859 in the abdominal wall itself. The pro-peritoneal layer of fat was probably very sensitive, and to some extent this accounted for post-operative pain ; but the muscular layer was the chief culprit. If this was true it was wise, if possible, not to sever or split the muscles but to draw them aside. If sutures were put into the aponeurotic sheaths rather than the muscles themselves, the patient seemed to suffer less pain. The definition of pain as a hyperstimulation of normal sensation, continued the President, applied also to involuntary muscles. At the present time one school of thought believed that all abdominal pain was referred and could not be felt nor even produced in situ. Another school held that there was one form of abdominal pain produced and felt in situ, and caused by intravisceral changes of tension. Sensations were only present when they were of physiological use, and pain, heat, and cold all had a definite purposive physiology, whilst muscles conveyed the sensation of localisation. In hollow viscera there was no necessity for the sensations of heat, cold, touch, or, with very few exceptions, localisation ; but there was a very real need that the intestines should be constantly kept informed of their state of tension. The purposive physiological sensation of the alimentary tract was the state of tension of its involuntary muscle, and when, for any reason, this became abnormal pain was produced locally, and, he believed, not uncom- monly felt locally. It had been said that abdominal pain was due to tension on the mesentery, and that when the intestine dilated the mesenteries were pulled on, the nerves in them stimulated, and pain produced. The President very much doubted whether this was true. In colostomy the mesosigmoid was stretched but the operation was not painful. The pain caused by sequestration of a part of the gut was probably caused by the secretion of gas, which over- stimulated the involuntary muscle surrounding it. This kind of pain, due to alteration of tension-e.g., in hernia or appendicitis-could often be localised fairly accurately, the patient placing his finger at the site of the lesion. On two occasions the President had been able to alter the intra-intestinal tension by in- serting a plug, and on each occasion produced pain. In conclusion, the President said that he believed that there was a form of abdominal pain produced and felt locally, and that abdominal pain could be produced by, at all events, one mechanism which made it comparable to pain elsewhere in the body- namely, by hyper-stimulation of a normal and specific sensation. Discussion. Dr. D. A. COLES inquired what was the most reliable sign of pain and how it was to be measured. Dr. CAMpBELL MCCLURE pointed out that if an elastic bag in the rectum was rapidly inflated it caused pain referred to the sacral area and over the pubes. He thought that the facts did not support the idea that pain was an exaggeration of normal sensation. Dr. J. A. RYLE considered that there was something in the view that pain represented an exaggeration of normal sensation, although this was contested by neurologists. It was a familiar experience that every grade of sensation existed in the stomach and bladder, for example. He believed that an increase in the tension of muscle-fibre-especially when rapid-or simply its failure to relax, was the cause of pain in a viscus. Distension, however, might exist without anv pain, whilst the most severe biliary colic occurred without distension of the gall-bladder. He thought that the same argument applied to arterial pain -e.g., intermittent claudication-for which, he said, angina cruris would be a better name since the con- dition was analogous to angina pectoris and abdominis. From some cause-such as arterial disease, toxins, tubacco, or nervous unrest-the artery was unable to relax to adapt its posture. The mechanism was the same in all cases-an increase in visceral pressure with inability to relax. General practitioners, said Dr. Ryle, had a great opportunity for registering a series of observations on pain, and these would be of great diagnostic and practical importance. Such work could not be done in the laboratory or with animals. He believed that referred pains depended upon inflammatory changes, a different stimulus to that which caused visceral pain. The referred pains- -e.g., those due to irritation of nerve-endings in a damaged organ-might persist for days after a visceral pain had subsided. It was important to observe also the gesture which accompanied visceral pain and which often localised it with great accuracy. Dr. F. G. CROOKSHANK supported the theory that pain was an exaggeration of a normal stimulus. He- said that dissociation of gas from the capillaries in the wall of a viscus certainly caused a visceral distension and was analogous to what happened in the swim- bladder of fishes. Dr. E. P. POULTON cited the