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surely Professor Lankester knows that tsetse flies have beenknown to occur in Uganda for many years past. Sir HarryJohnston in his book on the Uganda Protectora’e says,"Flies of the genus glossina exist in the Uganda Protec-toiate. They have been caught there by Mr. Jackson andmyself, not to mention many other collectors." Pro-fessor Lankester’s generosity towards Colonel Bruce has nolimits. In the preface to Mr. Austen’s monograph on tsetseflies, he states that the discovery by Colonel Bruce of try-panosoma Brucei in nagana has been followed by a discoveryof a similar para-ite in surra. Unfortunately, the surra
parasite was discovered 15 years previously. Sir PatrickManson expressed a doubt that trypanosoma Gambieinsemight not be the cause of sleeping sickness. And this doubtwas also expressed by Professor E. Ray Lankester. Con-
sidering that Sir Patrick Manson has himself contributed themost convincing evidence in favour of a causal connexionbetween the trypanosoma and the disease I think his doubtwas more figurative than otherwise. The analogy betweenthe symptoms of sleeping sickness and those peculiar tonagana, surra, and other trypanosoma diseases of horses,dog,, and cattle, the constant presence of trypanosomes inpatients suffering from the disease, the appearance ofbrain symptoms in concomitance with the invasion of thecentral nervous system by the parasite, the development ofsleeping sickness in people far and long removed fromthe endemic centres of the disease, the demonstration herein England of trypanosomes in the blood of Sir PatrickManson’s case long before the manifestation of nervous
symptoms, and the striking experiments mentioned by Dr.Brumpt show that there can be no further doubt as to thecause of sleeping sickness.
HUNTERIAN SOCIETY.
Pain and its Importance in Diagnosis and Tendency to
Mislead. --Diffuse Mastitis of the -Right BreastA MEETING of this society was held on Jan. 13th at
the London Institution, Finsbury-circus, the President, Dr.STEPHEN ApPLEFORD, being in the chair.The second Hunterian lecture was delivered by Mr.
ANTHONY A. BOWLBY, the subject being Pain and its
Importance in Diagnosis and Tendency to Mislead. Thelecturer first pointed out the great utility of pain andhow it was essential to the preservation not only of theorganism but of every tiasue. He went on to point out howvariable was the value of pain as a symptom. In children itwas a most important and valuable sign. ’’ Growing pains "and ’’ rheumatic pains " were frequently due to tuberculousbone and joint diseases and many other serious conditions.In old age pain is often very slight considering the gravity ofthe condition which excites it, such as strangulated herniaand calculus of the bladder. Mr. Bwlby then gave illus-trative cases where dull, stolid people complained of no
pain, whilst nervous, highly cultured people stated thatthey were in agony with similar conditions. Neurasthenicpain may be produced in previously strong men by illness,accident, excessive mental strain, or indulgence in drugs.This Mr. Bowlby illustrated from his South Africanexperience:. He then passed to the localisation of pain andparticularly to what is knoan as "referred pain." Hewarned his hearers against the diagnosis of eiatica andgave cases in which this diagnosis obscured a sarcoma ofthe ilium, a secondary deposit of cancer in the femur, and alarge tuberculous abscess in the gluteal region. Mr. Bowlbythen spoke on the reference of intestinal pain to theumbilicus and pointed out that in the earlier cases of
appendicitis the pain often was not located in the right iliacfossa but was general or was referred to the umbilicus.The appendix hung free in the peritoneum in these cases,but when it contracted adhesions to neighbouring parts thepain was localised -Dr. T. GLOVER LYON, after thanking Mr.Bowlby, spoke of pain in Semi tics and the possibility of
causing it by suggestion.-Dr. J. ADAMS contrasted thesensibility to pain in Hebrews and in Indian fanatics andspoke of the absence of pain in some cases of cancer and I,appendicitis.-Dr. ARTHUR DAVIES narrated a case ofaneurysm which was painless, although it eroded vertebrae.He thought medical men should guard against suggestingpains t3 their patients.-Dr. E. W. GOODALL raised thequestion as to whether the power to bear pain had increasedsince the introduction of anaesthetics. He pointed out that
the abdominal petin in some cases of acute pneumoniaoften led to errors in diagnosis.-Mr. J. S. HoSFORD*referred to multiple aneurysms without pain.-Dr. W.LANGDON BROWN spoke of a case of extreme pain inthe head which was never accounted for. He alluded toMr. H. L. Barnard’s published opinion that where abdo-minal pain occurred in chest cases the diaphragm was, asa rule, involved.-Mr. BOWLBY, in reply, said that Semiticsbewildered surgeons by unaccountable rises of temperatureas well as by pain. He thought that the appreciation of painincreased with the development of the intellectual faculties.
