862 EDINBURGH OBSTETRICAL SOCIET

PERMEWAN thought that there was a real risk of ordinarysurgical principles being lost sight of in the eager rush tovaccines in certain cases. He instanced cases of chronicsuppurative ear disease where much time had been wastedand danger incurred by the useless injection of vaccine.-Dr. W. B. WARRINGTON said that impressions formed froma large number of cases were valuable, but that it wasdesirable to obtain when possible detailed analyses, since, asfar as he knew, no single case of septicaemia had yet beenproved to have been cured by these means ; for local infec-tion the vaccines of coli, gonococcus, and staphylococcus wereof approved benefit.-Dr. R. W. MACKENNA said he had beendisappointed in tuberculin ; he had found no improvementin cases of lupus from the use of Koch’s T.R., and hiscolleagues at the skin hospital had had the same experience.He had had a large experience of staphylococcic vaccinefrom various sources, and in many cases the most gratifyingresults had followed treatment. A pustular acne in a patientpast the acne age would rapidly yield to vaccine therapy,but vaccines were not ’’ cure-alls."—Dr. ORAM stated that hehad never seen any improvement from the administration oftuberculin in the treatment of cases of lupus. He was of

opinion that vaccines were unsuitable in acute cases, and thattheir use should be limited to those cases in which therewas reason to believe that the toxin from the focus of infec-tion was not obtaining access to the system. He related acase of furunculosis where ill-effects had followed the injec-tion of vaccine during the negative stage, and repeatedtemporary improvement followed each injection of serum.-Dr. HENRY H. CLARKE, Dr. G. A. CRACE-CALVERT, and Dr.0. T. WILLIAMS also discussed the paper.

EDINBURGH OBSTETRICAL SOCIETY.

Importance of Removin,q the Uterus in Certain -Diseased Con-ditions of the dnexa.--Uter2es Bicornib.-AnttnatalLobar Pneumonia.

A MEETING of this society was held on March 9th, Dr.F. W. N. HAULTAIN, the President, being in the chair.

Dr. J. M. MUNRO KERR (Glasgow) read a paper on theImportance of Removing the Uterus in Certain DiseasedConditions of the Adnexa. He first of all referred to thenecessity of conservative surgery when that was at all

possible in diseased conditions of the uterus and appendages.He then discussed the desirability of radical operative pro-cedures in cases in which the adnexa were hopelesslydiseased. He believed in such cases it was undesirable toleave the uterus behind. The two diseases of the adnexa towhich he specially referred were malignant disease of theovaries and pyosalpinx. As regards malignant disease of theovaries, Dr. Kerr pointed out how unsurgical it was to

leave the uterus behind. It was generally now acceptedthat in malignant disease the operation should be as radicalas possible. He referred to several cases in support of thiscontention. As regards double pyosalpinx he considered itadvisable that the uterus should be removed alongwith the pus tubes, and that for the following reasons :

(1) the diseased tubes could be more satisfactorily removedif the uterus were also taken away ; () by removing theuterus along with the appendages there was less likelihood ofthe tubes being burst during the operation ; and (3) in not afew cases where the tubes only were removed the uteruscaused trouble, and a subsequent operation for its removalbecame necessary. Dr. Kerr finally referred to the importanceof dealing thoroughly with any bowel that might be injured.He believed it was better to resect the portion of bowel badlyinjured rather than try to patch it up. He mentioned in thisconnexion a case recently operated upon where both tubesand ovaries were removed along with a very much injuredcaecum. The patient was now perfectly well. As regardsresults, Dr. Kerr stated that when it was his customto simply remove pus tubes he had a maternal mortalityof 10 per cent., but during the last two or three years, sincethe more radical treatment was adopted, neither he nor hisassistant, Dr D. Dickie, had had any maternal deaths.-Pro-fessor Sir J. HALLIDAY GROOM, Dr. A. H. FREELANDBARBOUR, Dr. N. T. BREWIS, Dr. W. FORDYCE, Dr. E. W.SCOTT CARMICHAEL, and the PRESIDENT made remarks onthe paper, and Dr. KERR replied.

