607

the fact that the appendix was dull and lustreless whilstthe cascum was shiny in appearance; this is possiblyaccounted for by the fact that the appendicular arteryanastomoses with the vessels in the csocum to a very limited

extent,l so that in the event of it becoming obstructed,gangrene of the appendix is very prone to supervene with

great rapidity. ,

CASE OF EXTRA - UTERINE GESTATION.

BY EVELYN A. CONSTABLE, M.B., B.S. DURH.,SURGICAL REGISTRAR, LONDON TEMPERANCE HOSPITAL.

Patient, aged 31, was admitted to the London TemperanceHospital on Oct. 10th, 1916, under the care of Dr. KevinByrne; she had had abdominal pain for 12 months. Shewas married in August, 1914. Confined on Nov. 4th, 1915, ofher first child at seven months (died in 15 hours). Six weekslater had her first monthly period, which was a heavy oneand lasted one week. One month after this there was a veryscanty loss every few days up to February, 1916, when a" piece of shaggy flesh" " was passed (no blood with it). Thentotal cessation of menses until August, after which periodsbecame regular and normal in amount. Patient had hadabdominal pain since her confinement, but in February lastshe had "labour-like pains,"and considered herself pregnant.Sent into an infirmary, where she remained from March toJuly. Here she was curetted "for a miscarriage." The painscontinued, and patient felt weak.

, b, Fœtal bones. ‘

On admission to the London Temperance Hospital on Oct. 10th a large swelling was in right side of pelvis and tpouch of Douglas. No vaginal discharge. Uterus slightly (larger than normal and pushed over to the left. Nov. 8th :Note by Dr. Byrne. " The swelling on right side is smaller but still tender. There is a swelling, not previously observed, (in corresponding region to left of uterus. She has com- plained of rather more pain in lower abdomen and extendingfrom right side to left." Nov. 12th : Menstruating. Nov. 16th : Pain in lower abdomen, especially right side, much worseto-day. Pain on superficial palpation; relieved on deep ipalpation. No rigidity. Nov. 24th: Operation by Mr. J.McClure. On opening abdomen the omentum, vermiform appendix,

and a loop of ileum were found adherent to the fundus ofthe uterus on the left side. On freeing these (in doing whicha small part of serous coat of gut was torn and had to bestitched up) a hard mass was found at the left tubo-uterinejunction. This turned out to be the left greatly dilated tubeand ovary, on the surface of which were some fœtal bones (asin figure, b)—viz., a femur, tibia, and fibula, also metatarsalsof both feet. Close to the former and parallel to them weresome nodules thought to be the spine, with cranium at lowerpole. Parts removed were both Fallopian tubes, left ovary,gestation sac, and vermiform appendix. Patient made anuninterrupted recovery.

I am indebted to Dr. Byrne and Mr. McClure for permissionto report this case.

1 A Treatise on Applied Anatomy, by E. H. Taylor, p. 485.

ST. THOMAS’S HOSPITAL MEDICAL SCHOOL.- (R. H. 0. B. Robinson, King’s College, Cambridge, has been awarded the University Scholarship of £50.

Reviews and Notices of Books.1. The Causes of Tuberculosis. By Loms COBBETT, M.D.

Camb., F.R.C.S. Eng., University Lecturer in Pathology,Cambridge. Cambridge : The University Press. 1917.Pp. 707. Price 21s. net.

2. Clinical Tuberculosis. By FRANCIS MARION POTTENGER,A.M., M.D., LL.D. With a chapter on LaboratoryMethods by JOSEPH ELBERT PoTTENGER, A.B., M.D. Intwo volumes. London and Glasgow : Henry Kimpton.1917. Pp. 1416.

1. THIS book on the Causes of Tuberculosis is primaiily adigest of the work of the late Royal Commission on Tuberculosis,of the reported activities of the Local Government Board, ofthe Health Department of the City of New York, and of theImperial Board of Health of Berlin. It is also a good dealmore, for the author, who has personally contributed muchspade-work to researches on tuberculosis, has gone con-

siderably further afield in collecting valuable material.He has also brought out his facts so skilfully that the

validity of most of his conclusions will be questioned byfew. His is the ambitious object of providing a book atonce for the medical profession and the lay public. Un-

doubtedly it will prove useful to both, and as a basis forlectures both to students and the public it should beinvaluable. The earlier chapters deal with the incidence oftuberculosis and the wonderful decline in the mortality fromthis cause during the last half century. On the basis of thecalculation that the ratio of deaths to population hasfallen by more than 50 per cent." in this period, the authoranticipates that tuberculosis will have become a rare

disease before the end of the century." One of his mostinteresting conclusions is that in the case of both human andbovine tuberculosis " iu the main it is the large dosesof bacilli which are dangerous, and that small ones are oftenharmless or even beneficial by increasing resistance."