Dr. H. V. HiaxMArr showed a case of diffuse Mastitisof the Right Breast in a woman, aged 44 years. Tenmonths ago a diffuse lump appeared in the lower part ofthe breast. This did not feel very different from the rest ofthe breast. Two months ago a hard cord appeared whichnow reached nearly to the umbilicus. Dr. Hickman askedfor a diagnosis.-Mr. BOWLBY and Mr. BARNARD agreedthat the lump was probably scirrhus starting in a chronic.mastitis and should be explored and dealt with accordingly.
EDINBURGH OBSTETRICAL SOCIETY.-A meetingof this society was held on Jan. 13th, Dr. N. T. Brewis,the President, being in the chair.-Dr. J. M. Munro Kerr,Glasgow, read a paper on Vaginal Csesarean Section. Hepointed out that Duhrssen’s name was specially associatedwith this operation as he had since 1895 strongly re-
commended it. Speaking generally, criticism had beenrather adverse to the operation although Bumm and a fewothers had expressed themselves strongly in its favour.Dr. Kerr thought it most unfortunate that this method oftreatment should be pitted against dilatation by Bossi’sor other dilators as each had its place. The operationwas a much more extensive one than the making ofdeep incisions into the cervix already obliterated, for itconsisted in stripping the bladder off the anterior uterinewall, possibly the peritoneum from the posterior, and splittingthe cervix anteriorly and if necessary posteriorly right intothe uterine cavity. He then described a case in which thepatient was suffering from hyperemesis gravidarum and atthe end of the fifth month became suddenly and extremelycollapsed. Dilatation was attempted but the cervix was
extremely rigid, so much so that only a No. 10 Hegar’sdilator could be introduced. The bladder was then strippedoff the uterine wall and a median incision was made rightthrough the internal os and the foetus and placenta wereeasily removed. The uterine wall was then stitched up and thebladder was brought down into its place. The stitching wasnot difficult and there was no bleeding. The patient madean excellent recovery and the wound healed perfectly. The
following arguments in favour of Duhrssen’s operation havebeen advanced. 1. It is sometimes the only method bywhich rapid emptying of the uterus is possible, as in casesof extreme rigidity of the cervix. 2. It is the most rapidmethod of emptying the uterus. 3. There is little shock andthe wound obtained has clean-cut edges. The disadvantagesare that it requires some surgical skill, good light, and com-petent assistants. It was an operation less suited to generalpractice than dilatation with Bossi’s instrument. In conclu-sion, Dr. Kerr thought on the whole that the operation wasnot otten called for, although he was quite convinced it wasthe best method of treating certain cases. The conditions inwhich he thought the operation most suitable were cases ofextreme rigidity of the cervix and accidental hæmorrhagewhere hysterectomy was at present advocated.-Dr. J. W.Ballantyne read a paper on the use of Bossi’s Dilator inEight Cases of Complicated Labour. He had made use of itin both gynaecological and obstetric practice but had not beenimpressed with its advantages over other means of cervicaldilatation in purely gynaecological cases. Details of eightobstetric cases in which Dr. Ballantyne had used this dilatorwere given. Case 1 was that of a primipara with eclampsia.(Edema was present, she had a narrow pelvis, and thehead was in the right occipito-posterior position. Whenseen she had passed through three convulsive seizures andthe os was about one inch in diameter. Bossi’s dilatorwas introduced and in 20 minutes the os was as fullydilated as the pelvis would permit. Forceps were appliedwith difficulty but traction had no effect and as there wasvery little chance of saving the child basilysis was per-formed. Hæmorrhage occurred in the third stage, whichwas found to be due to adherent membranes and not fromany laceration caused by the dilator. The mother made a