Dr. B. P. WATSON read notes on two cases of Uterus

Bioornis. The first case was a woman, aged 26 years, who>had a full-term child eight months previously. She was

nursing the child. There had been no menses since the birthof the child, only a slight discharge of blood at the thirdmonth of lactation. About four months afterwards she hada severe vaginal haemorrhage and something came away. Themedical man was called in a few days afterwards and foundfoetid decidual remains On clearing the uterus out, the fingerin the cervical canal slipped into another smaller cavity to theleft of the one containing the remains of the decidua. This

proved to be the left half of a double uterus. The forefingercould be passed into one and the middle finger into the otherhorn and each moved separately. On bimanual examinationthe fingers of the external. hand could be passed between thetwo and depressed as far as the junction of the horns at theos internum. No decidua was felt in the left half. Therewas a common cervical canal, but a mesial band dividedthe external os into two halves. There was also a looseband at the roof of the vagina, the remains of a septumattached at its ends close to the middle of the anteriorand posterior vaginal walls. The second case was dis-covered accidentally while removing a retained placentawhich was in the right half of the uterus. The lefthalf admitted the linger at the termination of labour. Thetwo halves were separate down to the os internum, butthere were a common cervical canal and external os. She hadhad four full-time labours previously without any trouble.This condition seemed to interfere very little with the fertilityof the patient, and it seldom gave rise to any trouble atlabour except in those cases where the pregnancy was in anoocluded horn. In all cases the non-pregnant half enlargedduring pregnancy and contracted with the pregnant hornduring labour. In some cases a decidual cast had been

expelled.—Professor Sir J. HALLIDAY CROOM referred to thegreat difficulty there was in diagnosing such a condition.He related two cases where he had operated and found itpresent ; he had expected to find an extra-uterine pregnancyin one case, and an ovarian tumour complicating pregnancyin the other. On the double-horned uteri being recognisedthe operation was stopped, and in both cases the piegnancywent on to full time.-Dr. BARBOUR, Dr. FORDYCE, and thePRESIDENT discussed the paper, and Dr. WATSON replied.The SECRETARY read a paper by Dr. ALEXANDER DON

(Dundee) on a case of Antenatal Lobar Pneumonia. Thechild on being born did not breathe well and had to

be well rubbed and slapped to help the respiration. Fourhours after birth the child was cyanosed, and on examinationthe lower half of the left side of the chest was found to bedull, and moist crackling râles were heard over the area.There had been cough with some brownish expectoration,and later some blood-stained mucus. The child died 19hours after birth. A swab of mucus taken from the mouth

immediately after death was reported on by Professor L. R.Sutherland (Dundee) : "Pneumococci are present in largenumbers in cultures incubated over night ; there are also afew colonies of staphylococci ; no streptococci are found." "

The child’s head on being born was still enclosed in the

unruptured membranes, so that the brownish material

coughed up could not have been obtained from the maternalpassages.

B SOCIETY OF MEDICAL OFFICERS OF HEALTH.-Ameeting of this society was held on March llth. Dr. H.

Cooper Pattin, the President, being in the chair.-Mr. T. W.Naylor Barlow read a paper on Disinfectants, their ScientificUses, their Quack Uses, and their Dangers, in which hereviewed the situation with regard to disinfectants and thepractice of disinfection. He suggested that a large amountof the disinfection as at present carried out was nothingmore than quackery in its worst form ; that of the remaindermuch was useless owing either to the fact that the dis-infectant used was of no value or that its mode of userendered it valueless ; that much public and private moneywas wasted on the purchase of disinfectants ; and that thedistorted view which the public had of the value of dis-infectants constituted a real danger. After enumeratingsome of the special uses to which disinfectants were put,including the watering of streets, the sprinkling of ashpits,and the washing down of drains, Mr. Barlow said that, inhis opinion, their only rational use was in connexion with theinfectious fevers. Here there was some definite object inview-namely, to kill the germ causing the disease, and by

863WEST LONDON MEDICO-CHIRURGICAL SOCIETY.

so doing to prevent the infection from spreading. He

pointed out, however, that it had been shown from clinicalobservation that the organisms which were presumed to bethe cause of the various infectious diseases differed widely sofar as their infecting qualities were concerned. Each diseaseshould be treated on its merits. The measures suitable for

typhoid fever were vastly different from those applic-able to diphtheria. Referring to the dangers attend-

ing the universal practice of throwing disinfectants about,Mr. Barlow declared that many housewives thought thatwhen they had a case of infectious disease in their householdit was not necessary to be ordinarily clean, certainlyunnecessary to isolate the patient, provided a sufficientamount of disinfectant was used. He suggested that dis-infectants were now frequently used at the expense ofcleanliness and markedly so in regard to the daily dis-infection of schools.-Dr. William Butler, although scepticalas to the use of disinfection after scarlet fever, consideredthat its uselessness had not yet been proven, and as the costwas not very great it was better to act on the possibility ofgood resulting. Among some of the advantages of dis-infection was the thorough cleansing of the house concerned.- Dr. F. J. Allan strongly disapproved of the indiscriminatedistribution of disinfectant fluids and powders, and consideredthat medical officers of health should take a firm standwith their councils in expressing this disapproval. He

