1843 OPHTHALMOLOCAL SOCIETY. - ialse joint and the middle portion of the glenoid cavity, without disturbing the important origins of the biceps and triceps from the upper and lower borders of the rim. 3. At the operation an assistant could cause the deformity resulting from the dislocation to aid the surgeon ; by means of the arm he could push the neck of the scapula towards the surgeon and hold it fixed whilst the glenoid cavity was being excavated. 4. The head of the humerus was replaced with its muscular insertions and its articular surface intact. It - could then move freely in the excavated glenoid cavity. But it was not liable to become displaced again, for all the muscles were still attached yet had become somewhat shortened in the time which had elapsed after the accident. Hence passive and active movements could be begun early. If indeed the operation were to be adopted for a quite recent dislocation, whilst the rotators of the head were still stretched or perhaps partly torn, then it might be necessary to limit the movements of the shoulder until the muscles shculd have contracted up.- The PRESIDENT said that the value of the operation was in obviating the division of the important muscles round the shoulder-joint.-Mr. RUSHTON PARKER said that enough was not done in these cases to make surgeons acquainted with the amount of defect that might be tolerated without impair- ing the power of a working man to earn his living. He thought that the operation described by Mr. Spencer was ,deservirg of recommendation.-Mr. T. H. KELLOCK gave the details of a similar case in which he had performed an operation like that described by Mr. Spencer, but he (Mr. Kellock) had used an anterior incision. He suggested that a posterior and an anterior incision would be the most satis- factory way of approaching the joint in these cases.-Mr. SPENCER replied. Mr. ALBAN H. G. DORAN read a paper on a Cystic Tumour of the Suprarenal Body successfully removed by - operation. He reviewed the records of 13 cases of cystic tumour of the suprarenal body, large enough to be of clinical ,and surgical interest, including one in his own practice of a woman aged 62 years who had been subject for ten years to .attacks of pain after food, and recently to sharp pains referred to a firm oval tumour in the left hypochondrium. It was half hidden under the ribs but could be pushed down. wards below them. There was resonance on percussion over part of its anterior surface. Diagnosis was uncertain. He operated, making the abdominal wound along the outer border of the left rectus. The peritoneum was incised externally to the descending colon and the tumour was enucleated with ease. Some large vessels running into its upper and inner part required ligature. The left kidney was seen lying internally to the tumour and mainly below it. No drainage was employed. The tumour was a thick-walled uni- locular cyst, containing half a pint of bloody fluid. Much adrenal tissue was detected in its walls. It was an instance of the struma suprarenalis cystica hæmorrhagica of Henschen. :Several other cysts of this class were included in the series, to which was added a doubtful case recorded by Lockwood. The minority were adenomatous or lymphomatous cysts. A history of injury existed in two out of the 13 cases ; attacks of local pain were the rule ; bronzing of the skin was noted in one case only (McCosh) and it disappeared after removal of the tumour. Incision and drainage had proved most un- satisfactory ; the wall of a blood cyst was soft and in one instance tore itself away when sutured to the abdominal wound, with a fatal result. In another case the patient died, and it was afterwards found that the cyst could easily have been enucleated. This incomplete operation was adopted in a third case because the cyst was believed to be pancreatic sc its base was not removed. The patient recovered. Com. plete removal of the cyst was the proper surgical treatment ’Recovery followed respectively in Pawlik’s, McCosh’s, anc his own (Mr. Doran’s) cases, as well as in Lockwood’s case where the nature of the cyst was doubtful. The proximity o: the aorta or vena cava should always be borne in mind. Six of the cases were mainly of clinical interest, not having bee! subjected to operation.