever. I venture to say that no ordinary practitioner to-day,

who makes claim to the modern point of view, would for a moment

think of sheltering behind a proposition such as this. To-day we acknowledge, not without fear and trembling, that sepsis occurring

in a healthy woman during the puerperium, is due to some error on the part of her attendants.

But not only has the old complicated view of these conditions

failed to lay the blame on the right shoulders, it has also created a paralysing amount of needless alarm. I have had, I regret to say, several cases of sepsis in my series of 700, the most serious of which

Inter. Med. JnI1 Analysis of Seven Hundred Confinement Cases. 65• Feb. 20, 1902

I reported at some length to the Victorian Medical Society ; but

they have all without exception yielded to treatment. I attribute

this to the simplification of the situation in my own mind. For all practical purposes, puerperal fever, so-called, has resolved itself into

secondary infection of retained membrane, placenta, or clot, or of

vaginal or uterine laceration.

Of true septicaemia or systemic infection occurring at the time of

the confinement, I can only recall one case, which was attended by

a midwife, and to which I was called subsequently.

As soon as I am persuaded of the existence of sepsis, I at once

give an intra-uterine douche of warm carbolic or lysol solution. If

after repetition of this no improvement takes place, I proceed to

curette. I have quite ceased to regard elaborate warnings against

primary curettage during the puerperium. I am fully persuaded of

the immediate necessity for an early and thorough toilet of the

parturient canal, and the removal of all infectious material. My

statistics are not complete upon this point, but so far as I can find a

morbidity even as high as Io per cent. has not carried with it more

than a I per cent. necessity for curettage, using the term morbidity

to denote, as in the Rotunda statistics, all cases in which the tem-

perature has once risen above mo.8°.

As to the wisdom of curetting when secondary endometritis has

become established, I am not prepared to express an opinion ; that

is another and much more difficult question. The academic discus-

sion of puerperal sepsis, especially from the side of bacteriology, has created such a maze of technicalities, that amid the bewildering

profusion of deviations—saprmic, toxmic, and bacterial—the

practical obstetrician is in danger of missing the straight path to the

duty that lies before him.

A PLEA FOR " STANDARD DETAILS " IN MIDWIFERY.

It will be said that a series of boo cases, without a death from

sepsis, cannot be held to establish definite conclusions on such

important questions as the use of the forceps, the management of

the third stage, or even the proper treatment of sepsis itself. Since

this paper was prepared, however, a record in every way better, of

over goo cases with one maternal death, has been read by Dr. W.

B. Walsh, of Kew, before the Medical Society of Victoria, and it

would seem that it is only by the careful collation of more and more

exact records that we can hope to approach finality on these points.

66 Intercolonial Medical, Journal. Feb. 20, 1902

They have been discussed ad nauseant and ad infinitum, but without appreciable advance towards certainty. Some definite pronounce-ment is imperative. While the profession hesitates, women die, because the onus of decision, day by day, and in the weary watches of the night, is laid upon the individual practitioner.

In engineering, I am told, certain details of construction are taken for granted by designer and builder, which greatly facilitate the work of each. These are known as " standard." Now, while it is not machines we have to consider, yet parturition is a process sufficiently true to type, in power, mechanism, and result, to admit of certain definite generalisations ; and I am convinced that the efficiency and safety of our practice would be greatly enhanced by the enunciation of " standard details " in midwifery. The standard-isation of surgical technique, while still leaving scope for the initiative and skill of the brilliant operator, has led to a notable improvement in general results, and a not less notable increase in public confidence. And obstetrics will not be brought into line with this advance, until some such unanimity has been attained. We all deplore the maintenance of the high death-rate in private practice from a preventable cause, such as puerperal sepsis. But no sensible improvement can be looked for until we leave the shifting sands of individual experiment for the sure standing ground of collective experience.

Chitral an tIcro4:ritat 4ecorbe. " Imperat, ecce, suis nova nostra Australia doctis,

Quod discis, comites, jussus ah arte, doce."

HEART DISEASE IN CHILDREN—THE SYPHILITIC

FACTOR.

By WILLIAM MACKENZIE, M.D. Melb.

That the prognosis of heart disease in children is uncertain is generally admitted; that the prognosis is on the whole unfavourable, no matter what the origin, is also admitted. From a study of the following, which have been taken from a series of some fifty cardiac cases, an endeavour is made to point out the immense importance of a healthy heredity in the prognosis in children, and to show-

Inter. Med. JnI.1 Heart Disease in Children. 67 Feb. 20, 1902

(a) Why the disease runs a more rapid course in some cases than in

others ; (b) the relation of dropsy to heart disease in children ; (c) its

determining factor and relation to longevity. We may consider cardiac patients as met with under four distinct

classes :- Class I.—Patients who are the subject of heart disease, be it of

rheumatic or choreic origin, may return into hospital again and

again With heart failure as manifested by dyspncea, cervical pulsa-

tion, quick feeble pulse and diminished urine, but no dropsy, no

albumen. Such patients respond well to rest and cardiac tonics,

and get toned up time after time. Class II.—When dropsy does occur (if at all), it does so later on in

life, generally about puberty—the stage of life beyond which the

cardiac patient is rarely allowed to pass, and at which difficulty of

compensation, even in a healthy patient is experienced, should the

origin be a recent one. These two classes refer to the ordinary cases, i.e., rheumatism

and heart disease, with a basis of healthy heredity, and form the

vast majority of cardiac cases in childhood. Class III.—A class of patients developing rheumatism with endo-

carditis, and showing manifestations of heart failure without dropsy,

as a rule, fatal in from one to five weeks ; or a class with like

symptoms and course, and little or no arthritic manifestations. Class IV.—If such patients live longer, whether as the result of a

good resisting medium or an insufficient infection, they develop an

early dropsy, and death (unless especial care be taken) occurs during

the first twelve months, rarely later. These last two classes, to which the subsequent histories and

statements are mainly directed, refer to attacks of rheumatism and

endocarditis, or endocarditis sine arthritis in syphilitic subjects, and

such cases show clinically little response to the use of cardiac tonics

and rest. The following cases may be taken as illustrating the vulnerability

and the lessened resistance of patients with the luetic taint, to what

may be regarded as slightly infective attacks, which the healthy

patient would readily repel, or at any rate, postpone serious symptoms

for a considerably longer period. In two of these cases, definite

attacks of arthritis preceded the onset of the endocarditis. In all

the acuteness of the infection, as judged by the temperature, was not great. In all cases the patients went rapidly down hill, and in those


. treated showed no response to cardiac tonics or stimulants, or to

treatment directed towards the rheumatic state. In no case was

dropsy or albuminous urine a feature of the failure. In all, so rapid

was the down grade, as to suggest a malignant endocarditis, of

which, however, there was no clinical or pathological evidence :—

CASE I. J. T., aet. 5, male, was admitted into wards, September 20, 1900,

with the following history:—Ill two weeks, but especially so during the

last few days ; no previous illness. First complained of vague pains

about legs and joints, which were stated to be slightly swollen. Has now, on admission, a bad cough, pain in left side, gets short of

breath on any exertion, appetite fair, no vomiting, febrile evidences.

On admission, respirations 68, soon falling to 52, then 44, and in

three days 28 ; temp. 104°, falling in two days to 99°, and never

after exceeding 99.6° ; and a (?) pericardial rub, which had apparently cleared up in five days sine effusion ; a few scattered rhonchi over chest.

September 26.—Friction rub apparently gone, but now a well-marked presystolic murmur heard at the apex as a maximum intensity, and heard faintly in the axilla. Pulse 120 ; respirations 46 ; temp. 97.6°.

September 28.— Relative dyspncea, pulsation in epigastrium, precordial distress, apex beat diffuse, and a murmur to be detected

over lower sternum. Temp. 99° ; pulse I 12 ; respirations 56. From 1st to 19th October, the condition was variable, but ever on

the down grade. At times dyspncea lessened, and at others marked. The temperature fell eventually to subnormal. Pulse 132 on

admission, soon falling to 110, and at end, fluctuated from 76 to 64. The patient died on October 21, i.e., about six weeks from the

onset of . the illness, with dyspncea, an aemia, vomiting, and precordial distress as prominent features. Pulse 78 ; temp. 97.4° ; respirations

56. At no time was there any semblance of dropsy. Urine varied

from eight to twelve ounces daily ; specific gravity, average 1020 ;

no albumen at any time. At first treated with sodium salicyl. ; later, with mag. sulph., digitalis, strychnine, brandy.