" Hisrecommendations for combating both these forms of tuber-culosis reflect this view. The author is in favour of segrega-tion, but he thinks that compulsion with this object must,except in very exceptional cases, be renounced. He is, as arule, so careful to weigh available evidence before attemptingto formulate his conclusions that it is surprising to find himdigressing from his main thesis to pass judgment on theachievements of sanatoriums without adequately reviewingthe arguments for and against them. They take," hesays,

" away with one hand what they give with the other."

This attitude is surprising in a "segregationalist," as theprovision of ample sanatorium accommodation automaticallyhelps to solve the problem of segregation in the least objec-tionable manner. To recommend segregation without a fulldiscussion of all it implies is dangerous in a book partlyintended for non-medical readers. The book, as an

exposition of present-day knowledge of the causes oftuberculosis, merits unreserved praise.

2. Progress in our knowledge of tuberculosis is, alongcertain lines, so rapid that the sight of these bulky volumesat once suggests the mournful reflection that in a few yearsthey may be out of date. But on closer scrutiny theseregrets prove superfluous, for this work is not just acompilation of others’ researches brought up to date.It represents rather the experience and thoughts of oneman-the author. His is a record of observations made

! during 20 years of clinical study conducted mainlyat the Pottenger Sanatorium, California, and the readerwill be struck by the originality of thought’and the con-sistency of effort directed along certain specialised lines.And yet the author shows a catholic knowledge of other

’ aspects of his subject. In the chapter on modes of infection, the author says he has not had a single case of direct infec-

tion of employees and attendants in sanatoriums broughtto his attention. He sees in "massive" infection of

i children the chief danger which, if avoided, would greatlylimit active tuberculosis in the adult. Further, hebelieves that recognition of the significance of earlylymphatic tuberculosis would supply the key to thetuberculous problem." He notes that tuberculin in

. childhood may often be the determining factor for goodL between the years 5 to 10 or 12. In a later chapter he

says of tuberculin that, after 20 years’ experience, he

608

balieves that, properly administered, it " will add at least aminimum of 20 per cent. to the chances of healing." Buthe is evidently no bli d tuberculin fanatic, and he insistson its uselessness except in the hands of the expert preparedto individualise and to avoid all routine or haphazard methuds. A distinctive feature of the chapters on diagnosisis the almost meticulous study of symptoms, of which, evenin the early stages, about 30 are described. By carefulanalysis these symptoms are placed in three groupsaccording to their etiology, which may be toxæmic, reflex,or local (the tuberculous process per se). Nervous instabilitybelongs, for example, to the first group, cough to the second,and haemoptysis to the third. The author then tries to showhow toxaemia can produce nervous instability and reflexaction produce cough. His main clue to these problems issought in the nervous system, and he is indefatigable infollowing up the paths of reflex action. As he says :-In tuberculosis we must conceive of a condition in which

both the vagus and the sympathetic systems are simul-taneously stimulated, but one in which either one or theother usually yields with a resultant disturbed equilibrium.This, for example, is how he analyses the rapid pulse oftuberculosis (p. 231) :-

It has long been said that a persistently rapid pulse intuberculosis means a bad prognosis. While this is not

invariably true, there is some ground for it, because it Imeans that the patient’s sympathetic tonus is in theascendancy....... It would be more rational to state thatthose patients who are distinctly of the sympathetic tonustype, or those people who have a decreased vagus tonus, whichmeans practically the same thing, are not as able to with-stand the disease as those who have increased vagus tonus.

The author attaches great importance to the mental factorin tuberculosis, and he sees in the possession of magnetism,"Geist." personality by the physician an almost essentialqualification. Thus (p. 651) :-

I would rather have a patient treated in a room, if I couldgive him the benefit of hydrotherapy and psychotherapy,with good food, than treat him in the open air, with hydro-therapy and psychotherapy omitted.We have dwelt rather on the unusual than on the more

commonplace features of this book, so let us add thatit also represents, broadly speaking, the views of the ablestpathologists and physicians of the day on the various aspectsof tuberculosis. The author has a trick of iteration. The

points he would emphasise and establish as pivots aboutwhich lesser factors revolve recur again and again. Theyconstitute refrains running throughout his work. It wouldbe easv enough for him greatly to condense what he has tosay, but it would be at the loss of a fluent easy rhythmwhich conveys a vast store of knowledge. The book offersno points of comparison with the average text-book andforms a comprehensive survey of its subject.