-Mr. C. B. LOCKWOOD said that hi had in 1898 exhibited a retroperitoneal cyst supposed to hav4 .originated in remains of the Wolffman body and he ha< operated in two additional cases in which both the patient were young women, recovery following the operation in eacl -case. Both the cysts were in the left side. One was th <usual type of cyst, full of clear fluid and freely moveable "The other cyst was attached to the lower end of the lef 5 See THE LANCET March 5th, 1898, p. 615. kidney and at its attachment some solid growth was found which proved to be adrenal tissue. Mr. Lockwood considered this case to supply a very important link in the chain of evi- dence which had led him to attribute the ongin of these retroperitoneal cysts to remains of the Wolffian body which, as was well known, gave origin to the adrenal body and . adrenal remains. These retroperitoneal cysts had fairly con- . stant clinical characters. The patients were nearly always females. The tumour was on the left side, it was freely moveable, and was usually thought to be a moveable kidney. It caused continual pain and discomfort. In the four cases of which Mr. Lockwood had had experience the cysts were , safely removed by incision into the abdomen through the i outer edge of the left rectus abdominis, the cysts being l exposed by dividing the descending meso-colon. In the case E of the cyst attached to the kidney the kidney substance was , incised and brought together with catgut.-Mr. DORAN E replied. Mr. RUSHTON PARKER read a paper on a case of very i severe Compound Fracture of the Arm which he illustrated by photographs and lantern slides. The points to which he desired to draw attention were the slinging of the arm to 1 the neck and the flexion of the elbow to a more or less - acute angle. In a fracture of the lower fourth of the 3 humerus on account of the invariable tendency to adduction s of the condyles under the weight of the elbow a twist imparted to a metal splint hollowed to fit the limb effectually 1 maintained the lower smaller fragment in line with the . upper while controlling both. a Mr. PARKER also read a paper on Two Cases of Ununited . Fracture treated by Planting Small Fragments of Bone . between the Ends. OPHTHALMOLOGICAL SOCIETY. An Epidemic of Contagious Conjunctivitis Due to the Pneumo- coccus.-Hereditary Eye Disease.-Secondary Xerosis.- Lower Corneal Plaques.-Exhibition of Cases and Card Specimens. A MEETING of this society was held on June llth, Mr. R. MARCUS Gmm, the President, being in the chair. Mr. P. E. H. ADAMS read a paper on an Epidemic of Con- tagious Conjunctivitis due to the Pneumococcus. He said that the epidemic occurred in the spring in a small school of 37 boys, 21 of whom were attacked. The eldest boy affected was 14 years of age, the youngest beirg nearly ten years old. All the smears taken except one showed numerous Gram- positive diplococci. Most of them were typically flame- shaped pneumococci with capsules, though a few of them were rounder in shape and in some the capsules were not evident. This agreed with the description given by Schmidt 1 of smears taken from cases of pneumococcal conjunctivitis. On blood agar the colonies were typical slow-growing pneumococci and there was no growth on agar. Only three of the cases were at all acute, most of them being subacute or quite mild. Four cases of relapse were reported. The condition found on examination was fairly constant-general congestion of the lower palpebral conjunctiva, with slight injection of the ocular conjunctiva, and in the acute caes a thin line of muco-pus in the folds of the conjunctiva of the lower lid. The upper lid showed slight enlargement of follicles at the angles, and a row of minute follicles along the everted edge. The whole epidemic lasted about five weeks and spread in spite of isolation. It agreEd in almost every respect with previously reported outbreaks, the chief difference being the generally mild nature of the cases. Mr. E. NET’rLESHIP read notes of three cases of Hereditary Eye Diseases. Case 1 was that of a husband and wife who had senile cataract at an advanced age, and both were operated on with success. They had ten children, seven of whom had cataract in various degrees, two of these having had them "matured and operated upon at a much earlier age than in their parents. There were also slight lenticular changes in the grandchildren of the original couple. The second family showed the occurrence of I I Cioppock " or discoid cataract, and lamellar cataracts of various sizes, and likewise of retinitis pigmentosa. Among about 250 persons Mr. Nettleship had been able to trace, belonging to the family, 32 with family cataract and 15 with retinitis pigmentosa. The sex incidence and mode of descent were shown to be different for the cataract and retinal disease 1 Archives of Ophthalmology, vol. xxxvii., No. 2.