CASE II.

C. B., xt. female, admitted on October 22, 1900, with the following history :—First came to Out-patient Department five days

previously, complaining of a swelling in' right foot, the " result of

Inter. Med. Jul.] Heart Disease in Children. 69 Feb.20.1902 J

a tight shoe." On examination, the right ankle and foot were

swollen and painful, with tenderness in the right knee as well. No

previous illness. Mother had the luetic facies and history of mis-

carriages. In the Out-patient Department, a bruit was detected,

audible in the mitral area, at first localised, but afterwards trans-

mitted to axilla. For this she was treated with sodium salicyl.

During the next few days the child's condition became worse, and

she was admitted into hospital. On admission, temp. Ioo°, pulse 96, respirations 26, lungs clear,

vesicular murmur harsh and puerile ; no dulness. Child looking much

worse, apex beat at first not displaced, but now diffuse ; bruit marked, and transmissible into axilla. Later, child pale, pulse 132,

temp. 99°, evident dyspncea. Pulse quick, poor volume and tension;

bruit still marked and transmissible ; no oedema ; joint swellings

subsided. In the ward, the clinical picture was not unlike a peri-

cardial effusion—pallor, dyspncea, weak pulse, poor volume and

tension, no anasarca. No symptoms suggestive of embolic plugging.

The patient got rapidly worse, and died on October 25, with dyspncea, vomiting, and anemia as prominent symptoms, but no

traces of cedema. Temp. subnormal at end ; pulse 122 ; respira-

tions 64 ; urine averaged twelve ounces in twenty-four hours;

specific gravity 1020, acid, amber, and at no time was albumen

found in the urine. CASE III.

V. M., female, admitted October 1, 1901, with a slow pulse, slight

cyanosis, and vomiting as prominent features. First commenced to

get ill the week before admission, but three days ago became worse,

with pain in the stomach, retching, and vomiting. Bowels regular ;

no headache ; facial congestion since yesterday ; very restless ; no

head retraction ; passes urine very frequently. Pulse slow, 40 ;

respiration rapid, 50 ; temperature subnormal. October 4.—No Kernig's sign ; knee-jerks normal ; superficial

reflexes present ; no tache ; no paralysis ; still facial congestion.

Pulse 54 ; respirations 40 ; temp. subnormal. Screams at times, but

no head retraction. Pupils equal and small. Lungs clear. No cardiac

bruit detected, but heart's action irregular. Liver enlarged, and

extends nearly down to the level of the umbilicus. Is very irritable

when touched. Prefers the upright position in bed. Seems very

thirsty. Vomiting persistently since admission. No cedema present.

Retained nutrient suppositories.


Death occurred suddenly three days after admission, shortly after an examination of the chest in the upright position. There was no albumen in the urine. Pulse was slowed till the last, 40 to 58, but the respirations continued rapid, 36 to 54. Patient was on brandy, 2 ozs., in wards.

Family History.—Mother had a miscarriage since V. M. was born. Both parents are said to be " quite healthy." When very young, V. M. had been ill with diarrhoea and wasting, and said to have " marasmus." There was no snuffling then. Said to have had buttockal eruptions. Mother did not notice any facial congestion till the day of admission. Bowels acted well since admission.

CASE IV. G. V., female, wt. 6, admitted October 3, 19o1 ; died October 12,

1901. Ill five days before admission. At first the condition resembled an oncoming typhoid attack ; but later, with the onset of unconsciousness three days after admission, the clinical picture resembled tubercular meningitis. There was no albumen in the urine. Lumbar puncture gave no fluid. A systolic bruit was detected at the apex. Death occurred suddenly nine days after admission, with dyspncea and vomiting as prominent symptoms. Pulse varied, 96 to 156 ; respirations 24 to 28 ; temperature 98° to Ica°.

A family history of lues was unobtainable.

CASE V. Female, 20 months old. History incomplete. We were only

called in to make the autopsy, the data being obtained from the parents. It probaby represents a condition more common than is generally supposed, and too often called gastric or pneumonic. The child was ill only three days. At onset, vomiting, fidgety, and off food ; hot and feverish at times. Shortly before death, had an attack of twitchings and convulsions, and seemed to have abdominal pain. Death occurred in three days, with pallor and increased respirations as prominent features.

A fairly distinct family history of lues was obtained.

CASE VI. N. G., male, wt. 8. The clinical history resembled a severe

typhoid or a meningitis. Patient was admitted with delirium, reten-tion of urine, tache, obstinate constipation, slight Kernig's. There was slight basal pneumonia present.. Urine contained no albumen.

Inter. Med. Jnl.1 Heart Disease in Children. 71 Feb. 20, 1902

Child had been ill one week, and the illness had been ascribed to ,

gastric derangement, the result of ingestion of mulberries. Uncon-

sciousness occurred twenty-four hours after admission, and persisted

till the end. Lumbar puncture and Widal gave a negative result.

Cystitis developed. The second cardiac sounds were accentuated,

but no bruit was detected. No dysphagia. Liver dulness extended

two inches below the costal edge. Pulse varied 78 to 156 ; respira-

tions 24 to 26 ; temperature 98° to roe.

Death occurred suddenly five days after admission, dyspncea being

at no stage a feature of the attack.

CASE VII

Was especially interesting, as the attack developed in the wards.

E. G., male, wt. 7, was admitted into hospital with an ununited

fracture of the femur. On the day for discharge, a slight rise of

temperature was noted, and he was retained in the wards. Next

day, though the temperature had fallen, the boy was evidently ill; vomiting, collapse, pallor, quick pulse, and increasing respirations.

Good abdominal breathing ; nothing abnormal in lungs ; first mitral

sound was murmurish. His condition gradually became worse ;

coldness of the extremities, pallor, tachycardia, pulse registering 18o,

and death occurred on third day.

In this case there was a fairly distinct luetic history, and about

the aortic valves (post-mortem) several early atheromatous patches

were detected.

Since writing the above, no less than five cases (all fatal) have

come under notice. One had had membranous faucitis two weeks

before admission to hospital. The liver extended three and a half

fingers' breadth below the costal edge.

Another, a boy, wt. 21-, had had varicella, the impetiginous sores

taking on a rupial character. The child, who was collapsed on

admission, dying in eight hours, had been seriously ill two days.

Facial congestion, increased respirations, temperature subnormal,

and rapid pulse, were features of the condition. As the post-mortems of these cases (with certain variations in the

individual case) were practically identical, no purpose can be served

in recording each separately. The following description may be regarded as typical of this

class :—The heart in all these cases was slightly smaller than

normal. The right heart and tricuspid orifice, as a rule, were little


dilated, and in only one case were a few vegetations detected on the

valve. Hypertrophy of the left ventricle, when present, was slight.

The important changes were at the mitral valve ; round the edge of

these there was a limited inflammatory areola. The valves showed

recent vegetative fringes on their surface, especially the anterior

cusps, which were narrowed and contracted, and in some cases

bound down with the chordae tendinem tightened. In some the

adjacent auricular endocardium was thickened and fibrous. The

pericardium as a rule showed little change. Lungs.—In one case

carnification of the lower third of the right lung occurred ; in others,

areas of recent consolidation were present ; some basal congestion

was present in the majority. The brain showed nothing abnormal

in any case. The liver was firm, tough, inelastic, enlarged, and resisted cutting ; the smaller vessels showing out abnormally on

section. In some, fatty areas were seen on the surface, extending into the substance of the organ ; in others the fatty changes were more

marked. The spleen was enlarged, and tougher than normal.

The pancreas was in most cases much tougher and fibrous than normal, especially towards the head. The kidneys showed little

macroscopic change ; as a rule, slightly tougher than normal. Capsule peeled readily, and in only one case was the cortex

narrowed. The thymus showed little macroscopic alteration.

The most noteworthy feature in connection with the preceding class is that all the cases ran a fatal course, a fact quite sufficient in

itself to justify the assertion of the seriousness of the condition.