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good recovery. Case 2 was that of a primipara who hadhad five eclamptic seizures before being seen. She was six and a half months pregnant; the os was very rigidand little more than one inch in diameter when thedilator was inserted. Owing to the rigidity 35 minuteswere allowed to elapse before the size of the os was
increased to three inches. The child, non-viable, was
easily delivered with forceps. The mother made a goodrecovery. Case 3 was another case of eclampsia in a
primipara in the eighth month of pregnancy. When thedilator was inserted the os was little more than one inch indiameter and in 15 minutes it was dilated to 9 5 centimetres.(nearly four inches). The child, who was alive, was easilydelivered with forceps ; the mother recovered. Case 4 wasthat of a quartipara with albuminmia and a very rigid os.Morphine and chloral had been given but with no goodeffect. After 50 hours of labour the os was about two inchesin diameter and the cervix was very hard. Digital dilata-tion had no effect on it, so Bossi’s dilator was introducedand the os was fully dilated in 30 minutes. Delivery wasthen accomplished easily by forceps. Case 5 was that ofa tertipara with a narrow pelvis who had had craniotomyperformed in her two previous pregnancies. Induction of
premature labour was decided on in this pregnancy andBossi’s dilator was used for this purpose. In half an
hour the os was dilated to about three and a quarterinches, the blades then being in close contact with thepelvic walls. Forceps were applied and a living childwas born alive but died in a few hours. Case 6 was thatof a primipara with probable post-maturity of pregnancy.Labour was induced by passing a bougie into the cervixbut dilatation was very slow and as the membranes hadruptured Bossi’s dilator was applied and effected its com-
plete dilatation in 25 minutes. Case 7 was that of a quinti-para with hydramnios, p’acenta prasvia, face presentation,and a rigid cervix. Bossi’s dilator was used and the os wasdilated up to three inches but the cervical tissues were veryresistant and in this instance the effect of the dilator wasrather disappointing. Perhaps the character of the cervixwas not such as to yield readily to strong pressure in a shorttime ; it might have been better to dilate more gradually.Cae 8 was that of a sextipara near full term. Accidentalhæmorrhage had occurred with great loss of blood beforebeing seen. The os was one and a half inches in diameter andthe placenta could not be felt. The general symptoms wereurgent and as bleeding was still going on it was necessaryto deliver as soon as possible. The dilator was insertedand complete dilatation was effected in ten minutes.Bossi’s dilator was a powerful instrument for use in excep-tional obstetric conditions. It was much to be preferred tomultiple incision of the cervix for rapid dilatation of the os.In its use experience taught the degree of resistance whendilatation should be suspended and a pause given before againturning the screw for further dilatation. If dilatation werecarried out intermittently there was little danger of a cervicatear. The distal ends of the blades must be inside the osinternum or the cervix would be torn. Dr. Ballantyne pre-ferred the four-bladed Bossi dilator to the other types. Thetwo dangers in its use were sepsis and laceration of thecervix. It must be remembered that it was the most powerfulinstrument in the obstetric armamentarium with the excer-tion of the destructive cranioclasts and comminutors. Asepsismust be carefully attended to.-The President, Professor A.R. Simpson, Dr. James Ritchie, Dr. F. W. N. Haultain, andDr. A. D. Webster discussed these papers and Dr. Kerr and Dr. Ballantyne replied. ’