Transcript
1843OPHTHALMOLOCAL SOCIETY. -
ialse joint and the middle portion of the glenoid cavity,without disturbing the important origins of the biceps andtriceps from the upper and lower borders of the rim.3. At the operation an assistant could cause the deformityresulting from the dislocation to aid the surgeon ; by meansof the arm he could push the neck of the scapula towards thesurgeon and hold it fixed whilst the glenoid cavity was beingexcavated. 4. The head of the humerus was replaced withits muscular insertions and its articular surface intact. It- could then move freely in the excavated glenoid cavity. Butit was not liable to become displaced again, for all themuscles were still attached yet had become somewhatshortened in the time which had elapsed after the accident.Hence passive and active movements could be begunearly. If indeed the operation were to be adoptedfor a quite recent dislocation, whilst the rotators ofthe head were still stretched or perhaps partly torn,then it might be necessary to limit the movements ofthe shoulder until the muscles shculd have contracted up.-The PRESIDENT said that the value of the operation was inobviating the division of the important muscles round theshoulder-joint.-Mr. RUSHTON PARKER said that enough wasnot done in these cases to make surgeons acquainted withthe amount of defect that might be tolerated without impair-ing the power of a working man to earn his living. He
thought that the operation described by Mr. Spencer was,deservirg of recommendation.-Mr. T. H. KELLOCK gavethe details of a similar case in which he had performed anoperation like that described by Mr. Spencer, but he (Mr.Kellock) had used an anterior incision. He suggested that aposterior and an anterior incision would be the most satis-factory way of approaching the joint in these cases.-Mr.SPENCER replied.
Mr. ALBAN H. G. DORAN read a paper on a CysticTumour of the Suprarenal Body successfully removed by- operation. He reviewed the records of 13 cases of cystictumour of the suprarenal body, large enough to be of clinical,and surgical interest, including one in his own practice of awoman aged 62 years who had been subject for ten years to.attacks of pain after food, and recently to sharp painsreferred to a firm oval tumour in the left hypochondrium. Itwas half hidden under the ribs but could be pushed down.wards below them. There was resonance on percussion overpart of its anterior surface. Diagnosis was uncertain. He
operated, making the abdominal wound along the outerborder of the left rectus. The peritoneum was incisedexternally to the descending colon and the tumour wasenucleated with ease. Some large vessels running into itsupper and inner part required ligature. The left kidney wasseen lying internally to the tumour and mainly below it. No
drainage was employed. The tumour was a thick-walled uni-locular cyst, containing half a pint of bloody fluid. Muchadrenal tissue was detected in its walls. It was an instance ofthe struma suprarenalis cystica hæmorrhagica of Henschen.:Several other cysts of this class were included in the series,to which was added a doubtful case recorded by Lockwood.The minority were adenomatous or lymphomatous cysts. A
history of injury existed in two out of the 13 cases ; attacksof local pain were the rule ; bronzing of the skin was notedin one case only (McCosh) and it disappeared after removalof the tumour. Incision and drainage had proved most un-satisfactory ; the wall of a blood cyst was soft and in oneinstance tore itself away when sutured to the abdominalwound, with a fatal result. In another case the patient died,and it was afterwards found that the cyst could easily havebeen enucleated. This incomplete operation was adopted in athird case because the cyst was believed to be pancreatic scits base was not removed. The patient recovered. Com.
plete removal of the cyst was the proper surgical treatment’Recovery followed respectively in Pawlik’s, McCosh’s, anchis own (Mr. Doran’s) cases, as well as in Lockwood’s casewhere the nature of the cyst was doubtful. The proximity o:the aorta or vena cava should always be borne in mind. Sixof the cases were mainly of clinical interest, not having bee!subjected to operation.-Mr. C. B. LOCKWOOD said that hihad in 1898 exhibited a retroperitoneal cyst supposed to hav4.originated in remains of the Wolffman body and he ha<operated in two additional cases in which both the patientwere young women, recovery following the operation in eacl-case. Both the cysts were in the left side. One was th<usual type of cyst, full of clear fluid and freely moveable"The other cyst was attached to the lower end of the lef