At the outset, we have to consider either a strong invasion of the

individual, or a weakened resistance, or both combined. In any

diseased condition of childhood, the luetic taint, if present, must he

considered paramount, and too often explains the fact that an acute

inflammation may in one case rapidly resolve, and in another, though

of less intensity, prove rapidly fatal. And similarly, granted any

affection of the cardiac valves, apart from the initial difficulty of

overcoming the toxicity of the infection, the question of adequate

response to overcome the obstruction due to a diseased valve must

depend on the inherent quality of the heart wall itself, and if this be

diseased, a fatal course (though postponement for a time may take place) is inevitable.

That the cases present a diversity of clinical signs no one denies,

and yet in most, by a process of exclusion, an accurate opinion was suggested.

Inter. Med. Jn1.1

Heart Disease in Children. 73 Feb. 20, 1002

In Cases V to VII of the series, the clinical history was short,

and suggestive of a malignant endocarditis, but the intensity of the

symptoms was not present, and the amount of valvular change post-

mortem relatively small, yet the visceral derangement was great, and only wanted a terminal infection to bring about the inevitable end.

In Cases III, IV, and VI, the symptoms were largely meningeal,

and only by a process of exclusion was a diagnosis of tubercular

meningitis doubted, and yet, post-mortem, the brain showed no

change. In these three cases, pneumonia of a varying degree was

present, and besides being a big factor in the causation of death,

was also an important ally in the depression preceding it. In the

case of V. M., the pulse was slow and death sudden, and suggested

a toxic interference with the function of the vagus. Cases I and II

resembled the endocarditis of a rheumatic arthritis at the outset, but

their rapid termination pointed to some additional factor to that

ordinarily met with.

In connection with such cases, two points suggest themselves—

(I) Granted that these were cases of an ordinary rheumatic endo-carditis, why did they run such a rapid and fatal course ? Why

did they not respond to ordinary cardiac or rheumatic treatment ?

(2) Granted that these cases died of a progressive heart failure, why

was not dropsy a prominent feature of the condition. The fact that

a child has lues must be comparable to the adult with phthisis, or

the old man with cirrhotic kidneys. In these, the general vitality is

lowered by the chronic process, their vulnerability is increased, and

given the exciting cause, e.g., pneumonia or nephritis, the end soon

comes ; and in these cases, just as the syphilis has attacked the liver

and spleen, so also is it probable (microscopic evidence notwithstand-

ing) that it has attacked other of the viscera as the heart, so that in

addition to the endocarditis, a probable syphilitic myocarditis may

be assumed.

As regards Case II, e.g., such a patient could not be regarded as

having died of an ordinary right heart failure, for of this there was

no positive evidence ; the death was rather an asthenia, a defective

nourishment, an ill-effected blood supply, from the failure of vis-a-

tergo of a left ventricle to do its work, and functional impairment

of all the organs thereby resulting. In other cases, however, where

life had been prolonged, dilatation of the right heart and congestion

of organs were present, but no dropsy.

In ordinary heart cases in children, we recognise the stage of heart failure sine dropsy (seen so frequently in the wards), in which the

1 G

74

Intercolonial Medical Journal. Feb. 20, 1902

symptoms are dyspncea and cyanosis, and death, as in the case of aortic regurgitation, comes through the portal of an acute dilatation of the ventricles and paralysis of the wall. Postpone the death as we so often do by rest and treatment, allow a condition of vessel hypoplasia to be produced, and we get the heart failure of later life, associated with a gradual rising dropsy and albuminous urine. But in syphilis, apart from the late right heart failure—for these patients rarely live long enough to see what must be regarded in their cases as a salutary lesion—we may get, and often do, a dropsy in the primary stage of heart failure which, as shown by the next series of cases, is only explainable on the assumption of a syphilitic hypo-plasia, with leaking and diminished absorption through the vessel wall. In these cases, the absence of the cedema in this early, and in their cases terminal, stage of heart failure, is only explainable by one of two conditions—(t) Either that the resistance was so lowered that death rapidly ensued by asthenia before the dropsy was mani-fest (for in the next series of cases the cardiac history was of a much longer standing) ; or (2) that the syphilitic degeneration of the blood-vessels was slight, and the visceral affection marked.

The prominent features in the diagnosis of these cases are :—(r) A patient going rapidly down hill from no apparent cause ; (2) a pulse rate greatly increased—poor in volume and tension ; (3) the tempera-ture little, if ever, raised—generally subnormal ; (4) dyspncea par-taking of the nature of air-hunger—the patient, especially towards the end, literally fighting for breath ; (5) pallor, and in some cases, profuse sweating ; (6) vomiting ; (7) a bruit is not frequently to be detected over the heart.

As for treatment, the mortality rate shows the hopelessness of the condition. Sodium salicyl., ammon. acet., and quinine are of little use, and digitalis, opium, and strychnine probably hasten the end. The two most important drugs are brandy and hydrarg. perchlor., the latter owing its property, not only to its antiseptic action on the toxines, but also to its power of increasing the resistance of the individual, owing to definite syphilitic action. These are the two remedies that in our hands seem to be of any benefit at all.

The next series of cases deal with Class IV, and have special reference to the occurrence of dropsy :—

CASE I.

C. M., male, 7i, was first admitted to the Children's Hospital on October 10, 1899. Patient complains of stiffness down the legs

Inter. Med. JnI.1 Heart Disease in Children. 75 Feb. 20, 1902 J

and joint pains, also occipital headache. Has been ill one week ;

febrile evidences ; no previous illness.

On examination, lungs clear. Heart.—There is some retraction

in the second left intercostal space, and a diffused impulse for a

couple of interspaces below the nipple, and extending as far to the

right as the tricuspid area ; apex beat is inside nipple line. On

auscultation, there is a distinct murmur in the fifth and sixth spaces,

not conducted far into the axilla, and rather limited in area. In the

other areas the heart sounds are clear.

October 19.—Severe cough ; basal crepitations ; heart sounds

weak.

October 3o.—Much better ; heart quieter ; takes food well.

Patient was signed up rheumatism and endocarditis, and sent to

Brighton on November 18.

December 27.—Re-admitted with some dyspncea sine dropsy.

Discharged February 1, 1900.

All went well apparently for some time, but in spite of as much

enforced rest as possible, and tonic treatment, he had to be re-

admitted into the wards in a collapsed state on June 2, with all the

evidences of a right heart failure, cough, cedema of the extremities,

cervical venous pulsation, dyspncea, and slight ascites. Had to be

propped up in bed on account of the dyspncea. Urine, 121 ozs. in

twenty-four hours, one-quarter albumen ; and a regurgitant bruit in

the tricuspid area. The patient showed no response to treatment—

digitalis, strychnine, brandy, mag. sulph.—and died June 15, 1900,

i.e., under twelve weeks from the time of admission, and eight

months from the previous rheumatic attack.

CASE II.

NI. M., at. 1l, sister of the preceding, admitted into wards on

October 15, 1900. On admission, said to have had " dropsy " for

the past two weeks sine albuminuria, and had been treated for

undoubted rickets. On examination, there is cedema of the feet and legs—hands, face,

and of the trunks slightly. The child is pale. Urine averages 6 to

8 ozs. in twenty-four hours, and is free from albumen. No venous

cervical pulsation. Apex beat scarcely defined ; no dyspncea. A

bruit is detected all over the precordia, with a maximum intensity

over the second left space. 1G 2

76 Intercolonial Medical Journal. Feb. 20 1902

Four days after admission, the patient had a severe " c:rdiac spell," with suffused face and extremities, with coldness, and a scarcely detected pulse, lasting several hours.

November 5.—Had a somewhat similar attack, and died.

At the autopsy, the liver and spleen were toughened, but the kidneys showed little apparent change. The right heart showed

considerable hypertrophy, a pulmonary stenosis being present ; no

valvular change. In this case, we have to do with a dropsy sine albuminuria, not running the gradual course of a cardiac dropsy,

unassociated with venous pulsation, and no dyspncea present, and

post-mortem, a congenitally obstructed pulmonary orifice, with a

fully compensated, and not a failing, dilated ventricle. The cedema

could scarcely be called that of a right heart failure. It was scarcely a congestive one, e.g., no albumen in the urine, and the kidneys showed little pathological change. She had a first syncopal attack,

from which she recovered. She died in the second, i.e., really a weakened left ventricle, unable to maintain a sufficient tension in

the arteries (a difficulty increased mechanically by the fluid exuded).