pointed out that in London the sanitary authority wasrequired to cleanse the ashbins. He urged the necessityfor insisting upon greater cleanliness in schools.-Dr.S. C. Lawrence thought that there was a danger ofdiscouraging cleanly ways by the too free use of dis-infectants. In the Edmonton district, where there was apopulation of 60,000 persons, .6240 were spent yearly upondisinfectants for general distribution, a sum which he con-sidered to be extravagantly high.-Dr. P. Caldwell Smith saidthat in Wandsworth all disinfection was carried out by thestaff of the health department. He considered that aftercases of infectious disease disinfection should be carried out by trained men.-Mr. F. E. Fremantle thought that until wecould get an alternative we must stick to the principleof disinfection, and considered that until the educatedclasses could be induced to regard disinfection in its truelight it was hopeless to expect the general public to do so.- Dr. Herbert Peck related the good results which hadfollowed the disinfection and scraping of privy vaults andpails in the Chesterfield rural district after an outbreak oftyphoid fever.-Mr. Edward Sergeant, while agreeing thatmuch money was wasted upon the injudicious use of dis-

infectants, considered that the time had not yet arrived for ageneral condemnation of disinfectants.-Mr. Herbert Jonespointed out the actual harm which was done by using dis-infectants in earth closets by the inhibition of the beneficentbacteria in the earth, and thus preventing its nitrifyingaction.

WEST LONDON MEDICO-CHIRURGICAL SOCIETY.-A meeting of this society was held on March 4th, Dr. NevilleJ. Wood, the President, being in the chair.-Mr. Donald J.Armour read a paper on the Treatment of Brain Tumours,which was illustrated by reference to cases, lantern slides,and specimens. He said that there was a general impressionamong the profession that little good could be expected fromoperations on brain tumours, but he pointed out the rapidadvances of cerebral surgery in the last few years, and

regretted also the want of early diagnosis met with and con-sequent late recourse to the surgeon, so that he generallyhad not to deal with an early stage and small size. He

disagreed with the classification of Walton and Paul, fromtheir statistics as to "operable," "inoperable," andI I doubtful," pointing out that by operable they evidentlymeant curable, and that their statistics were basedupon cases in which death was caused by the size ofthe tumour, and that statistics, to be of any value, mustbe derived from the records of cases operated on fairlyearly. He drew attention to what he considered a lackof clear distinction between the radical and palliativeoperation. He would describe as operable any case ofbrain tumour in which the growth could be wholly or

partially removed with subsequent benefit to the patient.He pointed out the importance of decompression at an earlystage before vision began to fail. As to syphilitic tumours,surgical interference was imperative in those cases where

symptoms were increasing in spite of adequate medicinal

treatment and where localisation was exact, and he would saythat when diagnosis and localisation had been arrived at,unless there was decided improvement under medicine in sixweeks’ time, operation should be recommended, and imme-diate operation without trying anti-syphilitic remedies whenthe symptoms were urgent and the risk to life too great to trymedicinal measures. Before operating it was impossible to saywhether the case would be suitable for a radical or a palliativeoperation-whenever possible the growth must be removed.Palliative operations were practically free from risk to lifeand were of the greatest value in relieving the distressingsymptoms of headache, vomiting, and optic neuritis, withits resulting blindness. The classes of cases for palliativeoperations were given : (1) those in which the tumour couldnot be removed, though localised ; and (2) those in which thetumour could not be localised but in which operation wasdemanded for the relief of symptoms. He discussed other

palliative operations, such as lumbar puncture, punctures oflateral ventricle, none of which could compare with

trephining. In a decompression operation the opening shouldbe over as unimportant an area of cortex as possible and meanstaken to restrain hernia cerebri. The questions referring tothe exploration for subcortical growths were discussed andalso the advisability under certain circumstances of doing theoperations in two stages, as was done at the National

Hospital, Queen-square. He referred to the dangersarising from interference with the respiratory and cardiaccentres. To sum up, he would divide cases of brain tumourinto three classes from the point of view of operation:(1) those in which the tumour was completely removed andthe patient cured ; (2) those in which it could be removedin part with marked temporary benefit to the patient; and(3) those in which the tumour could not be removed at all,but the patient was relieved of the painful symptoms of thedisease by the operation.-The paper was discussed by thePresident and Dr. T. Grainger Stewart.