5 See THE LANCET March 5th, 1898, p. 615.
kidney and at its attachment some solid growth was foundwhich proved to be adrenal tissue. Mr. Lockwood consideredthis case to supply a very important link in the chain of evi-dence which had led him to attribute the ongin of theseretroperitoneal cysts to remains of the Wolffian body which,as was well known, gave origin to the adrenal body and
. adrenal remains. These retroperitoneal cysts had fairly con-. stant clinical characters. The patients were nearly always
females. The tumour was on the left side, it was freelymoveable, and was usually thought to be a moveable kidney.It caused continual pain and discomfort. In the four casesof which Mr. Lockwood had had experience the cysts were
, safely removed by incision into the abdomen through thei outer edge of the left rectus abdominis, the cysts beingl exposed by dividing the descending meso-colon. In the caseE of the cyst attached to the kidney the kidney substance was, incised and brought together with catgut.-Mr. DORANE replied.- Mr. RUSHTON PARKER read a paper on a case of veryi severe Compound Fracture of the Arm which he illustrated
by photographs and lantern slides. The points to which hedesired to draw attention were the slinging of the arm to
1 the neck and the flexion of the elbow to a more or less- acute angle. In a fracture of the lower fourth of the3 humerus on account of the invariable tendency to adductions of the condyles under the weight of the elbow a twist
imparted to a metal splint hollowed to fit the limb effectually1 maintained the lower smaller fragment in line with the. upper while controlling both.a Mr. PARKER also read a paper on Two Cases of Ununited. Fracture treated by Planting Small Fragments of Bone. between the Ends.
OPHTHALMOLOGICAL SOCIETY.
An Epidemic of Contagious Conjunctivitis Due to the Pneumo-coccus.-Hereditary Eye Disease.-Secondary Xerosis.-Lower Corneal Plaques.-Exhibition of Cases and Card
Specimens.A MEETING of this society was held on June llth, Mr. R.
MARCUS Gmm, the President, being in the chair.Mr. P. E. H. ADAMS read a paper on an Epidemic of Con-
tagious Conjunctivitis due to the Pneumococcus. He saidthat the epidemic occurred in the spring in a small school of37 boys, 21 of whom were attacked. The eldest boy affectedwas 14 years of age, the youngest beirg nearly ten years old.All the smears taken except one showed numerous Gram-positive diplococci. Most of them were typically flame-
shaped pneumococci with capsules, though a few of themwere rounder in shape and in some the capsules were notevident. This agreed with the description given by Schmidt 1of smears taken from cases of pneumococcal conjunctivitis.On blood agar the colonies were typical slow-growingpneumococci and there was no growth on agar. Only threeof the cases were at all acute, most of them being subacuteor quite mild. Four cases of relapse were reported. Thecondition found on examination was fairly constant-generalcongestion of the lower palpebral conjunctiva, with slightinjection of the ocular conjunctiva, and in the acute caes athin line of muco-pus in the folds of the conjunctiva of thelower lid. The upper lid showed slight enlargement offollicles at the angles, and a row of minute follicles alongthe everted edge. The whole epidemic lasted about fiveweeks and spread in spite of isolation. It agreEd in almostevery respect with previously reported outbreaks, the chiefdifference being the generally mild nature of the cases.
Mr. E. NET’rLESHIP read notes of three cases of HereditaryEye Diseases. Case 1 was that of a husband and wife whohad senile cataract at an advanced age, and both were
operated on with success. They had ten children, seven ofwhom had cataract in various degrees, two of these havinghad them "matured and operated upon at a much earlierage than in their parents. There were also slight lenticularchanges in the grandchildren of the original couple. Thesecond family showed the occurrence of I I Cioppock " ordiscoid cataract, and lamellar cataracts of various sizes, andlikewise of retinitis pigmentosa. Among about 250 personsMr. Nettleship had been able to trace, belonging to the
family, 32 with family cataract and 15 with retinitis
pigmentosa. The sex incidence and mode of descent were
shown to be different for the cataract and retinal disease1 Archives of Ophthalmology, vol. xxxvii., No. 2.