Assuming the factors in the causation of dropsy to be—increased

exudation, diminished absorption, or a combination of both, and such changes to be dependent on venous stasis from right heart failure, or degenerative changes in the vessel wall itself, the latter

change in the causation of cedema in this case must be considered

paramount, for the right side, curiously enough, was shown post-

mortem compensatorily hypertrophied, and such disease was, on the

face of it, apparently syphilitic in origin. In this family a luetic

history was undoubted. The mother had several miscarriages, rapid

death of two children, and post-mortem evidences, and a third boy

" alive and healthy," who on examination showed degenerative arteritis and a displaced apex.

In a somewhat similar case brought before the London Clinical Society last year, there was considerable diversity of opinion, Dr.

Ewart regarding Herringham's case " as an illustration of a special disease not yet described."

" No explanation of this cedema is found in the urine. It is not albuminous. It is frequently very scanty, but is sometimes

apparently normal in amount. Opportunities for the examination

of the kidneys have been afforded in several instances, and these

organs have been in all cases normal, even upon microscopical examination."—Holt.

Inter. Med. JnI.1 Heart Disease in Children. 77 Feb. 20, 1902 J

Since writing the above, a case was seen in private. It was

referred to the Children's Hospital, and died in three days. The

child, a female, 4 months old, was brought up with swelling of the feet and legs and puffiness of the hands. There was scaling of

flexures of limbs, hands, and feet, oral fissuring, and buttockal

eruption. A diagnosis of congenital lues was made at the autopsy conducted by Dr. Stephens, to whom I am indebted for permission

to make the note. The heart was found to be small and pale, but

no valvular affection noted. The liver large, soft, and fatty ; the

spleen not enlarged, but tough ; the kidneys showed little change ; the bases of lungs tough, and tending to be carnified ; the pancreas

toughened, vessels prominent. Microscopic sections are to be

prepared. There was no albumen in the urine.

CASE III.

N. W., male, wt. 3, admitted into hospital collapsed, and died a

few hours after admission. Had been ill only three weeks. Onset

with vomiting and increasing dyspncea. On admission, cedema of limbs, facial cyanosis, dyspnoea and

vomiting. Owing to the exaggerated breath sounds, the cardiac

ones were scarcely audible. Urine had been scanty all along, and

an examination shortly before death showed it to be acid, specific

gravity 1020, and slight albuminuria. This was the earliest period in the series of cases in which dropsy

developed.

CASE IV.

M. P., female, wt. 9, admitted August 26, 190 ; died October 8,

1901. Had been quite well up to the preceding January, when she

had an attack of rheumatism, since when has never been well. Was

not treated by a medical man On admission, poor development, pallor, relative dyspncea coming

on for last two months ; no cedema ; no albumen in urine. A well-

Marked mitral murmur heard at the angle of the scapula. Liver

one and a half inches below the costal edge. Yet though this girl

had every attention, rest, cardiac tonics and the like, she gradually went

down hill, dying with cedema, dyspncea, albuminous urine diminished

in amount, vomiting, as prominent features, in less than two months

from admission, or nine months from the initial endocarditis.

In this case other family evidences of lues were present.


The cases of the latter class are those in which the initial valve

infection was overcome, either as a result of a not too intense

invasion, or a fair resistance on the part of the individual. Nature

endeavours to compensate the lesion, but the imperfection of the

cardiac hypertrophy is shown by the rapidity with which heart failure manifests itself, all our cases returning with dropsy and

dyspncea within six months, a condition quite unknown in connection

with the rheumatic endocarditis of the otherwise healthy individuals

who, if their heart does show signs of early failure, are toned up quickly,

and such failure is clinically never associated with dropsy. Some

other factor than mere heart failure must be adduced to explain the

fact that a pure rheumatic heart failure for a considerable period is

unassociated with dropsy (at any rate till on towards the stage of

puberty, when degenerative nutritional changes in the vessels are assumed to have taken place), while the luetic failure is ab initio. Such a failure is only explicable on the assumption that we have to do with degenerative changes in the blood-vessels---changes associated

with increased exudation and diminished absorption, and verified by

the fact that syphilis in the inherited form has a special predilection

for the blood-vessel wall. In other words, given a case of right

heart failure in a child occurring within twelve months of the initial

" rheumatism," and associated with dropsy and albuminous urine, the prognosis of such a case is most unfavourable. Degenerative

vessel changes, probably luetic, must be assumed to have taken

place, and the result of treatment by cardiac tonics, as shown in the case of M. P., is of little avail.

The last two cases are the only two alive out of the series. Both

had a rapid failure, with oedema, and it has only been by the most

careful attention that life has been prolonged. Their prognosis is a

hopeless one. They get dyspnceic on the least exertion, and an

extreme and fatal failure may occur at any time. In both cases the

extra strain at puberty will be a bar they can scarcely hope to sur-

mount, if perchance they ever reach that far. They are good examples of the effects of an inflammatory affection of the valves

occurring in patients whose resistance is lowered, vulnerability increased, and circulatory piping, by heredity, rotten.

CASE V.

E. R., male, 10 years, has a brother with congenital cyanosis, probably luetic, regarded as due to a pulmonary stenosis. Rheumatic

litter. Med. 3n1,1 Heart Disease in Children. 79 Feb. 20, 1902

attack in January. Heart failure with dropsy and albuminuria three

months later. Now, apex beat half an inch outside nipple ; well-

marked systolic murmur present. Slight pulsation in the cervical

veins, puffy ankles, and dyspncea on the least exertion ; hepatic

dulness half an inch below rib margin.

CASE VI.

H. K., mt. 12, male, admitted into hospital, on July 9, 1900, with

dyspncea, dropsy, and albuminous urine. Had " rheumatic fever "

six months previously. Apex beat in fifth and sixth spaces as far

out as nipple line, and a loud mitral murmur practically filling up

the whole cardiac cycle. Radial artery much too prominent for a

lad of 1o. Discharged August 31, 1900, sine dropsy, albuminuria, or

dyspncea. Last seen August 21, 1901. Anaemic and dyspncea on

the least exertion, and had recently had a " fainting spell," with

great prostration. His sister had a large breaking-down gumma,

which responded stating to pot. iod. This case was treated with

hg. biniodide and syr. ferri iod. The following case, though not of the syphilitic type, still presents

certain analogous features, especially with regard to the rapidity of

the failure, that it is included in the series :- J. C., aet. ro, male, was admitted into the Children's Hospital on

November 12, 1901. The history was that he had been quite well

up till last July, when he had rheumatic fever, for which he was

kept in bed for some four weeks. Since then he has never been well ; shortness of breath on exertion, and disinclination for food,

and his time has been spent chiefly in bed, or staying about the

house. He has been subjected to no exertion at any time since the

rheumatic attack. On admission, the boy is pale and wasted somewhat, lips blue ;

dyspncea even at rest ; only slight pulsation of the cervical veins ;

respirations 62. Propped up in bed, which seemed to give him relief;

no vomiting. The clinical picture was not unlike that of a pericarditis.

On examination, the liver extends three and a half fingers' breadth

below the costal edge ; splenic dulness slightly increased. Some

puffiness of the feet, which disappeared in a few hours. Dulness of

the bases posteriorly, with occasional crepitations ; cardiac impulse

forcible. Apex beat is diffuse, and seen one and half inches outside

nipple line in the sixth interspace. No epigastric pulsation. Aortic

second sound weak ; pulmonary second accentuated. In the mitral,

80 Intereolonial Medical Journal. Feb. 20, 1902

a loud blowing murmur is present, best heard just below the nipple,

and audible in the axilla, and at times, a to and fro murmur is

detectable over the precordia. Urine acid, 1025 ; 26 ozs. in twenty-

four hours ; no albuminuria. Nothing abnormal detected in the urine microscopically.

He died two days after admission.

Temperature remained subnormal. Pulse varied from i i6 to 128 ;

respirations 32, 52, 62, 6o, 64. He was treated with digitalis, strychnine, eth. and ammon. and trinitrinee, and brandy.