cornea, in which, he said, pain was the only sensation and was conveyed by uninsulated fibres. The pain of gastric ulcer was not located in the ulcer but in the viscus. He thought. that burning pain signified that muscles were con- tinuously on the stretch ; the pain of angina was du& partly to stretching of the heart muscle. Dr. DAVID BARCROFT threw doubt on the existence of pain in many cases. It often persisted long after its cause had gone away. Dr. HOWARD HUMPHRIS said that he had believed for many years that pain was due to pressure and. that the best treatment was the relief of that pressure Dr. BRANSBY YULE said that he had often found- that cesophageal pain was localised to the lesion. Muscle was often in a state of contraction ; it was hypertetanic contraction that meant pain. Dr. H. A. ELLIS said that he believed that pain was the overflow of central disturbance caused by local irritation. BRIGHTON AND SUSSEX MEDICO- CHIRURGICAL SOCIETY. A MEETING of this Society was held on Oct. 7th,. when the President, Dr. E. Rmnz HUNT, gave his presidential address on Cholecystitis. Dr. Hunt said that, according to Dr. Arthur Hurst, cholecystitis is the most common of all chronic abdominal disorders, probably occurring in at least 20 per cent. of all persons. It is probable that if practitioners were more definitely on the look-out for this condition many attacks of biliousness,. indigestion, flatulence, or even of that much-abused term " influenza," could be attributed to cholecystitis. Gall-stones, which are found post mortem in at least, 10 per cent. of all persons dying after the age of 20, are probably nearly always secondary to cholecystitis. which may have resolved long before. He emphasised. the importance of recognising this disease as a focus; of chronic sepsis. Dr. Hunt reviewed briefly the anatomy and physio- logy and pathology of the gall-bladder, and then described the symptomatology of cholecystitis. The onset was usually gradual, and as a rule there was little if any pyrexia, except at intervals when short. attacks of a characteristic type might occur. Flatulent dyspepsia was the most prominent symptom, usually- coming on immediately after meals, though when, associated with reflex hyperchlorhydria it simulated the hunger-pain of duodenal ulcer, beginning two or more hours after a meal, and being then relieved by- food, alkalis, or vomiting. Vomiting was uncommon, but nausea frequently present, and often some irregularity of the bowels. Jaundice was not a marked feature. The pain of cholecystitis was not infrequently a recurrent gastric pain, often worse at night ; owing-
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in the abdominal wall itself. The pro-peritoneal layerof fat was probably very sensitive, and to some extentthis accounted for post-operative pain ; but themuscular layer was the chief culprit. If this was trueit was wise, if possible, not to sever or split the musclesbut to draw them aside. If sutures were put intothe aponeurotic sheaths rather than the musclesthemselves, the patient seemed to suffer less pain.The definition of pain as a hyperstimulation of
normal sensation, continued the President, appliedalso to involuntary muscles. At the present time oneschool of thought believed that all abdominal painwas referred and could not be felt nor even producedin situ. Another school held that there was one formof abdominal pain produced and felt in situ, andcaused by intravisceral changes of tension. Sensationswere only present when they were of physiologicaluse, and pain, heat, and cold all had a definite purposivephysiology, whilst muscles conveyed the sensation oflocalisation. In hollow viscera there was no necessityfor the sensations of heat, cold, touch, or, with veryfew exceptions, localisation ; but there was a veryreal need that the intestines should be constantlykept informed of their state of tension. The purposivephysiological sensation of the alimentary tract wasthe state of tension of its involuntary muscle, andwhen, for any reason, this became abnormal painwas produced locally, and, he believed, not uncom-monly felt locally. It had been said that abdominalpain was due to tension on the mesentery, and thatwhen the intestine dilated the mesenteries were
pulled on, the nerves in them stimulated, and painproduced. The President very much doubted whetherthis was true. In colostomy the mesosigmoid wasstretched but the operation was not painful. Thepain caused by sequestration of a part of the gut wasprobably caused by the secretion of gas, which over-stimulated the involuntary muscle surrounding it.This kind of pain, due to alteration of tension-e.g., inhernia or appendicitis-could often be localised fairlyaccurately, the patient placing his finger at the siteof the lesion. On two occasions the President hadbeen able to alter the intra-intestinal tension by in-serting a plug, and on each occasion produced pain.