BRITISH GYNÆCOLOGICAL SOCIETY.-A meetingof this society was held on Jan. 14th, Dr. Heywood Smith,the President, being in the chair.-After the reading andadoption of the reports of the retiring honorary treasurer,Dr. W. Travers, and of the editor of the journal of thesociety, Dr. J. J. Macan, and some formal business, thefollowing cfhcers of the society were elected for the year1904: President: Dr. John W. Taylor. Vice-Presidents :Mr. E. Stanmore Bishop, Professor Murdoch Cameron,Mr. F. Bowreman Jessett, Sir Arthur V. Macan, Dr.H. MacNaughton-Jones, Dr. J. A. Mansell Moullin, Mr.Christopher Martin, Dr. F. F. Schacht, Professor Alfred J.Smi,h, Dr. Heywood Smith, Mr. W. D. Spanton, and Dr.Travers. Treasurer: Dr. W. H. Slimon. Members of theCcuncil : Mr. G. R. Carter, Dr. Eber Chambers, Dr. R J.Colenso, Sir J. Halliday Croom, Dr. T. M. Dolan, Dr. W.Duncan, Dr. F. Edge, Dr. George Elder, Dr. T. J. English,
Dr. Bedford Fenwick, Dr. J. Hai Ferguson, Dr. ClementGodson, Dr. Arthur Helme, Dr. James Jardine, Dr. HenryJellett, Dr. J. Macpherson Lawrie, Dr. R. P. Ranken Lyle,Dr. S. Lloyd, Mr. J. Padman, Mr. A. W. Mayo Robson,Mr. Charles Ryall, Dr. R T. Smith, Dr. Herbert Snow, andMr. H. F. Vaughan-Jackson. Secretaries : Dr. Macan,Dr. J. Hutchinsun Swanton. and Dr. S. Jervois Aarons.Auditors : Dr. F. A. Purcell and Mr. C. H Bennett.-ThePresident showed Frommer’s Modification of Bossi’s Instru-ment for dilating the cervix and demonstrated the easewith which each of the eight blades could be removed,the facility of its introduction, and the diminished riskof laceration.-Dr. Mendes de Leon of Amsterdam gavean address on a Source of Infection during Operationshitherto not sufficiently recognised, in which from a seriesof extended experiments he concluded that during an ordi-nary operation the surgeon would probably speak 300 words ;that the repetition of the same 300 words against preparedagar plates placed in a sterilised box of suitable CODstructionresulted in colonies of staphylococci, streptococci, and othermicro-organisms owing to the projection upon the plates ofabout a quarter of a million germs in minute particles ofsaliva; that inoculations of saliva produced in animals aspecific peritonitis from which the above micro-organismscould be cultivated ; and that though the power of resistanceof the peritoneum was great and the contact of such germs,which were not necessarily always virulent, did not invariablycause infection, the words of necessity uttered by an
operator were likely to convey such germs to the fieldof operation, and that masks of one or two folds ofgauze would not preclude such infection. He thereforerecommended the use of a respirator containing, between twoplates of perforated metal, a layer of cotton wool, whichhe had found prevented the infection of the agar platesin the sterilised box and which he had been able to wearwithout discomfort in operations lasting from one hour toone and a half hours.-The paper was discussed by the Pre-sident, Dr. Macnaughton-Jones, Dr. Snow, Dr. MacphersonLawrie, Dr. Bedford Fenwick, and Dr. W. J. Smyly, most ofwhom agreed that if the mouth required guarding the nostrilsshould also be protected.-Dr. Mendes de L6on, in reply,insisted that, save in case of disease of the respiratory tract,the danger was from the saliva rather than from the breath,and that satisfactcry as the results of operation, especially ingynaecology, now were, nought but good could result fromthe recognition of the danger he had described.-He wasthanked for his communication and the President then reada Valedictory Address, reviewing the work of the societyduring his year of office.-On the motion of Dr. Taylor acordial vote of thanks was carried by acclamation to thePresident for his address and for his conduct of the businessof the society during the past year.