At the autopsy, there were slight serous effusions in both the

pleural and peritoneal cavities. Kidneys not tough ; little congestion ;

capsule peeled readily ; good cortical area. Pancreas seemed normal

in appearance. Spleen enlarged, soft, friable, and engorged. Liver

enlarged, and presented the appearance of a chronic congested organ, breaking down readily under the finger ; the condition approached

towards the nutmeg type. Lungs.----Slight pleuritic adhesions in parts,

which readily broke down ; bases congested ; no pneumonic areas present. Heart.—Pericardium thickened, and adherent to the cardiac

surface ; strands of adhesions running across to the left lung. Over

the left ventricle towards the base there was evidences of a recent

pericarditis, flaky lymph being present. The right heart was thin and flabby ; the left thickened. The mitral valve showed a con-

siderable amount of erosion, and along the edge and on the surface

of the valve, numerous vegetations were present. Vegetations were

also present on the aortic valve, but the cusps were apparently

competent. No signs of atheroma could be detected. The right-

sided valves were clean, but the tricuspid orifice was dilated ; the

coronaries were healthy, and patent ; the mediastinal glands were not enlarged ; there was no fluid in the pericardium.

REMARKS.

In spite of the absence of confirmatory evidence, we regarded the

case as one of rapid heart failure, endocarditic in origin, occurring in

a syphilitic subject, and yet there were certain features which we had not met with in the other cases of our series :-

(1) His picture, and certain clinical signs, undoubtedly resembled

a pericarditis ; but the rule met with has been that, in syphilitic

subjects the endocardium, and not the pericardium, is the part attacked. Still, it was quite possible to explain the whole on the heart failure of a mitral regurgitation from previous valvulitis.

Inter. Med. Jn1.1 Heart Disease in Children. 81 Feb. 20, 1902

(2) He had no cedema.

(3) There was no albumen in the urine. His cardiac failure we must regard as not of recent origin. His

heart has never recovered the initial rheumatic attack. It has vainly

compensated the lesion. The hepatic enlargement could not occur in a few days, and yet we find a patient walking about with sufficient

mechanical cause to produce dropsy, and yet no cedema, no albumi-

nuria appearing—a condition sufficient to point to an absence of any

arteritis, any hereditary defect in the vessel wall. Should he have

been toned up and lived ; should the vessel wall become ill-nourished,

and hypoplasia occur, the result of the circulatory obstruction, and

later, the calls of puberty for increased development, then one would

expect the presence of a dropsy, coincident with the heart failure,

which we so frequently find in connection with pure rheumatic

hearts. The question then arises—If syphilis is out of the question, as

shown by the post-mortem evidences, the family history, and the

preceding statements, why has he gone down hill so rapidly ?

The condition of the heart at the autopsy explains everything ;

out of some thirty post-mortems on heart cases, it was noted for the

first time. An old endocarditis, producing contraction of the mitral

valve, and affecting also the aortic, was quite enough to keep the

boy on his back for a considerable period. It was a severe enough call for the heart to compensate at the growing period of existence.

Add to that a universal pericarditis, and the wonder is not that the

child's heart failed to compensate not only a mechanical obstruction

to its own action, but a circulatory obstruction within its own walls,

but that the child did not die outright at the time of the original

infection. What the state of the boy's health was at that time to

render him vulnerable we don't know, but the fact remains that a

big toxic infection must have occurred, from which he emerged but

never rallied. This patient was placed, as was noted, on the usual cardiac tonics

and stimulants. That such was wrong, I am fully convinced. Our

experience has been that where cardiac dilatation and a murmur are

becoming marked, and the apex becoming displaced out, digitalis,

with ferri iod. and strychnine is good, and acts beneficially, also in

those early failures sine cedema to which the rheumatic patient is so

frequently liable ; but where the patient, later on in life, comes in

with heart failure, general cedema, and albuminous urine, it does

82 Intercolonial Medical 5'ournal. Feb. 20, 1902

little good, and similarly in syphilitic hearts, early or late. The

demand for increased exertion is one to which the heart will not

respond, and probably owing to accumulation in the system, strych-

nine and digitalis, by their toxic action, only hasten the end. Indeed,

rest, calomel, and brandy or wine will do all that is required, and later, hydrarg. biniodide and syr. ferri iod.

As an example of the post-mortem appearances seen in this class, the case of M. P. may be cited. Microscopically, the abdomen con-

tained about 3o ozs. of serous fluid. There was also a small amount

in the pleura, but none in the pericardium ; the liver was enlarged, tough, fatty in places, with the capsule thickened, inelastic, and resisted cutting ; the spleen was congested, and somewhat toughened ;

the pancreas was fibrous and tough, and almost defied cutting with the knife ; the brain showed no structural alteration ; the kidneys

were larger than normal, tough ; cortex narrowed ; capsule thick-

ened, but not adherent ; the lungs were congested at base ; traces of old pleurisy present.

In the case of W. W., the lower part of the right lung showed a firm, tough, almost carnified condition, and some patches of bronchial

pneumonia were distributed here and there. Heart.—There were

some slight traces of recent pericarditis at the base and apex. The

heart was enlarged, especially on the left side, the ventricle of which

was hypertrophied ; the left auricle was dilated and enlarged ; the right side dilated, but the right-sided valves were apparently normal. The tricuspid orifice was relatively dilated. The aortic cusps were

thickened, but showed no traces of vegetative fringes. Thickenings

were present at the base of the aorta. The mitral orifice admitted

three fingers ; the valve had contracted down, and the chord

tendin were tightened. In some places, scarcely a trace of the original valve could be detected.

In the case of W. W., the same degree of mitral contraction was not present, but a recent ring of vegetations was present. The inner

surface of the left ventricle showed some fibrous thickenings of the endocardium.

HISTOLOGY.

I am indebted to Dr. Kilvington, of the Melbourne University, for

the microscopical work in connection with these cases. Examina-

tions were not made in every case. The organs examined were the liver, heart, spleen, lungs, kidney and pancreas.

Inter. Med. JnI.1

Heart Disease in Children. 83

Feb. 20, 1902

Liver.—The capsule was found thickened in some cases and not

in others. In some, the connective tissue in between the lobules,

though not increased in amount, is very active, as shown by the

large number of nuclei present in the connective tissue. The vessel

thickening was noticed chiefly in the smaller ones, especially the

intima, and in some cases endarteritis was present. One case, in

which the fibrous and vascular changes are not marked, showed areas of fatty cells in parts. Numerous fine bands of connective tissue

were seen in some passing into the liver substance from the capsule.

In one, very large fibrous bands, containing bile-ducts and vessels,

ran across the section. In another, under the capsule, the liver cells had disappeared, and a reticular mass of fibrous tissue was present,

suggestive of an early angioma.

Kidneys.—Contrary to Jacobi's opinion, the kidneys showed

changes in every case examined. In some cases there was a slight

uniform increase of connective tissue, both in the tufts and between

the tubes. In connection with the tufts, the increase is principally

in Bowman's capsule, and extends from here outwards. One showed

an increase of connective tissue radiating from the boundary zone

vessels. Others showed connective tissue of very old standing in

some in the tufts, and a slight but uniform amount running in between the tubes and cortex. The thickening of the renal vessels

affected chiefly the smaller ones.

Pancreas.—Vessels thickened ; little endarteritis ; markedly in-

creased connective tissue ; pancreatic cells all seem healthy.

Lungs.—In the specimens examined, the alveolar walls were

thickened by a deposit of connective tissue of fairly recent date.

Catarrhal cells were common in the air-spaces. Vascular changes

were not prominent, the vessels being thickened, but not markedly so. The maximum amount of connective tissue change is centred

round the blood-vessels and bronchi.

S/'leen.—The splenic sections that showed most marked changes

were those in which the diagnosis in the other organs was doubtful.

The changes were, increase of trabecular tissue, and marked thicken-

ing of the smaller vessels, with endarteritis. The capsule was also

in some cases thickened.

Heart.—Thickening of the vessels was noted, especially of the

middle coat. The muscle fibre was well outlined, though the striation was not marked in some cases (probably due to decompo-

sition). In some, the excess of fibrous tissue was present between

84 Intercolonial Medical Journal. Feb. 20, 190t

the bundles of cardiac fibres ; in others, it was chiefly round the

vessels, and not marked elsewhere. Occasionally there was seen an

excess of the small-celled elements, especially in the smaller bundles.