In conclusion, the President said that he believedthat there was a form of abdominal pain producedand felt locally, and that abdominal pain could beproduced by, at all events, one mechanism whichmade it comparable to pain elsewhere in the body-namely, by hyper-stimulation of a normal and specificsensation.
Discussion.Dr. D. A. COLES inquired what was the most reliable
sign of pain and how it was to be measured.Dr. CAMpBELL MCCLURE pointed out that if an
elastic bag in the rectum was rapidly inflated itcaused pain referred to the sacral area and over thepubes. He thought that the facts did not supportthe idea that pain was an exaggeration of normalsensation.
Dr. J. A. RYLE considered that there was somethingin the view that pain represented an exaggerationof normal sensation, although this was contested byneurologists. It was a familiar experience that everygrade of sensation existed in the stomach and bladder,for example. He believed that an increase in thetension of muscle-fibre-especially when rapid-orsimply its failure to relax, was the cause of pain ina viscus. Distension, however, might exist withoutanv pain, whilst the most severe biliary colic occurredwithout distension of the gall-bladder. He thoughtthat the same argument applied to arterial pain-e.g., intermittent claudication-for which, he said,angina cruris would be a better name since the con-dition was analogous to angina pectoris and abdominis.From some cause-such as arterial disease, toxins,tubacco, or nervous unrest-the artery was unableto relax to adapt its posture. The mechanism wasthe same in all cases-an increase in visceral pressurewith inability to relax. General practitioners, said
Dr. Ryle, had a great opportunity for registering aseries of observations on pain, and these would beof great diagnostic and practical importance. Suchwork could not be done in the laboratory or withanimals. He believed that referred pains dependedupon inflammatory changes, a different stimulus tothat which caused visceral pain. The referred pains--e.g., those due to irritation of nerve-endings in adamaged organ-might persist for days after a visceralpain had subsided. It was important to observe alsothe gesture which accompanied visceral pain andwhich often localised it with great accuracy.
Dr. F. G. CROOKSHANK supported the theory thatpain was an exaggeration of a normal stimulus. He-said that dissociation of gas from the capillaries in thewall of a viscus certainly caused a visceral distensionand was analogous to what happened in the swim-bladder of fishes.
Dr. E. P. POULTON cited the cornea, in which, hesaid, pain was the only sensation and was conveyedby uninsulated fibres. The pain of gastric ulcer wasnot located in the ulcer but in the viscus. He thought.that burning pain signified that muscles were con-tinuously on the stretch ; the pain of angina was du&partly to stretching of the heart muscle.
Dr. DAVID BARCROFT threw doubt on the existenceof pain in many cases. It often persisted long afterits cause had gone away.
Dr. HOWARD HUMPHRIS said that he had believedfor many years that pain was due to pressure and.that the best treatment was the relief of that pressure
Dr. BRANSBY YULE said that he had often found-that cesophageal pain was localised to the lesion.Muscle was often in a state of contraction ; it washypertetanic contraction that meant pain.
Dr. H. A. ELLIS said that he believed that pain wasthe overflow of central disturbance caused by localirritation.
BRIGHTON AND SUSSEX MEDICO-CHIRURGICAL SOCIETY.
A MEETING of this Society was held on Oct. 7th,.when the President, Dr. E. Rmnz HUNT, gave hispresidential address on
Cholecystitis.Dr. Hunt said that, according to Dr. Arthur Hurst,cholecystitis is the most common of all chronicabdominal disorders, probably occurring in at least20 per cent. of all persons. It is probable that ifpractitioners were more definitely on the look-outfor this condition many attacks of biliousness,.indigestion, flatulence, or even of that much-abusedterm " influenza," could be attributed to cholecystitis.Gall-stones, which are found post mortem in at least,10 per cent. of all persons dying after the age of 20,are probably nearly always secondary to cholecystitis.which may have resolved long before. He emphasised.the importance of recognising this disease as a focus;of chronic sepsis.
