600

e

out of 49 cases of acute broncho-pneumonia thepercentage was 14, and of 336 of influenzal-pneu-monia, 5-7, an estimate which corresponded with thefigures of Mounetier. A possible explanation wasthat broncho-pneumonia affected the more debilitatedchild, and that empyema was but an indication of ageneral want of vitality. On the other hand, the widerdistribution of the broncho-pneumonia offered a

greater opportunity for spread to the surface. Anotherpoint of supreme importance in the progress andconduct of the case was the nature of the infectingorganism. In 53 pneumococcal cases the mortalityaveraged 6-9 per cent., whilst in 17 streptococcalcases it was 24-7 per cent. In streptococcal casesadhesions were few and the effusion widespread,whereas in the pneumococcal cases adhesions weremany and relatively stronger, so that the effusiontended to be limited. This point was of great import-ance in considering treatment, for stereotyped treat-ment was to be deprecated. Points to consider were(1) the general condition of the child, (2) the type ofinfecting organism, (3) were adhesions present toany extent between visceral and parietal pleurae ?(1) and (2) were easily decided. With regard to.question (3) the type of infection gave an indication,but was not a certain guide, nor were X rays infallible.Valuable information could be obtained from theamount of intra-pleural tension. A large-boreaspirating needle connected with a water manometerwas inserted into the pleural cavity. The pressure-varied within wide limits according to the amount ofquid present, but on the average it registered about100 mm. of water. The important finding, however,was the degree of oscillation. In the absence ofadhesions the play was wide, whilst the movement-limiting effect of their presence resulted in the main-tenance of a constant pressure with comparativelylittle variation.

Mr. Fraser went on to discuss the practical detailsof treatment. In a case where adhesions had beendemonstrated the aim was to open freely into theabscess cavity, to evacuate the pus, and also massesof fibrin adherent to the pleura, to establish a closeddrainage from the most dependent part of the cavity,and to close completely the original wound after

disinfecting its edges. Details of the technique weregiven. Dr. Fraser found that the results were mostencouraging. After a period varying from 20 to 28days the post-operative pneumothorax had dis-appeared, and the lung expanded to fill the cavity ofthe chest. In streptococcal cases free incision, owingto the absence of adhesions, led to extensive collapseof the lung, often -vvith fatal result. Aspiration was,therefore, practised for four or five days to permit of the ’,formation of adhesions, after which a procedure similarto the above might be applied with a considerablemargin of safety. Every care must be taken to avoidbreaking down the adhesions. Mr. Fraser consideredthis method superior to any other yet evolved.

Various points in the technique were illustrated bylantern slides.

The subsequent discussion was opened by thePRESIDENT.-Mr. D. P. D. WILKIE referred to the workof the commission on post-influenzal empyema inAmerican camps, from which it was concluded thatthe best results were obtained from aspiration. Healso spoke of the method of aspiration followed byinjection of an amount of 1/2500 gentian violet equalto half the aspirated fluid.-Mr. W. J. STUART spokeof a method of suction drainage by means of a Politzerbag, which he had employed in adults with success.-Dr. S. DAVIDSON spoke of the importance of knowingthe type of pneumococcus, and suggested the value- of serum injection after aspiration.-Mr. J. W.DOWDEN, Dr. FERGUS HEWAT, and Mr. JOHNSTRUTHERS also spoke, and Mr. FRASER replied.

Exhibition of Cases.Sir NORMAN WAr.KER, showed a case of leprosy.

The patient was an old woman who had been in Russia30 years before, but had had no communication withRussians even by post since then. She had apparently

been perfectly well up till three years ago. Treatmenby a vaccine prepared from one of the nodules byColonel W. Glen Liston was instigated with rather re-markable result, as shown by comparison of the presentcondition with a cast of the arm made before thecommencement of treatment. Films made from thenodules before and after showed a remarkablediminution of bacilli since treatment. Some 20

injections had been given.Mr. GEORGE CHIENE showed a case of snapping

hip in a girl of 15 successfully treated by operation,and Dr. JOHN EASON showed a case of congenitalheart disease in a woman aged 24.

LIVERPOOL MEDICAL INSTITUTION.