The above is a resume of the important changes found in the viscera.

CONCLUSIONS.

(1) Pericarditis, and not endocarditis, is the common lesion met

with in the so-called pure rheumatic hearts. Indeed, in most of

the cases that have died with heart failure, thickening and ad-

hesions of the pericardium, and a healthy endocardium, has been the rule.

(2) In the syphilitic patients the endocardium, and in no case the pericardium, was affected.

(3) In any child showing symptoms of early and rapid heart failure after the initial endocardial attack, a suspicion of lues must be entertained.

(4) Early dropsy is characteristic of the failure of the luetic

cases with endocarditis, should the patients live long enough, and

is probably largely dependent on syphilitic arteritis. Dropsy is not seen in the early failures of pure rheumatic cases. It is seen

in the later failures as the result probably of a degenerative arteritis from mal-nutrition, is irresponsive to treatment, and too often ushers in the end.

I am indebted to the honorary staff of the Children's Hospital

for permission to use cases, and to Dr. Stephens of the hospital for his invaluable assistance.

ifttebical orietri or Victoria. ORDINARY MONTHLY MEETING.

WEDNESDAY, FEBRUARY 5, 1902.

(Hall of the Society, 8 p.m.)

The President (Dr. J. P. RYAN) in the chair.

The minutes of the December meeting were read and confirmed.

A letter was received from Dr. W. Snowball expressing his grati-fication in accepting the honorary membership conferred on him by the Society.

Inter. Med. J111.1 Medical Society of Victoria. 85 Feb. 20, 1902 J

The paper read at the Annual Meeting by Dr. W. Moore, on

Hospital Management in relation to the Medical Profession, was

discussed. With a view to obtaining a definite result from the

discussion, a series of resolutions were drawn up by Dr. Moore, and appeared on the notice paper for the evening. They were as

follows :—

(I ) That the taking of payment from patients by Hospitals supported by grants

from the Government and by charitable subscriptions, is contrary to the

best interests of those Hospitals.

(2) That the repeated election at one time, by general vote of subscribers and

life-governors, of the whole of the members of the medical staffs of public

Hospitals, is a disgrace to the community, a scandal to the medical pro-

fession, and an injury to the Hospitals.

(3) That all vacancies on the in-door staffs should be filled by promotion from

the out-door staffs.

(4) That vacancies on the out-door staffs should be filled by election by the sub-

scribers and life-governors.

(5) That once a member of the profession has been elected to the staff of a

Hospital, he should be secure in his tenure of office until he reaches a

certain age ; due provision being made for removal in case of neglect or

incompetence.

(6) That the medical staffs should be represented on the committees of manage-

ment of all Hospitals.

(7) That the resident executive officer of all Hospitals should be a medical man

and not a layman.

Dr. BARRETT, in opening the discussion, thanked Dr. Moore for

introducing the subject of Hospital Management at the present

time. Different attempts had been made to arrive at some uniformity

of electing honorary medical staffs at the various hospitals, and

the Charity Organisation had suggested the creation of a Board for

the purpose. The executive committee of a hospital should adopt

that system which would ensure the best medical attention for the

patients in their institution. With regard to security of tenure

of office, if it had no existence, there would be constant changes, and

therefore the exclusion of the best men would result. On the other

hand, perpetual tenure was objectionable. The plan that usually

met with the best results was the age tenure, subject to the occupant

availing himself of the opportunities offered to him by his position.

He thought that there was likely to be a good deal of difference of

opinion with regard to the resolutions proposed by Dr. Moore. As

to the taking of payment from hospital patients, he thought that

those patients who were able to pay a little should be encouraged to

do so, granted that proper inquiries were made by a responsible


officer. With regard to the best means of making inquiries into the

position of patients, he thought that the matter might with advan-

tage be entrusted to the Charity Organisation Society. With the

second resolution he thoroughly agreed. The resolution that all

vacancies on the in-door staffs should be filled by promotion from

the out-door staffs should not at all times be a hard and fast rule. Capacity should count in some cases before seniority. And in

exceptional cases it might even be advisable to fill an appointment from outside the staff, as was done in the case of Sir Joseph Lister.

Security of tenure, however, was the main object to aim at, as it always encouraged the best work. Periodical revision of the work

clone by the members of the staff should be carried out, and the

removal of an officer for not taking proper advantages of his position

should he possible. He thought that the honorary medical staff

should always have representatives on the executive committee of

hospitals. In electing medical officers to the institution, the honor-

ary medical staff should consider the applications, and place the applicants in order of merit, and that the committee should elect.

If the committee of a large hospital had the election in their hands,

much greater attention would be paid as to the constitution of that

committee. He thought that the position of medical superintendent should be filled by keeping the best resident medical officer of his

year for a second year.

Mr. HAMILTON RUSSELL did not object to the repeated election of honorary medical officers so much as he did to the electorate, such as

existed at the Melbourne and Women's Hospitals. He thought

that no possible objection could be taken to the elections at the

Alfred and Children's Hospitals. He thought that the method

proposed in the fourth resolution of electing out-patient honoraries

was not a good one, as the electorate ought to be altered. He

thought that the time was ripe for the Melbourne Hospitals to follow

the lead of the London Hospitals and insist that all applicants for

hospital positions should hold senior degrees. In his opinion, the

honorary staff should certainly be represented on the committee of management.

Dr. STAWELL considered that a change should certainly be made

in the method of electing honorary medical officers to hospitals by the votes of governors and subscribers. The plan suggested by Dr.

Moore was a feasible one, but he thought it would be better if the

vacancies on the out-patient staff were filled by the committee after

Inter. Med. Jul.1 Medical Society of Victoria. 87 Feb. 20, 1902

consultation with the honorary staff. To make this form of election

an ideal one, it would be necessary to see to the personnel of the

committee. As vacancies occurred on this body, the medical pro-

fession should interest themselves and see that the vacancies were filled by persons who would consistently insist that the best is done

for the hospital. At present, interim vacancies at the Melbourne Hospital are filled by the Committee without any consultation with

the honorary medical staff, and then when the general election takes

place, the election is as a rule confirmed by an irresponsible mass.

A certainty of promotion by seniority is a mistake. In London and in Germany the hospital rules provide for invitations being extended

to men of note from various parts of the world. At present it was hard to see how such a provision would benefit us in the Colonies,

but it would be wise for us to make it clear that we do not wish to

exclude election by merit or distinction. Regarding the taking of

payment from hospital patients, he agreed with the resolution that

there should be no suspicion of payment for services received at a

general hospital. A small registration fee could not be objected to,

and served the purpose of keeping away a loafing class of patients ;

but it was certainly desirable that the deserving poor should have

no obstacle placed in their way of receiving medical assistance when

they needed it.

Dr. WALSH considered it wrong for general hospitals to receive

any payment, except a small registration fee from patients. The

constant recurrence of the election of the honorary staff at the

Melbourne and Women's Hospitals was bad, and he was in

favour of a security of tenure with an age limit, and a loophole for

the admission of exceptional men when the occasion occurred. He

suggested the creation of an electoral board for all Melbourne

Hospitals. Dr. NIHILL considered that the taking of payment from hospital

patients was an absolute necessity, as the funds of the charitable

institutions could not do without this source of income. He thought

that the tenure should be secure, and that the vacancies on the

in-door staff should be filled from the members of the out-door staff.

Dr. MCARTHUR considered that the taking of payment from

patients at a charitable institution was not only wrong, but an

injustice to the medical profession who gave their services free to

the institution. At the Launceston Hospital, the House Steward

interviewed new patients on their admission as to their ability to pay


during their stay at the hospital. A fortnight later, a very careful

inquiry was made by the House Committee, and they frequently

found that the circumstances of the patient did not justify his paying

what he had promised to do. Dr. W. BOYD considered that any attempt to take the election of

honorary medical officers from the hands of the governors and sub-

scribers would be met with very serious opposition. This being the

case, he thought that Dr. Moore's proposal to limit their powers to an occasional election of a medical man to the out-patient staff was a

good one. There would not be the same amount of excitement over the single election, and the members of the honorary staff would be

able to ensure the election of the best man with very little work. A resolution should certainly be passed by this Society condemning the

practice of demanding payment from patients at the hospitals, as

the real poor of Melbourne are actually kept away from the hospital by this practice. In his work in the out-patient department it was

not an uncommon occurrence for a patient to absent himself for two

or three weeks when in need of treatment, and on being asked why

he had stayed away so long, saying that he could not manage to

pay the fee. It is a practice in the Melbourne Hospital to take fees

up to ten shillings in the out-patient department for advice and

medicine. Patients paying this sum have no right to be received as

patients. There is no proper inquiry, but it has come to be a regular game of bluff between the clerk and the patient, and the

people who ought to be patients are excluded by the system.