GLASGOW PATHOLOGICAL AND CLINICAL SOCIETY.-A meeting of this society was held on Jan. llth, Mr. A. E.Maylard, the President, being in the chair.-Dr. John Rowanshowed an infant whom he had under observation and whosuffered from a growth of the iris which he believed to be agumma. There was a distinct syphilitic history.-ProfessorRobert Muir showed as a fresh specimen a haemorrhage intothe pons Varolii and crura cerebri and granular kidneysfrom the same case.-Dr. A. N. McGregor demonstrateda case of Varicosity of both Surerficial Epigastric Veins.The condition commenced after an attack of entericfever seven years ago and was regarded as due tothrombosis of the iliac veins on the left side. The vari-cosity acted as a relief channel, the blood flowing upthe left epigastric and through a large anastomosis anddown the right epigastric to the right femoral vein.The veins emptied themselves when the patient was in therecumbent position. Dr. McGregor was of opinion that thelumen of the thrombosed vessels had been partly restored.-Dr. James Carslaw and Professor Muir described the clinicaland patholcgical features of a case in which Rupture of aHydronephrosis occurred. The illness set in with vomitirgand pain which suggested appendicitis. Operation revealeda swelling round the right kidney. The swelling was thenincised and drained from behind. The patient died frcmsuppression of urine which set in immediately after the firtvomiting. At the post-mortem examination bilateral hydro-nephrosis with rupture of the pelvis of the right kidney wasdiscovered. The nature of the obstruction could not be madeout. Kinking of the ureters appeared to be the most
probable cause.-Mr. Henry E. Clark showed an Eyeball
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which had been removed on account of a tumour which hebelieved to be a secondary deposit resulting from carcinoma0: the mamma. The tumour of the mamma had beenremoved four years ago. It recurred and on accountof this double oöphorectomy was performed and treat-ment by the x rays was afterwards used. Secondarytumour in the eyeball was an extremely rare conditionand the specimen had not yet been examined micro-
scopically, so that its nature was still uncertain.-Mr. Henry Rutherfurd showed a specimen of Unilateral
Hydronephrosis due to kinking of the ureter by the renalvessels. He also showed a Humerus the seat of rapidlydeveloping sarcoma having a relation to an injury. Three
Iweeks after a fall the patient was examined but no evidenceof fracture was found. Three days later fracture resulted lfrom another fall and a tumour then formed very soon.
The arm was amputated seven weeks after the first injury ;the patient, who was a boy about six years old, died fromshock.
ROYAL MEDICAL SOCIETY OF EDINBURGH.-Ameeting of this society was held on Jan. 8th, Dr. H. D
Shepherd being in the chair.-Mr. J. W. Dowden gave anaddress on the Treatment of Shock. After discussing thevarieties and etiology of shock he referred to an interestingseries of experiments made in America on the effect produced Ion vaso-motor pressure by laceration of various parts of thebody in animals. In almost all regions the effect of injurywas increase in blood pressure, the abdomen and the scrotumbeing exceptions. In preventing shock as the result ofanaesthesia Mr. Dowden believed that there were great possi-bilities in the u;e of I)cal anaesthetics. Such major opera-tions as the removal of an arm with the corresponding part ofthe shoulder girdle had been performed under cocaine, thepatient being qaite ignorant of what was going on. In theuse of general ausesthetics the preparation of the patient asordinarily done by a process of starvation and purging shouldnot be too rigorously carried out Even within an hour or twoof the operation readily absorbed food might be given by themouth and the patient might have a nutrient enema. Inthe actual treatment of shock warmth and friction were im-
portant factors. Of drugs strychnine and digitalin were Jthe most valuab’e. Any good effect of alcohol was probablytemporary and due to its action as an irritant, such anirritant as capsicum being even more effective. Injection in-travenously of normal l3aEne solution, except in cases of
haemorrhage, was more dangerous than useful.-A paper onPubiotomy by Dr. F. D. Simpson was read in his absence byMr. A. MacRae.-Dr. T. B. Hamilton read a paper on PleuralESudon. He said that the microscopical examination ofthe fluid was very important, for in this way it could bedetermined whether the condition was of tuberculous or
icB.a.mmatory origin or whether it was merely dropsical.BRISTOL MEDICO-CHIRURGICAL SOCIETY. - A
meeting of this society was held on Jan. 13th, Mr. J.Paul Bush being in the chair.-Dr. H. Elwin Harrisshowed a cae of Congenital Absence of the Left Auricleand External Auditory Canal with Facial Paralysis.-Mr.H. F. Mole showed (1) patients on whom the RadicalMa,toid Operation or Ossioulectomy had been performed forthe cure of chrjnic suppuration in the middle ear ; (2) apatient on whom Choledochotomy had been performed ;(3) a specimen of a Tumour growing from the cartilaginousseptum of the nose ; and (4) a Skiagram of an UnusualDislocation of the Akle.—Dr. J M. Fortescue-Brickdaleshowed a specimen of a Cyst below the liver, apparently anaccessory gall-bladder, and the Brain of a child showingsimple meningitis and considerable dilatation of theventricles.-Mr. Jdmes Taylor showed a skiagram from aca-e of Scurvy Rickets.-Dr. E. W. Hey Groves read notesand showed the specimen of a case of Tubal Gestation pro-ducing severe internal haemorrhage without rupture.-Mr.W. Rger Williams discussed the case.-Dr. W. K. Willsread a paper on the Present Position of Radiography inTherapeutics.-Mr. Bush, Dr. Harrison, Dr. P. WatsonWilliams, and Mr. Taylor discussed the paper.-Dr. TheodoreFisher read a short paper on Hasmate’Be-is associated withsmall white kidneys.-Dr. Watson Williams, Dr. E. H. E.Sack, and Dr. J. A. Nixon made remarks on the cases.