1844 EDINBURGH OBSTETRICAL SOCIETY.
respectively. The third case was that of a family containingcolour-blind individuals. Mr. Nettleship had examined allthe available members, and of 33 males 14 were found to becolour-blind, and of 36 females only one was affected, andshe slightly. There were 40 others in the pedigree whowere either dead or inaccessible.
Lieutenant-Colonel H. HERBERT, I.M.S. (retired), read anote on Secondary (Parenchymatous) Xerosis. He drewattention to the part played by pannus in the developmentof xerosis after trachoma, and pointed out that old pannusrendered the corneal surface insensitive. Hence with bothcorneas covered with pannus the blinking movements of thelids tended to be imperfect, and thus to lead to exposure ofthe globe. This appeared to be an important factor in thedryness which followed, for in such cases xerosis of thecornea and conjunctiva was often very marked when thecicatricial degeneration of the conjunctiva was much lessadvanced than in other old trachomatous cases in which theeyes remained moist and the corneas clear. The exposureof the cornea rendered it more opaque and insensitive, sothat the blinking movements might amount to only veryinfrequent and slight twitches of the lids. Similarlyinactive lids were seen in India in a few cases of severe
primary (epithelial) xerosis. In these cases the exposedcornea became not only opaque but pigmented, like the
degenerate conjunctiva. Here the primarily defective reflexaction of the lids seemed to be attributable to malnutritiononly. Another factor in the production of cicatricialxerosis was the reduced transudation of fluid from the
palpebral conjunctiva. If the upper lid were everted in anycase of ordinary acute conjunctivitis a free flow of wateryfluid was readily demonstrable from the exposed con-
junctiva. Bat a similar flow was not obtainable from acirrhosed or cicatricial conjunctiva, however much inflam-mation might be present.
Lieutenant-Colonel HERBERT also read a paper on LowerCorneal Plaques. These, he said, were slightly raised,feebly vascular, grey patches with rough surfaces, close tothe lower margin of the cornea. Their opacity varied withtheir thickness. They were often of curious shapes and weremostly multiple and binocular. They were not very un- Icommon in India and appeared to be due to slightly defectiveclosure of the lids, together with more or less chronic con-junctivitis, trachomatous or otherwise.
Mr. J. PRIESTLEY SMITH showed a small instrument, con-sisting of a series of lenses aranged in a frame, for use withthe shadow test. The feature of the apparatus was the closepacking of the lenses, about 16 of them being contained ina linear foot, which enabled very rapid examinations to bemade.
Mr. LESLIE J. PATON showed a case with Connective Tissuein front of the Optic Disc.
Dr. F. W. EDRIDGE-GREEN exhibited an improved Lanternfor Testing Colour-perception. There was an arrangementconsisting of three slides in a vertical column, each slidebeing fitted with variously coloured glasses which could bebrought opposite an aperture with an iris diaphragm.Mr. J. H. ToMLiNSON showed a Nernst Lamp Projecting
Lantern.Mr. SYDNEY STEPHENSON showed a patient with a curious
Congenital Anomaly of the Iris.Mr. G. W. ROLL showed a patient with Sky-blue Sclerotics,
and also one with Double Papillitis.Mr. A. C. HUDSON showed a case of Thiersch Grafting.Mr. G. COATS showed a case of Exudation in the Retina.
EDINBURGH OBSTETRICAL SOCIETY.-A meetingof this society was held on June 10th, Professor W.