Dr. ARGYLE said that the question of the electorate seemed to be

the most important defect in the hospital elections. The creation

of an electoral body seemed to be the best way out of the difficulty,

and he thought that the governors and subscribers might elect this

body. He was opposed to the prevailing practice of exacting

payment from hospital patients, and thought that the Society should

affirm the principle of free medical assistance to all hospital

patients.

Dr. JANE S. GREIG considered that no payment should be taken

from patients at those hospitals which were supported by Govern-

ment grants and charitable subscriptions. If this practice were

carried out, a large number of middle class people, who were not

in poverty, but who were unable to pay private hospital fees of

,C3 3s. a week and upwards, would be debarred from hospital care,

so often necessary for successful treatment. The present method

Inter. Mei. Jaij

Medical Society of Victoria. 89 Feb. 20, 1902

seemed to be for such people to contribute to the public charities whatever amount they were able to afford, provided that it was less than the amount required for the necessary hospital treatment at a private institution. She thought that the election of members to the medical staff should be in the hands of experts only, such as nominations for vacancies being made by the honorary staff of the hospitals, ratified, if desired, by a responible lay committee.

Dr. BRETT asked what was intended by bringing forward the present resolutions ? He felt confident that a large number of cases well able to pay medical fees were treated at the hospitals, where they had no right to be treated. He thought that the election of honorary medical officers might be left in the hands of an electoral body, with representatives from hospital subscribers, the medical profession, the Melbourne University, and the Government.

The PRESIDENT, in reply to Dr. Brett, stated that the object in view, when the resolutions were framed, was to promote discus-sion, and so elicit the opinions of the members on the question of Hospital Management.

Dr. C. BALE considered that a buffer of some kind should exist between the general mass of the subscribers and the applicants for positions on the honorary staff of the hospital. In his opinion, the committee of the hospital was the proper electoral body, and the subscribers' duty was to see that the best available men were placed on the committee. He thought that the honorary medical staff should be represented on the committee to advise the latter on medical matters. Medical men were on the Melbourne Hospital Committee some years ago, but they were not members of the honorary staff, and in some instances were men who had stood for election on the staff and been defeated. He expressed surprise at hearing the sums that were obtained from patients at the hospitals, and thought that no payment should be asked for. Is the patient poor, and is he sick ? should be the only conditions as to the admis-sion of a patient to the privileges of hospital treatment.

Dr. J. P. RYAN said that the speakers seemed to be unanimous in their condemnation of the election by the general body of governors and subscribers. As to the substitution of a better system, there seemed to be less unanimity, but most of the speakers seemed to favour a smaller electorate, such as the committee advised by the

staff, or a small electoral body of representative men. He hoped that the medical profession would continue to move in the matter,

1H


and demonstrate to the general public that it is to their interest to alter the present state of affairs. He considered it wrong that pay-ment should be taken from patients, and related the case of a visitor from Sydney who came under his (Dr. Ryan's) care in the Eye and Ear Hospital. This man stated that he had paid ten shillings at the desk before coming in to see the honorary.

Dr. MooRE, in reply, stated that even taking a registration fee from hospital patients was a wrong principle. A proper officer should be appointed to inquire into the patients' positions, and ensure that none but the deserving should be received at a hospital. He did not think that the conditions in Melbourne were the least like those in London with its various medical schools, and that the so-called loophole for the admission of special merit cases was unnecessary. The honorary staff of the Melbourne Hospital object more strongly to placing their election in the hands of the committee, as present constituted, than in the hands of the general body of life-governors and subscribers. If an attempt was made to improve the personnel of the committee, the mover would probably suffer and lose his position. If you allow for a committee doing that which is good, you put them in a position to do that which is bad. It is a mistaken rule to legislate for exceptions.

Dr. BARRETT moved that a Sub-committee, consisting of the President, senior Vice-President, Drs. Moore, Stawell, Walsh, Argyle, and the Hon. Secretary, should be formed to further consider the subject of Hospital Management, and report to the Society at a future meeting.

Iltruiemo. •

A Text-book of the Practice of Medicine. By Dr. H. EICHHORST.

Authorised translation from the German. Edited by A. A. ESHNER, M.D. Philadelphia and London : W. B. Saunders and Co., 1901. Melbourne : Jas. Little.

Still another addition to the ever increasing array of American medical works is a translation, by Dr. Eshner, of Prof. Eichhorst's text-book on medicine. We confess our German is too meagre to enable us to be familiar with the work in the original tongue, but make no question that Dr. Eshner's translation faithfully reproduces its character and phraseology. We can congratulate him therefore

Inter. Med. Jn1.1 'Reviews. 91 Feb. 20, 1902 J

on his industry and—wonder at it. By the latter, we merely mean to convey our inability to be off with any of the old loves in medical text-books, in order to be on with the new one.

One great feature about the work, which is something to be thankful for, is that it bears the impress of personal observation, and originality of mind, although, when the author follows his own conclusions, he is at times in conflict with the opinion of his editor and the profession generally. No space is devoted to any pre-liminary consideration of " essentials," but the reader is introduced, on page r, to Diseases of the Myocardium. For beginners, this might prove a trifle disheartening.

The section on Circulatory Organs is distinctly poor, both in extent and method. Such abrupt sentences as " Acquired valvular disease of the heart is one of the most common diseases of the heart and diseases in general" (Vol. I., p. 35); and again (p. 36) " Acquired valvular disease of the heart occurs more frequently in adults than children, because articular rheumatism occurs but rarely in the latter," require a little more consideration in detail. In the treatment of angina pectoris, or as the authors prefer to write "stenocardia," morphia is recommended as " most likely to terminate the attack. I have seen," says Professor Eichhorst, " no convincing results from inhalations of amyl nitrite, and from the internal use of nitro-glycerine."

On page 175 is the following statement :—" Little is known with regard to primary infections, catarrhal stomatitis. It may arise, for instance, by inoculation of gonococci upon the mucous membrane of the mouth." Such may be Continental practice—there is no accounting for tastes—but in Australia, we should as frequently expect to find porcine animals developing habits of aerial

locomotion. Diseases of the Digestive Organs receive adequate consideration,

and more attention is paid to oesophageal affections than is usually the case. We imagine the authors' experience in the following respect is a little unique—" Rumination is a much more common disorder than is generally believed. I have quite accidentally detected a number of persons engaged in rumination who, from a sense of shame, were cleverly able to conceal the

unpleasant practice." With regard to Appendicitis, Professor Eichhorst writes—"When

the acute inflammatory manifestations have subsided, and the 1x 2


exudate is well circumscribed, the icebag should be replaced by a hot cataplasm, which will better favour the absorption of the pus." On 265, the statement that " The contention of some surgeons that appendicitis and perityphlitis are always surgical diseases is an error, as most cases pursue a favourable course with internal treatment," draws a foot-note of protest from Dr. Eshner.

The descriptions of animal parasites of intestine are not par-ticularly luminous, and the use of the word "measle," in a sense not employed in English, is confusing. Somewhat quaint sounds the direction that, "on the night before the teniacide is admini-stered, the patient should take a salad constituted of dried herring, garlic and onions." We imagine the tapeworm who could survive the supper would find the succeeding breakfast of turpentine or male-fern the merest bagatelle.

The author is apparently unacquainted with Australian work in connection with hydatids, or at least makes no mention of it.

In the treatment of cerebral hemorrhage, it is advised that, "at the time of the apoplectic attack, the head should be elevated, and venesection practised if the patient presents a congested appear-ance and a tense pulse, soo c.c. of blood being withdrawn."

A somewhat unusual feature in a medical text-book is the inclusion of local venereal diseases. A short account of diseases of the skin is also given.