Dr. Hunt reviewed briefly the anatomy and physio-logy and pathology of the gall-bladder, and thendescribed the symptomatology of cholecystitis. Theonset was usually gradual, and as a rule there waslittle if any pyrexia, except at intervals when short.attacks of a characteristic type might occur. Flatulentdyspepsia was the most prominent symptom, usually-coming on immediately after meals, though when,associated with reflex hyperchlorhydria it simulatedthe hunger-pain of duodenal ulcer, beginning two ormore hours after a meal, and being then relieved by-food, alkalis, or vomiting. Vomiting was uncommon,but nausea frequently present, and often some
irregularity of the bowels. Jaundice was not a markedfeature. The pain of cholecystitis was not infrequentlya recurrent gastric pain, often worse at night ; owing-
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to the close association of the centres in the spinalcord innervating the stomach, liver, and gall-bladder,the irritable focus in the cord might not be necessarilydue to a gastric lesion, but might arise from diseaseof a neighbouring organ. Viscerosensory accompani-ments of cholecystitis included superficial and deepsoreness in the right upper gradient of the abdomen,right subscapular and interscapular pains, andtenderness over the middle dorsal spines and alongthe course of the eleventh right rib. In some cases ofcholecystitis in which the gall-bladder was situatedabnormally high up the inflammation of the gall-bladder might extend to the under surface of thediaphragm, giving rise to many of the signs andsymptoms of subphrenic abscess, and might evenmasquerade as a pulmonary affection with slightdullness at the base of the right lung, rales, andslight pyrexia.
Dr. Hunt described various methods of demonstrat-ing gall-bladder tenderness, and considered thedifferential diagnosis of an enlarged gall-bladder.He emphasised the importance of remembering thatsuch newer methods should be considered as accessoryonly and not as short-cuts to diagnosis to the exclusionof the older and simpler methods. The treatment ofacute cholecystitis was surgical. The treatment ofchronic cholecystitis might be broadly divided intotwo classes : (1) Cases in which secondary complica-tions, such as gall-stones or evidence of secondaryseptic troubles elsewhere are present. For theseoperation is the ideal course. (2) Cases in which
secondary complications’ are absent or in whichoperation is declined or for some other reason isinadvisable. For these medical treatment may befirst tried. An important point was the removal ofany primary focus from which infection may beconveyed to the gall-bladder. Oral sepsis, tonsillitis,infection of the accessory nasal sinuses, chronicappendicitis, pelvic infections in women, and Bacilluscoli infections must be 1 ooked for and treated. An
attempt must be made to treat the gall-bladderinfection by means of biliary antiseptics and pro-vision of adequate drainage. Large doses of urotropine,combined with alkalis, given in the manner advocatedby Dr. Hurst, may be used, or the same drug,combined with cholic acid, as in felamine tablets,is sometimes efficacious. Salicylates or aspirinin large and regular doses have been advocated.Magnesium sulphate in concentrated solution by themouth promotes biliary drainage.
Dr. Hunt insisted on the importance of exercise,especially horse-riding and rowing. The diet should becarefully supervised so as to avoid or restrict thosearticles of food which contain or produce cholesterol.
Dr. Hunt concluded his paper by giving a briefdescription of cases illustrating points referred to.
DONCASTER INFIRMARY.—The Prince of Wales, onOct. 12th, visited Doncaster primarily for the purpose oflaying the foundation-stone of the new wards at the RoyalInfirmary, which will be associated with the memory ofQueen Alexandra. Since the infirmary was founded in1868 the population has risen from 18,000 to 200,000. Thenumber of beds in the new building will eventually be 600,and of the 110,000 immediately required for the new wardsoB48,000 has already been subscribed. It is hoped that muchof the remaining sum needed will be contributed by theMiners’ Association when work in the pits is resumed.