1. Les Psyehon6vroseq de Guerre. By G. Roussy, Professeuragrégé la Faculte de Medecine de Paris ; and JEANLHERMITTE, Ancien Chpf de Laboratoire à la Faculté deMedecine de Paris. With 13 plates. Paris : Masson etCie. 1917. Pp. 187. Price 4 francs.

2. Hysterie-Pithi2tisme et Troîbles Nerveux d’Ordre Réflexe.By J. BABINSKI, Membre de l’Académie de Medecine ; andJ. FROMENT, Professeur agrege, Medecin des Hôpitaux deLyon. With 37 figures and 8 plates. 1917. Pp. 267.Same publishers and price.

1. THIS useful little volume is one of the latest additionsto the series of war monographs published by the well-knownhouse of Masson. The authors include under the term

psychoneurosis every variety of functional disturbance fromthe simplest to the most complex, from those whose expres-sion is almost entirely physical to those where psychicalsymptoms predominate. Thus they comprise in their precisimpairment of gait, involuntary movements of all sorts,sensory phenomena, disturbances of the special senses,visceral troubles, anxiety-hysteria, and the various mentalsymptoms of head injuries, shell shock cases, and the otherpathological states with which the war has made us familiar.A chapter is devoted to commotio cerebralis. The etiology ofthese different neuropathic and psychopathic conditions isoutlined in some detail, and several sections are taken upwith an attempt to guide the reader to a clear understandingof the part played by "simulation-exaggeration" and"simulation-prolongation." The chapters on treatment are

particularly good. The r6le of the physician, and of the-patient, the environment, and the exact procedures desirablereceive full consideration. The authors believe in reasonedand persuasive psychotherapy after the manner of Dejerine,Dubois, and Babinski. They hold that suggestion underhypnotism should be abandoned altogether. In their handsthe methods here specified have been successful in from 98.to 99 per cent. of cases.

2. In view of the therapeutic importance of clearly dis-tinguishing hysterical from other functional disorders of thecentral nervous system arising in the course of warfare a

practical knowledge of their differential diagnosis is essential.We do not know any modern volume in which the reader willfind these difficult subjects so lucidly explained as in this,not merely because one of the best working hypotheses ofhysteria is associated with the name of M. Babinski, but alsobecause of the learned way in which the peculiarities of thecondition known as reflex paralysis, often confused withhysteria, are here presented for consideration. Reflex

paralysis is a subject to which much attention has beengiven, yet in England the profession as a whole can scarcelybe said to be familiar with it; since, however, it appears tooccupy a place intermediate between the organic and thefunctional, its importance is considerable. No doubt in thisexcellent little book the authors are more concerned with anexposition of their own views than with an examination ofthe views of others, but its obvious merits should commendit to all who are in search of a compendium of informationon war hysteria and allied conditions, where questions of

diagnosis, prognosis, and treatment are handled at somelength. There is, at the same time, more in the book thanits appeal to the physician on the ground of practicalusefulness; its appendices contain observations of muchscientific interest for the neurologist, and there is a biblio-

graphy of some 250 references. There are illustrative

photographs and diagrams.

Microbiology: A Text-book of Micro-organisms, General andApplied. By Various Contributors. Edited bv CHARLESE. MARSHALL, Professor of Microbiology and Director ofGraduate School, Massachusetts Agricultural College.Second edition, revised and enlarged. With 186 illustra-tions. London : J. and A. Churchill. Pp. 900. Price12s. 6d. net.