PATHOLOGICAL SOCIETY OF MANCHESTER.-Ameeting of this society was held on March 9th, Dr. W. E.Fothergill, the President, being in the chair.-Dr. C. PowellWhite gave a lantern demonstration illustrating experimentson Cell Proliferation. The experiments consisted in the in-jection of fatty acids subcutaneously into the external ears ofrabbits and the mammary glands of guinea-pigs. The acidsused were oleic and palmitic acids. The injection set upaseptic suppuration with the formation of an abscess. Whensuch an abscess came in contact with any epithelium, suchas a hair follicle or sebaceous gland, the epithelium pro-liferated and grew over the surface of the abscess forming acomplete lining of squamous epithelium. In two cases inwhich oleic acid saturated with carbonic acid was used the

epithelium showed more active proliferation, and penetratedinto the subjacent connective tissue, forming columns and iso- -lated groups of epithelial cells. In two cases in which the oleicacid was saturated with methyl oxalate emboli of squamousepithelial cells were found in the lymphatics, and in thesetwo cases also there were found multiple cartilaginousnodules growing from the auricular cartilage. The abscessesformed by injecting oleic acid into the mammary glandsbecame liaed with squamous epithelium derived by meta-plasia from the mammary epithelium.-Dr. W. Milligan’made some remarks on the Pathology and Treatment ofOtitic Meningitis, pointing out the usual channels of infec-tion, the various types of meningitis, and the organismsresponsible for its incidence. In addition, he referred to thevalue of lumbar puncture as a diagnostic and as a thera-peutic measure, and to the necessity of early operation com-bined with frequent lumbar puncture to relieve intracranialtension.-Dr. A. Hill Griffith showed some Tumours of theEyelid, including a lipoma, a condition which is stated in thetext-books not to occur.

OXFORD MEDICAL SOCIETY.-A meeting ofthis society was held on March lltb, when Mr. H. S.Souttar gave a demonstration of the Gastroscope inventedby himself. Mr. Souttar said that the mucous membranewas the all-important element in stomach diseases, andthat before the introduction of the gastroscope no methodexisted for distinguishing the different macroscopic lesions.He then described the appearance of the gastric mucousmembrane in various sites ; the fundus could easily be dis-tinguished from the pyloric end, and the pylorus with itsradiating folds formed a most conspicuous object. The walls

864 REVIEWS AND NOTICES OF BOOKS.

of the stomach were in constant rhythmical notion. The

passage of the instrument ordinarily required generalanaesthesia ; difficulties were usually felt opposite the cricoidcaitilage and at the cardiac orifice, but with gentle pressurethe resistance could be overcome. By the courtesy of thestaff of the Radcliffe Infirmary two patients suffering fromdoubtful gastric disease were then examined by this method,in one of whom the diagnosis of gastric ulcer was established.

Reviews and Notices of Books.Sprains and Allied Injueies of .Tnints. By R. H. ANGLIN

WHITELOOKE, M.D., M. C. Edin., F. R. C. S. Eng., HonorarySurgeon to the Radcliffe Infirmary and County Hospital atOxford ; Lichfield Lecturer in Surgery in the University.London : Henry Frowde and Hodder and Stoughton.

’ 1909. Pp. 241. Price 7s. 6d. net.

IN no part of surgery has more assistance been given tothe surgeon by the introduction of the Roentgen rays than inthe diagnosis of injuries of the joints. No rays are neededfor the recognition of an ordinary dislocation, but it is onthose numerous and slight cases of injuries to joints whichare ordinarily called sprains that a great flood of light hasbeen thrown by the introduction of the X rays. Many casesthat formerly we should have called, quite justifiably, sprainswe now know are instances of injury to bone, and therefore weare able to understand better than was then possible the tardyconvalescence which so often ensues on the best treatmentat our command. The rays do not absolve the surgeon from

the employment of the ordinary diagnostic means such aspalpation, but if the slightest obscurity persists after thesehave been employed he is not justified in refraining fromavailing himself of the advantage offered by a skiagram. It

is clear, therefore, that there is ample justification for thewriting of a special treatise devoted to these, as they maystill be called, minor injuries of joints, and the work hasbeen well done here.The bock commences with a short account of the struc-

ture and function of joints, passing to the general considera-tion of sprains. The theories of sprains are then con- sidered, and the lesions of individual joints are discussed.In the fifth and sixth chapters injuries to the knee-joint aredealt with, especially those many lesions which are con-

veniently classed together as internal derangements of theknee-joint. The two following chapters are concerned withinjuries of muscles and tendons, and the last deals with theuse of massage, movement, and exercises in the treatment of