A MEETING was held on March 6th, with Mr. G. P.NEWBOLT, the President, in the chair, when Mr.HUGH REID read a note on an

Obscure Case due to Calculusin the pelvis of an ectopic kidney situated below thebrim of the bony pelvis. The case was seen by Mr.Reid while the patient was under the care of Mr.Thelwall Thomas in the Royal Infirmary. The patient,a man, had a history of cutting pain in the left lumbo-sacral region shooting towards the groin. He also hadpain in the suprapubic region passing down the penis.Blood had been passed in the urine. The clinicalfindings were negative. Urine examination showedurea 1-97 per cent., a few blood and pus cells, andstaphylococci. The X ray diagnosis was " stone in thebladder." At a cystoscope examination pus was seencoming from the left ureter and from this it wasdecided that the condition was due to a stone in amuch dilated ureter, low down. An operation wasperformed by Mr. Thomas. A split-muscle incisionover the left iliac fossa was made, the ureter was notfound, and the kidney was then noticed to be placedentirely below the brim of the bony pelvis ; the organcould not be brought out if its bed through the woundand the renal vessels were seen arising from the commoniliac. The stone was felt in the pelvis of the kidneyand removed. One month after the first X ray exa-mination the patient was discharged with the woundhealed after a normal convalescence. Mr. Reidexhibited a lantern slide of the X ray plate and gavea short review of the literature on the subject, togetherwith an account of the embryology, clinical features,pathological changes, diagnosis, and treatment ofectopic kidneys.

Dr. MORRIS J. CoHEN, who assisted at the operation,said that the presence of pelvic kidney was unsus-pected. The right kidney was shown on the X rayplates in its normal position. The shadow of thepelvic bones would naturally obscure the outline ofthe left kidney. No pyelogram had been made.Recently he had seen a post-mortem of a female casein which the left kidney was fixed below the brim ofthe pelvis. In both instances the suprarenal bodiesdid not descend with the kidneys.

Dr. J. C. MATTHEWS read a note on two cases of

Hodgkin’s Diseaseshowing the periodic pyrexia usually known as thePel-Ebstein syndrome. In one of them the diagnosisof Hodgkin’s disease had been confirmed by post-mortem examination. A condensed temperaturechart, prepared on the lines suggested by Hall andDouglas, was shown. This showed a wave-lengthof about 21 days. The second case was observed overa much shorter period and showed a wave-length ofabout 14 days.

’

Dr. S. W. PATTERSON read a paper on 31 casesof the same disease. Having outlined the clinicalfeatures and pathological appearances of the blood-forming organs, he discussed the absence of any

1 We recorded last week with regret the sudden death ofMr. Newbolt; an obituary notice appears on p. 626 of the presentissue.—ED. L.

601

significant setiological factor. Syphilis and tubercleweie related to Hodgkin’s disease only as secondaryaccidental infections. Three cases had been attendingthe skin department for chronic skin lesions, in one

instance for six years, before severe symptoms ofHodgkin’s disease appeared. The pathologicalchanges in the liver and spleen had led by analogywith malignant disease to Hodgkin’s having beenregarded wrongly as a new growth affecting the blood-forming organs. Having regard, however, to the

peculiar disturbances of temperature with remit-tances and big oscillations, the more or less progressivecourse ending in death, and the pathological appear-ances, the causative agent was likely to be parasitic.Mr. J. T. MoRRisoN spoke of the uncertainty that

prevailed as to the nature of the disease and evenas to whether it was one disease or a group whichwas called lymphadenoma. In view of this heemphasised the importance of concentrating on whatwas known and of making the diagnosis as accurateas possible. He declared that no patient with anoperable mass of glands in the neck should becondemned to the label lymphadenoma until a glandhad been submitted to microscopic examination.In excluding tubercle this was most important.In regard to treatment, he declared that results ofexcision in early cases followed up by full courses ofX ray treatment and arsenic were better than fromany of these methods taken individually, and hepleaded for further trial of this plan.

Reviews and Notices of Books.OPERATIVE SURGERY.

Covering the Operative Technique involved in theOperations of General and Special Surgery. ByWARREN STONE BicKHAM, M.D., F.A.C.S., formerSurgeon in Charge of General Surgery, ManhattanState Hospital ; Instructor in Operative Surgery,College of Physicians and Surgeons (ColumbiaUniversity). In six octavo volumes. London andPhiladelphia: W. B. Saunders Company, Ltd.1924. Vols. 1. and II. Pp. 1726. 50s. net per vol.