IN a review of the first edition of this book in THE LANCETof April 27th, 1912, the special features which distinguishedthe work were noted at some length. It differed from the

ordinary text-book in that it was a collection of short

monographs by specialists and not the product of a singleauthor. There was, however, less overlapping and greater’uniformity of treatment than might have been anticipated.Further, the book was not apparently directed to the needsof any special group of readers, but furnished part ofa general liberal education. Its descriptive title was11 Microbiology for Agricultural and Domestic ScienceStudents," and" domestic science" was interpreted so asto include the diseases of men and animals, plant diseases,sanitation, and, in fact. any subject in which micro-organismsplayed a part. The articles were not, however, of a popularcharacter, but were a series of able, if necessarily limited,monographs. All laboratory methods were eliminated.The qualifying expressions of the original title have nowbeen dropped, and the book is described as an elementarytechnical treatise on the subjects included under the termmicrobiology, but there is no essential change in thissecond edition either in method or scope. There has been ageneral revision of the work, and certain additions havebeen made which have increased the size of the book bysome 300 pases, while the illustrations are also more

numerous. The cytology of micro-organisms has becomemore defined in recent years and has, received additionalattention in the present edition at the hands of Dr.Guilliermond. professor of botany at Lyons. A chapter hasalso been added on intestinal microbiology. The spacedevoted to the microbial diseases of insects has beenincreased, and especial attention is paid to those diseaseswhich are of economic importance, such as that caused byB acridiorun in locusts and those which affect bees.The book certainly gives a good general view of a very

wide field of knowledge. The size of the book still remainsmoderate, and no fault can be found with the type andgeneral appearance.

609

Cerebellar Abscess; its Etiology, Pathology, Diagnosis, andTreatment, including Anatomy and Physiology of theCerebellum By ISIDORE FRIESNER, M.D., Adjunct Pro- S

fe"sor of Otology and Assistant Aural Surgeon, ManhattanEye,. Ear, and Throat Hospital, New York, &c.. and iALFRED BRAUN, M. D., F. A. C. S., Assistant Aural Surgeon, EManhattan Eye, Ear, and Throat Ho.-pital, New York, &c. With 10 full-page plates and 16 illustrations in text.

sLondon : William Heinemann. 1917. Pp. 186. Price12s. 6d. net. r

THE authors have compiled a useful monograph on cerebellar abscess in all its bearings. The sections on t

the anatomy and physiology of the cerebellum contain a t

resume of the most recent work on the subject, of German (

origin, be it remarked, for while Lewandowsky, Rothmann, and Ba’any are quoted from freely there is little apparent iappreciation of the investigations of Horsley and R. H. Clarke, and the valuable researches of Andre Thomas and Durupt oncerebellar localisation are ignored. Further, in the sections ion symptomatology B6,rdny’s tests are described in full, butthere is no reference to the methods of Babinski, which are in some ways preferable. It is curious, too, that whileinvestigations associated with the names of German workers are usually quoted from the original sources, methods ofexamination for which we are entirely indebted to the French and English schools of neurology, are freely described without any acknowledgment of their origin. The apparentlyone-sided nature of the writers’ knowledge of cerebellar research is regrettable. From the clinical standpoint the common cerebellar

symptoms are, on the whole, fairly presented to the reader, though we notice a differentiation is diawn between the 1

"character " and the "behaviour" " of nystagmus which is far from clear. Further, we are of the opinion that a greater acquaintance with cerebellar disease other than abscess might have led the authors to modify certain of their state- ments. Tremor is mentioned, but its localising significanceis not stated; deviation of the head in certain cases isreferred to, but not described in the specific way in which it :

usually occurs. Cerebellar gait is not noted except in thebriefest fashion ; dysmetria, asynergy, and adiadokokinesisare described separately without any hint of their -inter-relation. The chapters on the prognosis and treatment ofcerebellar abscess are, on the other hand, more completeand satisfactory. .

The Treatment ot TabFtic Ataxia by Means of SystematicExercise. By Dr. H. S. FR"NKEL, Medical Superin-tendent of the Sanatorium -’ Freihof " in Heiden (Switzer-land). Second revised and enlarged English edition byL. FREYBERGER, J.P., M. D. Vienna, M.R.C.P.Lond.,

. Barrister-at-Law of the Middle Temple, &c. With 129illustrations. London : William Heinemann. 1917.Pp. 209. Price 12s. 6d. net.

Dr. Frenkel’s exercises for the treatment of the ataxia oftabes dorsalis have become justly famous, and their abidingvalue in the tackling of a troublesome symptom has beendemonstrated over and over again in the experience of

physicians of all countries. Their rationale can be readilygrasped when we remember the words of Hughlings Jackson,that when the dorsal columns of the cord are sclerosed thetabetic walks badly ’’ with what of his cord is left." Hencethe importance of endeavouring to educate, rather than tore-educate, the muscle groups by a new combination of theeye and what remains of the cutaneous and deep sensoryapparatus. In this new edition there is full apprecia-tion of the fact that the cause which keeps up thesclerosing process in the central nervous system must beobviated as far as possible by specific treatment, and in thelast chapter modern methods are described with some detail.It is not the purpose of the book, however, to go into thisquestion completely. But, given a tabetic in an early stageor, for that matter, in a chronic stage, his ataxia, other thingsbeing equal, will certainly be influenced favourably by patienttrfatment along the lines here described with ingenious care.We have said that Frenkel’s exercises are familiar to thephysician; he should become a possessor of this handbook torealise how much the method can effect and how applicableit is to all forms of impaired control over the muscularsystem.