Stephenson, the President, being in the chair.-Sir A. R.Simpson gave an account of his visit to the Gynaecological ’,and Medical Societies of Japan and exhibited albums pre- ’,sented to him by the members.-Mr. Henry Wade and Dr.B. P. Watson made a communication on the Anatomy andHistology of an Early Tubal Gestation, with lantern demon-stration. The gestation was one probably between thesecond and third week, and a complete picture of the casewas obtained as over 1900 sections were made of the affectedpart of the tube and the other pelvic organs were obtainedin a fresh condition at the necropsy. The patient, aged30 years, had been subject to gastric disorder. On the
night prior to her death she had sent for her medicalattendant for slight abdominal pain and diarrhoea. Sheinformed him that she had had a normal menstrual period
two or three weeks previously. On the next afternoon shebecame rapidly worse and died before arrangements could bemade for operation. At the post-mortem examination theabdomen contained a large amount of dark fluid bloodwith large clots in the pelvis. At the uterine end of theright Fallopian tube there was an almond-shaped swellingmeasuring a little over one centimetre in its long axis and ofa dark prune-juice colour. It was covered with glisteningperitoneum except over a small area about the middle, whichwas of a lighter colour, and the peritoneum was more opaqueand lustreless, and in its centre a minute perforation waspresent from which blood oozed on gentle pressure. Theright ovary showed no abnormality, but the left was
enlarged and cystic, and there was a small fibroma growingfrom the junction of the left ovary and ovarian ligament.The uterus was enlarged, soft, and somewhat boggy to thetouch ; on section its cavity was lined by a thick decidua.The swelling on the tube was found to be situated in theisthmus and bulged more towards the broad ligament attach-ment than to the upper surface. The swelling measured 1’ 3centimetre in length, 1 centimetre in breadth, and 1 centi-metre in thickness. The rest of the tube, including thefimbriated end, appeared quite normal. Transverse sectionsof the tube on the uterine side showed no abnormality in thefibrous and muscular tissue. The villous processes of themucosa were more numerous and complicated than usualand joined across the lumen to produce a net-like appear-ance on section, and the epithelium on these processeswas swollen and in many places desquamated. The capillarieswere engorged with proliferation of the endothelial liningand accumulation round the vessels of cells mainly of thesmall lymphocyte type. No diverticulum of the tube wasevident. If one or two sections had been examined it wouldhave appeared that there was a double channel in the tube,but on tracing this through other sections it was found to bedue to projection of connective tissue proliferation into thetube. Similar appearances would be produced by foldingand twisting a rubber tube. There was evidence of recentcatarrh in both tubes but it was slight in the non-pregnanttube and the appearances might be accounted for by a post-mortem change. On the right side-the pregnant side-it wasdistinctly present, especially on the uterine side. Sectionsthrough the middle of the gestation sac showed the ovumwith its villi filling up the whole interior of the tube and nolumen was visible. At either extremity of the sac the lumenwas intact and the ovum was seen extending not along thelumen but in the muscular coat of the tube ; that is, theovum was growing on the tube wall ; probably it hadpreviously become imbedded there. The villi of the ovumwere seen to penetrate and to destroy by the advancingtrophoblast the muscular wall of the periphery of the tube indifferent parts ; this was greatest near to the point of
rupture. There was a well-marked decidual lining in theuterine cavity, consisting of compact and spongy layers.The only other situation in which true decidual formationwas found was in the villous processes of the mucous mem-brane of the pregnant tube on the uterine side of thegestation sac, and of the interstitial portion ; but no
membrane, only a cellular reaction. It was entirely absentin the tube of the other side, in the ovaries, and in the con-nective tissue of the broad ligament. In sections throughthe middle of the gestation sac the chorionic vesicle, coveredwith epiblast and containing the embryo in its amnion, waswell seen. There was a reaction on the part of the maternaltissues by hyperasmia and oedema, with blood extravasationand fibrin formation; that was for protection of the maternaltissues against the invasion of the advancing trophoblast.
: In one place the wall of a blood sinus had been destroyed bythe trophoblast causing a large haemorrhage into the ovumbed in the thinned out wall of the tube. This had weakened
L the tube and possibly as the result of muscular contraction. of the remainder of the tube wall, the peritoneal coat of the. tube had ruptured and intraperitoneal haemorrhage hadI resulted. According to the view of Mr. Wade and Dr.. Watson the decidua must be looked upon not simply as a suitable bed in which the ovum can bury itself but as a barrier laid down to prevent the too greatl destructive action of the trophoblast. The absence ofI any distinct decidual membrane in the tube wall would. on this theory readily explain the frequency of tubalI rupture. The rupture was very small and opened intol a comparatively small vessel. Spontaneous arrest of theI bleeding might have been prevented by the failure of thel weakened muscular coat to contract, and there was the
1845REVIEWS AND NOTICES OF BOOKS.