THIS treatise on operative surgery, comprising inall nearly 6000 pages and 6300 illustrations, is mostunusual in that it is the work of a single individual.Nowadays we are accustomed to systems of surgeryand medicine, the results of the collaboration of anumber of writers welded into a whole by a singleeditor. Here we have an immense work writtenthroughout by a single author, free from overlapping,unevenness, and other short-comings of a collectivesystem, and with uniformity of outlook and expression.The author can only have achieved this success bycolossal industry and a tenacity which must surelyhave been strained almost to breaking point, whensubjects in which he was not particularly interestedhad to be dealt with. The two volumes under reviewshow no evidence of flagging in interest or effort. Inthe preface the author reveals the motives whichled to the writing of such a book. It is intended todeal with operative technique alone, but the authordoes not over-rate the place of technique in surgery.

IHe maintains that operations should be carried outwith a consummate regard to technical detail, whichshould be unobtrusive to the onlooker. His objecthas not been to describe all the operations of surgery,but the work is almost encyclopaedic; we find, forinstance, four methods of performing the rarely under-taken operation of ligature of the innominate artery.

Vol. I. deals with general surgical technique,including ansesthesia, local and general, plasticsurgery, amputations, and the excisions of bones andjoints. Each operation has a systematic heading,consisting of (1) a description of the operativetechnique in a few words ; (2) an anatomical designa-tion of the structures involved ; (3) the name of the

Isurgeon or surgeons to whom credit is given for theinvention or modification of the procedure. Each

section begins with a general consideration of theregion in question, including its surgical anatomy,while it is concluded by a paragraph labelled " com-ments." In this volume there are satisfactory accountsof the various amputations and excisions, whilstsome subjects to which much space is not usuallyallotted are fully considered. Amongst these is thequestion of the selection of the amputation site inrelation to modern protheses, a full description ofartificial limbs and what can be expected from them,kineplastic operations, and paraffin injections. Thesection on plastic surgery is very good, but, curiously,there is no mention of the method of the epithelialinlay graft, developed so extensively by Mr. Gillies.

In Vol. II. are found operations upon the blood-vessels, lymphatics, and nerves, operations uponbones, muscles, fasciae, tendons, bursse, cartilage,and joints (excluding excisions), together with twolarge sections upon the brain and spinal cord. Thisvolume contains a mass of information, an immensenumber of operations being described, some of whichare but little practised, such as Jonnesco’s excision ofthe cervico-sympathetic, and Cushing’s ventriculo-abdominal drainage for hydrocephalus. It is almosthypercritical to note an omission, but in the sectionon the closure of persistent bone cavities, amongstthe ten methods discussed, no mention is made of theuse of a pedicled muscle flap, which is very satisfactoryon occasions. The sections on brain and cord surgeryare unusually good.The author set himself the purpose of describing

technique only. One could wish that he could haveamplified this by more discussion of the relativemerits of the procedures he describes. Where hedeparts from this self-imposed restriction, unfortun-ately too seldom, his remarks are always valuable.For example, the lymphangioplasty of Handley andKondoleon’s operation appear in succession as

apparently equal competitors for the surgeon’s seriousattention ; the turning down of a section of nerveto bridge a gap and the implantation of a graft rankequally with direct union after slow stretching or thetransplantation of the nerve trunk so that it followsa shorter course.The author might have been more eclectic, even

while professing only to deal with technique. Butit was a great conception to write without assistancea large work dealing with all branches of surgicaltechnique ; in execution it has reached a pitch ofextraordinary success. ____

The Students’ Handbook of Surgical Operations.By the late Sir FREDERICK TREVES, F.R.C.S., andJONATHAN HUTCHINSON, F.R.C.S., ConsultingSurgeon to the London Hospital. London :Cassell and Co., Ltd. 1924. Pp. 552. 10s. 6d.

THIS fourth edition of a well-known manual has beenrevised and enlarged by Mr. Hutchinson. The taskhas been thoroughly carried out, as can be readily seenby references to such sections as those on the stomachand skull. The author justifies the devotion of somuch space to amputations and the tying of arterieson the grounds that these subjects bulk largely atexaminations, as they provide excellent and almostthe only available tests of the candidate’s skill andanatomical knowledge. There is a very great deal tobe said for the view whilst examinations are a necessity,and these sections do not seem to be over-emphasisedin the present volume ; more drastic revision of themwould have detracted from the value of the work.The book is so well established that a detailedcriticism is not required. It is likely to remain one ofthe best students’ manuals on operative surgery.

ASSYRIAN MEDICAL TEXTS.From the Originals in the British Museum. ByR. CAMPBELL THOMPSON, M.A., F.S.A. London :Humphrey Milford, Oxford University Press1923. Pp. 107. 42s.

Tnis compilation presents in 107 large plates the-carefully drawn facsimiles of the text of 660 cuneiformmedical tablets, for the most part hitherto unpublished,