SOUTH-WEST LONDON MEDICAL SOCIETY.-Themonthly meeting of this society was held on Jan. 13th, Mr.E. F. White, the President, being in the chair.-Mr. J. H.Targett read a paper on Some Difficult Cases of Uterine
Hemorrhage and exhibited specimens illustrating the lesionsdescribed. The cases were grouped under the following:headings : (1) Haemorrhages occurring in very early preg-nancy ; (3) post-climacteric heamorrhage ; and (3) hsemor-rhages due to general disorders, such as chronic alcoholism,Bright’s disease, and the like.-After the reading of the.
paper a discussion took place to which several members ofthe society contributed.-At the close of the meeting thegeneral business of the society was transacted.
Reviews and Notices of Books.The Lymphatics. In two Parts : 1. The General Anatomy of
the Lymphatics, by G. DFLAMARE. 2. The Special Studyof the Lymphatics in Different Parts of the Body, byP. POIRIER, Professor of Anatomy, and B. CUNECProfessor (agrege) to the Faculty of Medicine of ParisaTranslated and edited by CECIL H. LEAF, M.A., M.D:Cantab., F.R.C.S. Eng., Assistant Surgeon to the CanceJ1’Hospital. With 117 Illustrations and Diagrams. West.minster : Archibald Constable and Co., Limited. 19038vo, pp. 301. Price 18s. net.
DURING the last 12 years a monumental work on-
anatomy has been slowly but steadily progressing inFrance under the able direction of Professor Paul Poirierof Paris, with the collaboration of Professor A. Charpyof Toulouse, Professor A. Nicolas and Professor A.Prenant of Nancy, and Professor T. Jonnesco, prosectorto the Faculty of Paris. Four large volumes, averaging1000 pages each, have appeared and only the part devotedto the senses remains to complete this splendid treatise. The-section on the lymphatics belongs properly to the secondvolume long since published but its appearance has forsome reason been delayed and Professor Poirier, finding thathe was unable to write the description of the generalanatomy and histology of the lymphatic system, intrustedit to Dr. Gabriel Delamare, reserving for himself and Pro-fessor Cunéo the special study of the lymphatics of the-different parts of the body. The whole section, which
appeared in 1902, has now been translated into English byMr. Leaf, and after comparing many pages of the transla-tion with the original we congratulate him on havingrendered the French into English with great accuracy andon presenting to his countrymen an excellent account ofthe present state of knowledge of the lymphatics as it is-
taught and understood in France.The general anatomy of the lymphatics, written by Dr..
I Delamare (unaccountably written Delamere in the title-
page of Mr. Leaf’s translation and in the editor’s-
preface, and again at the heading of the article), com-
r mences with a description of the leucocytes of the blood,L their movements and reproduction, and the action of stain-! ing agents upon them The microcytes and macrocytes,and finally the cells of Ehrlich, are considered in succession. The microcytes, which are of about the size of red bloodi corpuscles, have received many names. They are the free nuclei of Robin, the lymphocytes of Einhorn and Ehrlich,. and the leucoblasts of Denys ; they are not phagocytes and
have only a limited power of movement. They are found. normally in the blood and lymph, the lymphatic glands,.
the spleen, and the red marrow of bones. By the concurrents estimates of several good observers they constitute about 2&1
per cent. of the white corpuscles of the blood. Dr. Delamarehimself found in the fluid taken from the thoracic duct ofthe dog (he does not specify whether after food or in the!. fasting state) that out of 133 elements 128 were microcytes.
The macrocytes or macrophages of Metchnikoff are of much
e larger size ; they are amoebic and extremely phagocytic.They digest the bacillus of Han3en, red corpuscles, leuco-
, cytes, and even particles of sulphate of arsenic. In the-e enumeration given by different observers their number varies