further possibility that the coagulability of the blood mightbe altered by the action of the trophoblast which seemed topossess the power of extending along vessel walls withoutproducing clotting. The complete embryo measured 1’9millimetres by 0’87 millimetre by 0 ’ 64 millimetre ; thesemeasurements corresponded with those ascribed to embryosbetween the second and third weeks.-Sir A. R. Simpson,Dr. W. Fordyce, Dr. A. H. F. Barbour, Dr. F. W. N.Haultain, Dr. J. Haig Ferguson, and the President discussedthe paper, and Mr. Wade replied.UNITED SERVICES MEDICAL SOCIETY.-A meeting
of the above society was held on June llth, Inspector-GeneralSir Herbert M. Ellis, K.C.B., R.N., the President, being inthe chair.-Lieutenant-Oolonel H. E. Deane, R A.M.C.
(retired), read a paper entitled " A Plea for a More DetailedStudy of the Soldier’s Heart," and presented each memberattending with a copy of a series of respiratory-pulse curveson which the paper was based. Having been obtained fromsoldiers, professional gymnasts, acrobats, and dancers,these were analysed, attention being given to the phenomenaof pulsus paradoxus, extra systoles, and the results of strain.A diagram-taken by means of an ortho-radiographicmachine--of the heart of a soldier who was holding hisbreath was exhibited and it showed a marked diminution ofall the diameters of the heart. Reference was next made tocases of disordered action of the heart in soldiers. It wasasked whether it was quite certain that the equipment hadnothing to do with the subject. Investigation as to the cir-cumstances in which the men broke down, a graphic recordof the cardiac conditions, and a detailed examinationof men after marching or after a field day were advocated.The instruments by which the tracings were obtainedby Lieutenant-Colonel Deane were exhibited.-In the dis-cussion which followed it was generally agreed that toomuch significance had hitherto been attached to the occur-rence of extra systoles and it was stated that candidates forlife insurance had been rejected or charged extra premiumsand men invalided from the Services unnecessarily on theiraccount. An example was given of a man being found doingheavy work as a luggage porter a few years after he hadbeen invalided from the Marines. Seamen of the Royal Navwere not found to be specially subject to heart trouble bulthe Marines, whose conditions of life were similar to those ojthe soldier, suffered. It was stated that in soldiers it was noiuncommon to find post mortem a certain amount of generahypertrophy of the heart.-Dr. Mackenzie, Colonel BeattieR.A.M.C. (retired), Lieutenant-Colonel W. B. Leishman
R.A,M.C., and the President were among the speakers.-In his replies Lieutenant-Colonel Deane suggested clothinand the hustling to which the soldier is subjected as element:in the causation of the condition.