sprains and bruises. In an appendix is an account of

liniments and bandages useful for affected joints. There

are numerous illustrations, and, like all books issued

by these publishers, it is well printed. The tendency ofthe present day, in spite of the spread of education, toresort to bone-setters and other unqualified practitionersis in some degree due to the lack of energy not rarelyseen in the orthodox treatment of the minor injuries of

joints. All medical practitioners should see to it that theydo not leave unfinished any of the treatment, lest theygive an excuse for the introduction of unqualified treat-ment, with its attendant ill results. In utilising X raysfor the diagnosis of obscure injuries of joints it must beborne in mind that it is often necessary that the jointshould be viewed from more than one aspect, for a fractureor the misplacement of a bone may be quite invisible whenlooked at from one direction but perfectly clear when seenfrom another, and, therefore, the use of a screen is of greatvalue, even though it may be advisable or necessary to havea skiagram taken to serve as a permanent register of thelesion found. The wrist is peculiarly liable to ill-definedinjuries, and it is now known that fracture of one or more

bones of the carpus is by no means rare, and apparentlythe commonest of these to be injured is the scaphoid.We think that this book will assist those who have to deal

with some obscure injury of a joint, and its perusal willcertainly help to equip the practitioner to treat such caseswhen they come his way.

Studies in By HENRY CLARKB, M.A.,Studies in Tuberculosis. By HENRY CLARKE, M.A.,

M.D. Cantab., Physician to the Liverpool Hospital for

Consumption and Diseases of the Chest ; Superintendentof the Research Laboratory of the Hospital. Liverpool :At the University Press ; London : Archibald Constableand Co. Pp. 53. Price 5s.

THE author explains in his preface that these studiesconsist mainly of a thesis submitted for the degree of Doctorof Medicine of the University of Cambridge. The work isdivided into three sections : Diagnosis, Prevention, andTreatment. In discussing the signs and symptoms of pul-monary tuberculosis Dr. Clarke draws attention to the study ofthe patient’s temperature. The effect of exercise in promotingauto-inoculation often gives substantial aid in arriving at adiagnosis. He relies on the mouth temperature for clinicalpurposes, and ample evidence is now to hand that for allpractical work this method of estimating the temperature issatisfactory. The rectal temperature is still resorted to at

some sanatoriums, but it subjects the patient to a certainamount of inconvenience, and we agree with Dr. Clarke thatthe mouth temperature may be depended upon, provided thatsufficient time is allowed to counteract the cooling of themouth by cold air. The remarks on the diagnostic value ofthe opsonic index are interesting, but the important fluctua-tions caused by exercise are not mentioned. The normal

limit allowed by Dr. Clarke (0 ’ 9 and 1 -1) we consider toonarrow, and we would substitute 0 - 8 and 1’ 2.A comparison is made between the method of administer-

ing tuberculin in this country and that adopted in Germany.Dr. Clarke, after trial of both, leans towards the latter, butwe think on insufficient grounds. He has not apparentlygrasped the most modern plan used by physicians in thiscountry-namely, that the dose, and especially the intervalsbetween the doses, must be judged by a study of the

patient’s temperature chart and certain symptoms, such asheadache and undue rapidity of pulse. The object of theGerman method is to push the dose until a rise of tem-

perature is produced, and then to give the same dose

when the temperature returns to normal. In this countrythe dose is increased until a " flattening" of the temperaturecurve is observed, and then another dose is not given untilthe temperature begins to "swing" again. We much

doubt whether Dr. Clarke’s suggestion would prove satisfac-tory-namely, that ’’ doses sufficient for a month at a timecan be sent by post or taken home by the patient." For

the proper effect of tuberculin to be produced the patientmust be under close observation, otherwise either the full

benefit will not be produced or over-doses may be taken.The treatment of tuberculosis by tuberculin will requireextended trial by many observers before the best methodof administration can be actually determined.

The Essentials of Chemical Physiology. By W. D. HALLI-BURTON, M.D. Lond., F. R. S. Seventh edition. London :BURTON, M.D. Lond., F.R.S. Seventh edition. London:Longmans, Green, and Co. 1909. Pp. 280. Price4s. 6d. net.

A GOOD deal that in previous editions of this book hasbecome antiquated has beer excised, and the subject matterhas been brought up to date, so that the bulk of the seventhedition has been little increased. The work consists of an

elementary and advanced course and hardly a page seems tohave escaped revision. A new lesson has been introducedinto the elementary course-viz., on " Some Typical Organic