JOURNALS. °

Military Surgeon (Washington, D.C., U.S.A.).-TheSeptember number of this journal contains several articles ofvalue on war surgery. Dr. E. B. Downer, Red Cross surgeonin Serbia and director of a private mission to Russia, reportsexcellent results from bone-grafting in the treatment ofununited fractures. The surgeon who takes up this branchshould be first a skilled mechanic and next requires motor-driven tools. Dr. Downer declares he himself has the onlymotor-driven outfit in Russia. Bone splints lead to boneformation, but steel plates prevent it. The author’s observa-tions on surgical methods in each of the successive years ofthe war are judicious and should be read.-Lieutenant-Colonel W. L. Keller, Medical Corps, U.S. Army, sends avaluable paper on Surgical Work in a United States ArmyHospital. Amongst other things he describes a novel andsuccessful treatment for bubo and for phagedsenio ulcer.The Report of the Mesopotamia Commission is reviewed. Itis regretted that the Commission included no medical member,and it is noted that, under those circumstances, it was

unlikely the medical department would escape censure. It isobserved that the preservation of the health of an army, andthe efficient removal of its wounded have so much influenceon the success or failure of every military undertakingthat so long as the medical department has no representa-tion on the General Staff, there never can be any team-playin an army."-Colonel Goodwin, A.M.S., in an address tothe United States War College, states as having held thepost of A.D.M S of two divisions in France, that when he hasheard staff officers declare a particular A.D.M.S. "difficultto manage," he has considered that a great compliment hadbeen paid to the administrative medical service. Heobserves that the higher the discipline of a unit the moreefficiently is its sanitation carried out, and that sanitarilythe best conducted troops are the Guards. He further notesthat to avoid " a medical breakdown " after an action, theA.D.M.S. must secure information in advance from theheadquarters staff. For he is always working with a roperound his neck, and when the medical breakdown comes, ascome it will, it is he who will be "hanged," so he hadbetter get this delaying of information removed before thebreakdown it is rendering inevitable occurs.-The same

issue of the journal contains an interesting account byLieutenant- Colonel E. L. Munson of an outbreak of measles,occurring in a military camp in Texas, in which the authorlays stress on the respiratory symptoms.

Archives de Médecine Navale.-In the issues of thisjournal for June and July Dr. René Potel, medecin deIre classe of the French Navy, gives an account of an

epidemic of typhus fever amongst Serbian soldiers and theFrenchmen who associated with them in February andMarch, 1916. On Feb. lst 2400 Serbian soldiers, who hadescaped from Serbia after manv hardships, were embarked atCorfu in the French transport France IV. for Tunis. There wasneither time nor opportunity to clean them before embarka-tion, nor even to give them clothing, and they came onboard in their rags. On Feb 12th cases of typhus beganto appear among the French sick-berth staff ; in all, 14 ofthe ship’s company were attacked. These men were onarrival sent to the naval hospital at Bizerta, where they, beingfew, were completely cleaned and no further cases occurred.The 486 Serbian cases were sent to Sidi-Abdallah, near

by, where emergency hospitals had been prepared for them,but as they arrived in scores and hundreds little couldbe at once done beyond washing them and putting theminto clean clothes; they were not like the others shavedand so freed from nits, and 21 days after their arrivalcases of typhus began to appear amongst the medical officersand the orderlies. This period of 21 days was occupied, itis suggested, three days of it in the hatching of the nitsand the development of the parasites therefrom, eight daysin the maturation of the cause of the infection within theseyoung parasites, and ten days in the incubation of thefever in the bitten human patient. Ten days after therehad been time to work over all the patients, to get themshaved completely, and their bedding disinfected, no morecases occurred. The cases amongst the Serbians were

numerous but mild ; those amongst the French few butsevere. Dr. Potel observes that the sanitary measuresemployed were directed against lice only, and that theybrought the epidemic to an end. Whence he concludes that