WEST LONDON MEDICO-CHIRURGICAL SOCIETY.-A meeting of this society was held on June 5th, Mr. Richar(Lake, the President, being in the chair.-Dr. AndrevElliot opened a discussion on the Causes of Unconsciousnesby a paper dealing with the causes of insensibility, ansecondly with the general methods of investigation whiclwould be found of use. He emphasised the necessity of ;clear idea of the various possible causes of unconsciousnesin order that none might be overlooked and suggested .tabulation of the possibilities based on a memoria technicaReferring to the examination of an individual case, he urgea systematic method of procedure by a scrutiny of thfollowing points in succession : (1) the history, if obtairable, of the case ; (2) the general condition of the patientand the depth of the coma present; (3) signs of injureespecially cranial fracture ; (4) any peculiarity in tbbreath; (5) the condition of the tongue and mouth ; (6) tbpulse, temperature, and respiration ; (7) local paralyses (
rigidities ; (8) the general sensation ; (9) the reflexes(10) the eyes (muscles, pupils, cornea, and fundus) ; (11) tlurine ; (12) the stomach contents ; and lastly, if necessaryan examination of the cerebro-spinal fluid withdrawn l:lumbar puncture.-Dr. A. E. Russell continued the dicussion and commented on the unconsciousness of epileps;pointing out that in some cases convulsions might be islight as to escape notice or even be absent. In some cases Ihysterical attacks the diagnosis from epilepsy was not easespecially in view of the frequent complete absence of knoBledge by the patient of what had occurred during the attaclthe possibility of some of these attacks being really the sequof unrecognised petit-mal had also to be borne in min,A.s regards apoplexy, in children embolism, and in Y01U
adults syphilitic endarteritis had to be considered, whilst inolder adults thrombosis from cerebral arterio-sclerosis andI cerebral haemorrhage were the chief factors. ThrombosisI was more common than was usually suspected. The chief
points in coming to a diagnosis were: the presence of pre-! monitory slight and transient attacks ; the frequent mildness, of onset and the presence of a low-pressure pulse and dilated. heart in cerebral thrombosis, as compared with the more1 violent onset, the deeper and more prolonged unconscious-
ness and the high blood pressure and hypertrophied heart, so., commonly found in cases of cerebral haemorrhage. The
1 importance of accuracy of diagnosis was obvious in view ofthe different methods of treatment required in the two
11 classes. The condition of ursemia was also considered.
i Catalepsy was a rare phenomenon but did occasionally occur.The unconsciousness met with in men working in deep wells
r and the holds of ships was also referred to. Dr. J. S.s Haldane had shown that this was due to absorption of oxygenn from the air leaving an atmosphere composed in the main of!, nitrogen. The danger of this was that the patient did nota
as a rule recognise his danger owing to the absence of1. marked dyspnoea or discomfort, and unconsciousness
is c occurred very suddenly.is
-- - _
Reviews and Notices of Books.Nothnagel’s Practice Diseases of the Heart. Bv Professor
TH. VON JÜRGENSEN, Professor L. VON SCHROTTER, andProfessor L. KREHL. Edited with additions by GEORGEDOCK, M.D., Professor of Theory and Practice of Medi-cine and Clinical Medicine, University of Michigan, AnnArbor. Authorised translation from the German underthe editorial supervision of ALFRED STENGEL. M.D., Pro-fessor of Clinical Medicine in the University of Penn-sylvania. London and Philadelphia: W. B. SaundersCompany. 1908. Pp. 848. Price 21s.
THIS work forms one volume of Nothnagel’s " Encyclopsediaof Practical Medicine" which is now being translated intoEnglish. The editor, Dr. Dock, remarks in his preface thatalthough several excellent works upon diseases of the hearthave appeared within the last quarter of a century in
Germany yet none of them have been translated into English.This is especially strange when it is considered that manyimportant contributions have been made by observers in thatcountry to the normal and pathological anatomy of the heartand circulatory system, the methods of diagnosis, the pharma-cology of cardiac remedies, and the application of non-
medicinal measures to the treatment of patients sufferingfrom affections of the heart. The volume now before us is a
large one, and in it we find, to quote Dr. Dock’s words, " thesound learning and wide clinical experience of Professors vonJiirgensen and von Schrötter and the deep and broad training
t in anatomy, physiology, and pathology, as well as the excel-: lent clinical observations of Professor Krehl."
Matters of interest brought out since the original wasl published have been added in brackets. These include
, American and English contributions, so that by this means. the work is brought well into line with recent observations,j which naturally increases the value of the book as a work of’ reference.
The first section of the book is by Professor Jiirgensen andr deals with Insufficiency (Weakness) of the Heart. An
; interesting account is given of the symptomatology of thiss affection, in the course of which some remarks are made’ on the development of dropsy which are well worthy ofr attention. The observations of von Lesser, Grawitz, and
others are carefully considered and criticised. There is
D no doubt that one of the chief conditions for the pro-f duction of dropsy is slowing of the circulation. Where-, ever the slowing is greatest oedema develops most early.- On the other hand, there are other factors at work which
,i are not so well understood. It has been shown that
1. cardiac imufficiency is attended more often by dilutiong than by concentration of the whole blood. It is probable