DONATIONS AND BEQUESTS.—Mr. Frederick LewisBrandon Siddons, of Hanger Hill, near Ealing, and formerlyof Calcutta, besides other bequests left oB700 each to KingEdward VII. Hospital, Ealing, St. Dunstan’s Hostel forthe Blind, the Hospital for Sick Children, Great Ormond-street ; to Bedford Grammar School for the benefit of theschool, and oB700 for the upkeep of the panel in the schoolchapel in memory of his three sons.-King Edward’s HospitalFund for London has received a gift of 610,000 sent by Mr.Albert W. Searle.-Under the will of the late Mr. A. B.Bosher, of Tunbridge Wells, some 265.000 will be dividedbetween the Lord Mayor and Corporation of London andthe Mayor and Corporation of Sheffield for allocation to
hospital charities within their respective areas.
Reviews and Notices of Books.L’ V VLU’1’lUtV.
jV omogenesis or Evolution determined by law.By LEO S. BERG, Chief of the Bureau of AppliedIchthyology, and Professor of Geography in theUniversity of Leningrad. With an introductionby D’ARCY THOMPSON. Translated by J. N.ROSTOVTSOW. London : Constable and Co. 1926.Pp. 477. 28s.
L’JCK, cunning or law ? To Darwin it was thegood fortune of happening on a variant which suitedthe surrounding’s and had a survival value in gettingthrough the sieve of natural selection. To SamuelButler it was the ingenuity of learning what hadhappened to one’s ancestors and storing it in anunconscious memory. To Dr. Berg the live world inits course of evolution is carrying out a predeterminedplan controlled by laws as definite as those whichkeep the developing individual in the proper path.He brings abundant experience as a naturalist andan extraordinary wealth of learning to enforce hisarguments for orthogenesis on the one hand, andfor the direct influence of environment on the other.An evolutionary series is comparable to an individual-simple and small to begin with, growing progres-sively larger and more complex as it progresses, andfinally reaching extinction in some gigantic geronticform. Palaeontology apparently contains abundantexamples of the process, and if we interpret them asevidence of predestined courses, inherent in eachanimal and plant,. it is obvious that our commonviews on evolution need modification. So, too,Dr. Berg attributes the similarity of animals ofdiverse groups living in the same environment tosomething deeper than chance variation. He is, inshort, rather heretical, and he has written a mostrefreshing independent attempt to make out justwhere we stand in evolutionary matters. Prof.D’Arcy Thompson’s introduction is delightful.
GOULD’S MEDICAL DICTIONARY.
By G. M. GouLD, A.M., M.D. Edited by R. J. E.SCOTT, M.A., B.C.L., M.D. London: H. K.Lewis and Co., Ltd. 1926. With illustrations.Pp. xi. + 1398. 30s.THE first of Dr. George M. Gould’s dictionaries was
published in 1890, and in various forms they havehad a large circulation ever since. The latest appearsunder the new title of " Gould’s Medical Dictionary,"edited by Dr. R. J. E. Scott, and has definitions ofsome 76,000 words. In a preface to one of his earliervolumes Dr. Gould referred to the medical vocabularyas a " strange hodge-podge of the medical languageof two or more thousand years and of many specialnational tongues, in mechanic, not chemic mixture,with modern sounds and symbols, the whole amazinglyheterogeneous and cacophonous," and it is alarmingto find that the reviser of this dictionary has had toadd another 5000 " legitimate new terms " to hiscollection. The lexicographer’s position is difficultbecause it is his duty to interpret all the words whichhis readers may come across, and he has little chanceof purifying them in the fire of his philologicalenthusiasm. Before his comments can appear theworst words are already on a thousand lips, andthough the mortality amongst scientific terms is hightheir deaths are generally caused only bv overcrowdingdue to the delivery of others worse than themselves.Dr. Scott remarks incidentally that no name shouldbe changed simply because it is inappropriate ; itssuitability should be canvassed thoroughly before it isapplied-a custom which would save much of theconfusion of modern medical terminology. Only thuscan be checked the growth of what Dr. Gould rightlycalls the ’.’ huge and unassimilated philologic mass,many tines greater than it should be, the despair ofmedical htudents and of the makers of dictionaries."
Attention is drawn to the steadily increasing use ofproper names, legitimate and otherwise. Where these