The work is presented in two volumes of handy size, well printed, and well and separately indexed. There are numerous illustrations, some good, some indifferent, and some evidently handed down from a dim past, wherein the art of wood engraving had its beginning. A. L.

Atlas and Epitome of the Nervous System and its Diseases. By Prof. Dr. C. JAKoB, of Erlangen ; edited by Prof. E. D. FISHER, of New York. Phil.: W. B. Saunders, 1901. Melb.: Jas. Little.

This volume is another of the medical hand-atlases published by Saunders. Its chromographic plates come up to the high standard maintained in the preceding volumes of this series, and are the main feature of the book.

The matter is dealt with in five parts. These parts contain a concise condensed description of the anatomy, development,

Inter. Med. Jn1.1 Feb. 20, 1902 _I

physiology, and diseases of the nervous system, and each part is illustrated by a series of plates. The anatomical part of the work is worthy of especial mention.

Many of the chromo-lithographs have outline drawings appended, in which the names of the various parts are written, and these are of considerable assistance in enabling one to use the plates with greater ease and speed than is usual. A number of plates representing sagittal, frontal, and horizontal sections through the brain bulb and spinal cord deserve notice. These were taken from Pal-preparations, and are very accurate. With their aid one can trace tracts and fibres throughout the entire course of the nervous system.

The descriptive part, as is usual in books of this class, is meagre and, in some ways, very elementary. The account of the develop-ment of the brain is very short, but the plates are good. They would enable one to follow the anatomy of the brain in the different months of foetal life. Some plates on the development of the spinal cord and the peripheral nerves illustrate, in an excel-lent manner, some important points in neurological embryology. A few diagrams are given on the course of the main tracts of fibres in the nervous system, and these are prepared with special reference to clinical medicine, neglecting points only of physio-logical interest. These diagrams are very accurate and complete, but they are difficult to follow, as so much detail is put in them, and one finds it difficult to disentangle the various tracts. This is especially so in those representing the motor and sensory paths in the cord.

In the pathological part of this book one might note two subjects which are dealt with by excellent groups of plates, viz., secondary degenerations following on cerebral, peduncular, and spinal lesions, and the main tract diseases of the spinal cord. Both of these subjects are illustrated by a number of plates, which bring out the principal features of the pathology of these portions of neurology.

Some plates on syringomyelia show how the characteristic sensory phenomena of this disease are brought about. The epitome of the diseases of this system suffers from the exceeding brevity with which it is written. One is astonished at the amount of detail brought under notice by such a few words, and yet is struck by the absence of reference to really important points.

Reviews. 93


A short account of anatomical and microscopic technique is appended, but is too brief to be of any value.

One can recommend the book to those interested in neurology on account of the plates dealing with pathological changes, but to others this book will be of little value. H. G. C.

Text-book of Medicine. New (Fourth) Edition. By WM. OSLER, M.D., LL.D., F.R.S., F.R.C.P. Thoroughly Revised and Re-written. London and Edinburgh : Young J. Pentland. Melbourne : Angus and Robertson. Price, 24s.

Osier's Medicine needs no introduction to the student and practitioner of medicine, for it is now well known as one of the standard text-books in medicine, and this new edition will certainly aid in keeping it in the first rank of works of its kind.

Since the last edition was issued many changes have been made, and much of the matter re-written and re-arranged, and it is quite evident that every effort has been made to bring the information up to date. The work bears the imprint of Professor Osler's personality and of the work of his clinic throughout, but that very fact leads to an occasional statement which is scarcely of the kind that students should be impressed with. As an example, we may quote the statement that simple tapping of hydatid cysts should always be first practised, and that it cannot do any harm, as being one likely to lead the unsuspecting student into serious difficulty sooner or later.

Very interesting and complete is the newly-written chapter on Typhoid Fever, and here it may be noted that Professor Osler thinks the evidence in favour of preventive inoculation against typhoid is, on the whole, favourable ; and he quotes the experi-ences in Ladysmith during the Boer war in favour of his statement.

As to treatment, he goes on the usual lines ; but we think that in a students' book, in mentioning inunction of guaiacol as a means of causing a rapid fall of temperature, a note of warning should have been given as to the collapse which has frequently followed such proceeding.

The chapter on Influenza is scanty and disappointing, but the articles on Plague and Diphtheria are very satisfactory ; and in the latter, the remarks as to dosage of antitoxin are very timely. He quotes the experience of Dr. J. H. McCollum, of the Boston

Inter. Med. Jn1 j 1 Reviews.

Feb. 20, 1902 95

City Hospital, who insists that the guiding experience in the use of antitoxin is to give it until the characteristic effects are pro-duced, whether 4000 or 70,000 units be required for this result. No case, he says, in the acute stage should be considered hopeless.

In speaking of Oxygen in Pneumonia, Professor Osler modifies the statement in his last edition that it is " harmless," and he now believes it requires very careful administration, so that it shall not have a tension of more than 8o per cent. of an atmosphere, and he is doubtful if it is really beneficial.

The article on Malaria has been thoroughly revised, and gives a digest of all recent work. It is of much interest to find that Professor Osler gives it as his opinion that " one of the greatest scourges of our race is now at our command " by means of—(a) Protection of houses against mosquitoes ; (b) extermination of

mosquitoes ; (c) thorough and prolonged treatment with quinine. Throughout the work there is abundant evidence of careful

revision, and though perhaps scarcely as authoritative as the student likes his text-book to be, Osler's Medicine can be safely recommended as being well abreast of modern medical work, and especially interesting as containing a careful digest, in most instances, of the clinical experiences of such a well-known clinic as that of its renowned author. J. F. W.

The American Illustrated Medical Dictionary. By W. A. NEWMAN DORLAND, A.M., M.D. Second Edition, 1901. Philadelphia and London: W. B. Saunders and Co. Melb.: Jas. Little.

Dorland's Medical Dictionary may be regarded as a standard work which fulfils all that one needs in a medical dictionary, and it will be found of considerable use to the reading prac-titioner. Not uncommonly, one comes across words or phrases which are unfamiliar, and a good dictionary of medical terms is now as much a necessity as is the ordinary dictionary to the student of literature. This work has been thoroughly revised, is of convenient size, beautifully bound, and can be confidently recommended to the student who requires such a work. In addition to the ordinary lexicon of words, we have numerous tables of arteries, nerves, muscles, tests, staining methods, &c., which will at times come in useful to the busy men who have not their standard works by them, J. F. W.

jj


Elements of Clinical Bacteriology. By Dr. ERNEST LEVY and Dr. FELIX KLEMPERER, of Strasburg, translated by AUGUSTUS A. ESHNER, M.D., Philadelphia. Philadelphia : W. B. Saunders. Melbourne : Jas. Little.

This work, which is an American translation from the German, is a new departure, in that it attempts to treat from the clinical stand-point the researches in bacteriology.

Practitioners intending to do some work in bacteriology will find useful practical hints on the preparation of culture media ; valuable advice is also given in the method of staining specimens, although in one or two particulars the authors are not explicit enough in the matter of time given to staining re-agents.

The difficult question of infection and immunity is well dealt with, while the methods given in the production of artificial immunity by vaccines, toxines and blood-serum of immunised animals are inter-esting and very clearly expressed. The authors accept the view that the action of the diphtheria antitoxin on the toxin is a purely chemical process. A. W.

Elements of Practical Medicine. By ALFRED H. CARTER, M.D., M.Sc., Professor of Medicine, University of Birmingham, &c. Eighth Edition, 1901. London: H. K. Lewis.

When a book has run to eight editions in the course of twenty years, it it evident that it has fulfilled some purpose, and if there is a use for a small introductory handbook of medicine, we know of none that so well fills the place as Carter's little work.

The new edition has been brought up to date by careful revision, and may be recommended to the junior student of medicine who may be just commencing his acquintance with practical medical work. There is an interesting therapeutic index attached, from which some useful hints might be obtained by even older practitioners. J. F. W.

Samples of Tabloid Ophthalmic (T) Alum, gr. 1.250 gr., in tubes of 25 each, are to hand from Messrs. Burroughs, Wellcome and Co.

A 4 oz. Sample of Syrup Hydriodic Acid (Gardner), the mild form of Iodine for internal administration, will be forwarded on application as stated in advertisement on p. vi.

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Title:

Intercolonial Medical Journal of Australasia 1902

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